Page 59 - Journal of Special Operations Medicine - Fall 2015

principles must incorporate an “all hazards” approach. To foster command leadership for casualty care train-
Still, ASIs generally remain the most frequent and high- ing, the Rangers developed the Casualty Response
profile type of AVI. Recent Federal Bureau of Investiga- Training for Ranger Leaders course. This program of
tion (FBI) data suggest that over 14 years, from 2000 instruction emphasized the importance of making in-
to 2013, there was a notable increase in both incidence formed tactical decisions that would result in fewer ca-
and impact of ASIs. Additionally, during the second half sualties while still completing the mission. Operational
of this time period, from 2007 to 2013, the number of leaders were taught casualty contingency planning, ca-
ASIs more than doubled (increasing from 6.4 to 16.4 in- sualty collection points, and casualty evacuation. The
cidents per year) and became more deadly (76% of all base principles emphasized the tactical implications of
casualties and 75% of all deaths were observed in this casualty management and the importance of distrib-
latter time frame). According to the FBI, a majority of uted trauma-care capabilities across all military occu-
active shooter events last less than 12 minutes, with 37% pational specialties.
ending in less than 5 minutes. The same data reveal that
50% end with law enforcement officer (LEO) arrival and The third critical factor to the RFR’s success is com-
engagement and a vast majority end violently. These mon operating language for casualty response, coupled
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observations are critical when analyzing combat lessons with the rapid integration and updating of material to
learned and applying them to the civilian setting. reflect the most cutting-edge recommendations from the
CoTCCC and other expert advisory groups. The RFR
Recent reports suggest that between 24% and 28% of US uses TCCC concepts as its foundation and continuously
military deaths during recent conflicts in Afghanistan and builds on these concepts through evolving operational
Iraq were potentially preventable. 11,12 The rate of poten- experience and CoTCCC updated guidelines. The RFR
tially preventable deaths was found to be approximately program trains all Rangers to identify and treat the three
15% for US Special Operations Forces deaths between most common causes of preventable death on the bat-
2001 and 2004. However, between 2001 and 2010 for tlefield. 12,20 Similar to other medical response practice
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the 75th Ranger Regiment, the rate was only 3%. The guidelines, protocols, and procedures, such as Advanced
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Ranger First Responder (RFR) program was a key com- Cardiac Life Support and Advanced Trauma Life Sup-
ponent for achieving this significant reduction in combat port, the universal implementation of TCCC allows all
mortality. The 75th Ranger Regiment has proven very Rangers responding to a wounded casualty to quickly
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successful in terms of integrating trauma care as a fun- assume critical roles in the assessment, treatment, and
damental soldier skill. The unit RFR program was based evacuation of that casualty.
on five key factors: (1) command ownership, (2) trauma
care as a core mission, (3) common operating language The RFR program is universal training for all Rangers.
for casualty response, (4) universal training, and (5) ag- The Rangers understood that non-medical personnel are
gressive process improvement (i.e., after-action reports likely to be the first responders in a combat trauma sce-
and data collected and analyzed for casualty care to vali- nario. When a Ranger platoon is engaged in combat ac-
date efforts and improve performance). 16 tion, there are typically two medical personnel who are
capable of delivering the most advanced medicine pos-
Command ownership of the RFR program was para- sible in an austere environment. However, there are also
mount. In 1998, while Commander of the 75th Ranger up to 40 personnel who can identify and treat wounded
Regiment, COL Stanley McChrystal included medical casualties. Accordingly, the RFR program was designed
training as part of his “Big Four” core areas of emphasis to provide three levels of education based upon the
for Ranger training (the other three were marksmanship, soldier’s primary mission and skill set. The education,
physical training, and small unit tactics). McChrystal training, and operational expectations are broadly di-
mandated that every soldier in the 75th Ranger Regiment vided into three categories: familiarization, proficiency,
would be able to treat and evacuate casualties who had and mastery (Figure 1). This distributed knowledge and
one of the three major causes of prehospital preventable capability are major force multipliers. In fact, according
death on the battlefield: extremity hemorrhage, tension to Kotwal et al., 42% of all tourniquet applications and
pneumothorax, and airway obstruction). 17–19 McChrys- 26% of all hemorrhage-control interventions adminis-
tal’s mandate also supported the second key principle of tered during combat operations in the Ranger Regiment
trauma care as a core mission for all Rangers. These two between 2001 and 2010 were completed by nonmedical
factors recognized that earlier intervention is critical in personnel. Through an aggressive process improve-
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trauma care and that many of the life-saving skills needed ment method, these data and other data for prehospital
to be pushed to the nonmedical first responder at the combat casualty care were documented, collected, and
point of wounding. After the initial development of the analyzed in near-real time. These methods permitted im-
RFR program in 1998, components of this program were mediate and continuous validation and improvement
subsequently integrated into all unit training events. 14 of prehospital tactics, techniques, and procedures that,

Community Approach to Reducing Mortality From AVIs 47