Page 20 - Journal of Special Operations Medicine - Winter 2015

area of medicine that is compelled to make at least some this body have now been well documented to improve
decisions regarding care with evidence that is not as survival in combat casualties, 2,9,15–17 and TCCC has been
strong as one would wish. Tricoci et al. noted in 2009 adopted throughout the US Military and by many allied
that only 11% of the American Heart Association/ nations. 9,15
American College of Cardiology practice guidelines are
based on level A evidence, while 48% of the guidelines The CoTCCC is made up of trauma surgeons, emer-
are based on level C evidence. 10 gency medicine physicians, combatant unit physicians,
physician assistants, and combat medical educators.
Another consideration with respect to RCTs is that even Additionally, any group making decisions about what
when they have been performed, the evidence obtained Combat medics should do on the battlefield should
from them applies directly to clinical practice only when include those individuals as part of the decision-mak-
the patient being treated meets all of the inclusion cri- ing process. Very importantly, by tradition, and now
teria for the study and the other circumstances of his or through its Mission Statement, the CoTCCC must have
her care reflect the care rendered in the study. As an ex- no less than 30% of its membership made up of active
ample, the 1994 Ben Taub study on prehospital fluid re- or former Combat medics, corpsmen, and PJs. This
suscitation was a well-done RCT in which it was found 42-member group, at present, has representation from
that aggressive prehospital fluid resuscitation for hy- all of the US Armed Services and has 100% deployed
potensive patients with uncontrolled hemorrhage from experience. The CoTCCC was relocated in 2007 to the
penetrating torso trauma worsens outcomes. This evi- Defense Health Board (DHB) and, in 2013, to the JTS.
11
dence is reflected in the controlled resuscitation strategy Figure 1 is the CoTCCC logo.
used in TCCC. 7,12–14 Critics of this decision have noted
(correctly) that the transport times in the Ben Taub study
were much shorter than those typically encountered in
military operations, and they have challenged the ap-
plicability of the findings of this study to combat casual-
ties on that basis. Combat wounding patterns are also Figure 1
different than from the wounding patterns encountered CoTCCC logo.
in the Ben Taub study. These observations, however, do
not negate the findings of that study; they dictate that
the findings be considered with the appropriate caveats.

Another important aspect of TCCC decision-making
has been that when an intervention is considered, the
evidence for both the current standard of care and the
proposed new intervention are considered in making the At its meetings and teleconferences, the CoTCCC meets
decision. Endorsing an intervention that has been the with designated TCCC subject matter experts (SMEs)
status quo for years should be treated as no less a deci- and with liaisons from other military organizations, in-
sion then recommending a new intervention and requir- teragency groups, and allied nations, as well as speakers
ing no less of an evidence base than a proposed new invited to present on specific topics in which they are
standard. The lack of high-quality evidence often ap- SMEs.
plies just as much to the existing standards of care as to
the proposed new intervention. Changes in TCCC are developed based on direct input
from Combat medical personnel, an ongoing review of
the published prehospital medical literature, new re-
The CoTCCC and the TCCC Working Group
search coming from military medical research organiza-
The original TCCC paper came out in Military Medi- tions, lessons learned from US and Allied Service medical
cine in 1996 and proposed the first set of TCCC Guide- departments, and from opportunities to improve prehos-
lines, but the need to provide a mechanism through pital trauma care noted in the JTS Performance Improve-
8
which TCCC could evolve as new medical technology ment process. Proposed changes to the TCCC Guidelines
and evidence became available was recognized from must pass by a supermajority (i.e., two-thirds of the vot-
the outset. The CoTCCC proposed in the 1996 paper ing membership) of the CoTCCC to be approved.
was established at the Naval Operational Medicine
Institute in 2001, with funding from the USSOCOM. Voting members of the CoTCCC monitor the emerging
Through the efforts of the CoTCCC, TCCC has been prehospital trauma care literature and take part in mul-
regularly updated over the ensuing 14 years. The battle- tiple forums in which the care of US Military casualties is
field trauma care management strategies developed by reviewed and opportunities to improve combat casualty

8 Journal of Special Operations Medicine Volume 15, Edition 4/Winter 2015