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civilian committees for prehospital care have embraced overcome this disparity, the federal government enacted
the TCCC concept for a wide range of civilian agencies, the Emergency Medical Services System Act of 1973,
26
such as firefighters, emergency medical services (EMS), resulting in both cardiopulmonary resuscitation (CPR)
and tactical law enforcement activities. 13–17 Examples standards and training, and core standards for prehos-
of violence, such as those in Newtown, Connecticut; pital medical care. Once BLS was subsumed under the
Boston, Massachusetts; and Aurora, Colorado, in ad- newly formed American Heart Association (AHA), stan-
dition to other recent events, such as in Paris, France, dards were nationalized. In other words, a BLS provider
led to trauma similar to military conflict. In addition to under one EMS had the exact same education and skill
civilian first-responder activities, governmental agencies sets as a BLS provider elsewhere in the United States.
other than the Department of Defense (DoD) have also This consistency has significant advantages both locally
adopted TCCC for federal security operations. 18 (fire, EMS, and police responders) and nationally, when
EMS personnel deploy to other areas of the country dur-
TCCC is now widely accepted by the US Armed Forces, ing disaster response. The same issues that were found
federal agencies such as Department of Homeland Secu- with BLS at the national level (i.e., AHA and Ameri-
rity, and civilian prehospital care organizations. Active can Red Cross both have different standards for CPR)
shooter events, such as the Navy Yard in Washington, currently apply to TCCC: lack of coordination between
DC, and the Columbine High School in Colorado, agencies, and differing recertification requirements, re-
have driven civilian first responders and tactical law sources, and funding.
enforcement departments toward the TCCC construct.
For instance, the Hartford Consensus, 14,19 published in Specifically, the benefits of TCCC standardization will
2013, is a list of recommendations directly related to be:
TCCC. Namely, that hemorrhage control should be a • Improved communication of best-practice prehospital
core function of law enforcement and the response to trauma care guidelines to Combat medical providers,
active shooter incidents requires a unified medical re- who, in turn, will be better prepared to render opti-
sponse involving all first responders and tactical person- mal care to our country’s Combat wounded
nel involved to minimize the loss of life. 16,20 Collectively, • More precise feedback to key stakeholders; namely, the
the work of the American College of Emergency Physi- US Armed Services (e.g., the JTS, geographical Com-
cians, the American College of Surgeons Committee on batant Commanders, and the Defense Health Agency)
Trauma, the Federal Bureau of Investigation, and for- • Improved identification of education gaps for TCCC
19
eign armed forces makes it clear that the TCCC con- providers
21
cept is quickly becoming the new accepted standard for • More easily identified casualty outcome trends across
all prehospital environments. Services and other agencies
• Promotion and support of JTS and facilitation of the
These different organizations, however, are currently conduct of prehospital research and the JTS perfor-
free to interpret and/or incorporate TCCC guidelines as mance improvement process
they see fit for their particular organization or needs.
The guidelines published by the CoTCCC are not uni- In conclusion, the continuing improvement efforts to
formly applied across a disparate landscape of military, develop TCCC guidelines under the leadership of the
federal, and prehospital organizations. Thus, the in- CoTCCC have transformed battlefield trauma care
terpretation of TCCC guiding principles varies widely in the US Military and greatly improved casualty sur-
from agency to agency. Naturally, this leads to an incon- vival. 9,10,27 Additionally, the realignment of CoTCCC
sistency from one agency’s TCCC provider to the next. under JTS has been of great benefit to the functioning
In turn, this lack of consistency is a threat to Service and of the CoTCCC and to the transition of both its prod-
agency interoperability at the trauma/prehospital level, ucts and life-saving tactics, techniques, and procedures
which is a DoD priority. 22–24 to our nation’s warfighters. 27,28 Much has been accom-
plished. As stated by Butler and Blackbourne, the US
10
One way to prevent this current low rate of interoper- Military and coalition partners now have the best pre-
ability between agencies is to move TCCC training to- hospital care and evacuation capabilities for managing
ward national certification. We see similarities between combat trauma.
the current state of TCCC standards and the evolution of
basic lifesaver (BLS), advanced cardiac life support, and We believe for the next generations of TCCC provid-
pediatric advanced life support national certifications ers, the gaps that need to be closed are (1) between the
from the 1960s. Like TCCC, BLS in the 1960s era was published TCCC guidelines and their implementation
25
a qualification. Without overarching national guidance, and execution, and (2) how the military certifies and
BLS standards varied widely from region to region, recertifies its members and instructors to establish a
with serious consequences to healthcare outcomes. To national/DoD certification process. We have identified

54 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2016