Page 154 - JSOM Spring 2018

community in general to eventually focusing on prehospital Please provide your assessment as to the differences
bleeding control. We rewrote the book. We do things differ- between the civilian and military tactical environments.
ently than we did then. So we may less often visit Arlington What obstacles, if any, do you see to adapting the mili-
National Cemetery. tary’s lessons learned to casualty care in the civilian high-
threat environment?
What do you think is the most notable achievement of Base rate. The rate of problems like limb-wound exsanguina-
TCCC during ongoing combat operations? tion differs. The rate in war is high. Peace is low. Therefore,
I am glad that the committee and community were unsat- the burden of injury differs. The need for intervention differs,
isfied with how things were, so they kept trying to improve as does the yield on resourcing, like training and supplying.
things. Not being satisfied with just getting work done but Tourniquets were a no-brainer, in hindsight, for land warfare,
actually trying to improve people’s skills, broaden experi- as the need was big, and the fix was worthwhile. But the jury
ence, reform policies, update training, fix snags with kit and is still out for civilians. Do not neglect the base rate. At the
logistics, rewrite doctrine, and not wait for someone else to same time, the psychology of aiding someone in peril is a
do it. The most notable achievement is perseverance with strong story in both military and civilian communities. Regret
vision, as shown by Frank Butler and Bill Donovan.
of not intervening yet losing someone we did not need to
lose—that is an even stronger story. Morale and mindset are
What do you consider the greatest obstacles to achieving a plainly valued, but we should talk more of them. We saw that
zero preventable death rate on the battlefield? How would the military was not one group, but 39,000 local governments
you address this? in the United States is a bigger barrier to enactment.
Human nature tends to obey the law of least effort. Best care
is hard because it requires multiple essentials and lacking Do you have any recommendations on how to more ef-
any one is suboptimal. Getting to the best practical outcome fectively evaluate civilian tactical incidents to improve ca-
for each patient is what best care aims for, and truly under- sualty care guidelines?
standing how to do that requires more vigilance than one Data. First thing is to get some data. You really cannot judge
would first assume. We have figured out a lot of how to con- things well until you have worked through enough decent
trol bleeding, yet it is still the big killer today. Furthermore, data. You never know, until you know, and then you know.
we widened our scope to ponder prolonged field care. Truly It sounds circular, but it is not. To me, it is straight, because
understanding is the greatest obstacle. Knowing ourselves, what we intuitively think and what we deliberately think can
our community, our patients, our systems, our gear. A little both trip us up. We are to work through both to know some-
understanding does not cut it. We are to do better. We are thing by that fast, intuitive side of the brain and also by that
to own our own competence. We are to seek both new op- slow, deliberate side of the brain before we understand the
portunities and what our assumptions miss. whole thing. Sometimes the breakthrough comes with a
change in how we measure, and new metrics of tourniquet
What do you view as areas where TCCC can be further
improved? performance helped the military a lot. Civilians really have
Everything is a candidate to me. The tourniquet is easy to been cornered and may have not seen this challenge com-
compare with. So we have a tourniquet guy. Who is the airway ing. I think if we truly do our jobs well, we can make the jobs
guy? The intraosseous gal? The chest-tube czar? What is the of others harder. We changed tourniquets, the training, the
learning curve for nasopharyngeal airway intubation? Has any- logistics, and so the rank and file had to adapt to the disrup-
one deconstructed the task of needle decompression? XSTAT tions in thinking, in practicing, and in resourcing. The military
usability studies*? What are the metrics of performance for did its tourniquet job well, which made the civilian job harder.
triage judgment? How good are we at the skill of bleeding We are to come to terms with such cold, hard facts.
assessment? Any first aid task or TCCC-related item has open
questions with a need for a better understanding through rele- Do you have any other comments you would like to share
vant scholarly work. Taking a problem-solving approach is like with our readers?
engineering: a practical application. It does not need to win Thanks for the privilege of participation. For me this ser-
a Nobel Prize. If anyone needs a guide to such work, Google vice has been the role of a lifetime. We are lucky that in our
a decent tourniquet study and ponder a parallel path. Tour- lifetimes, we improved in aiding others to hold onto their
niquet science, to me, is both aspirational and inspirational. lifetimes.
I aspire to do it better, and I hope it inspires others to do the
like in the lane of their choice. Someone with imagination and Dr Kragh has worked since 1981 for the US government,
grit can own a lane like no one else has ever owned it before. and most of the work was relevant to the operational health
community. His notable caregiving experience included tour-
What do you consider the greatest challenges to the niquet use for many casualties in the Baghdad emergency
work of the CoTCCC? room when the war was busy. His research and teaching have
Relevance development. Relevance does not manage itself. also been most notable for bleeding control.
The committee may want to ponder how it stays relevant as
things evolve. Evolution can be quick, so beware. I think the Keywords: interviews; performance improvement; Tactical
sergeants are key, the people on the ground now, the people Combat Casualty Care
actually doing it today. Keep them close and heed them to
keep everyone relevant. To me, they represent the end-user The opinions or assertions contained herein are the private views of
best. I cannot talk with lay [nonmedical] Soldiers much, and the author and are not to be construed as official or as reflecting the
so I seek their voice through the sergeants. We all work to views of the Department of the Army or the Department of Defense.
self-develop because the need is plain: We need to improve.
*XSTAT is a hemostatic device (RevMedx, http w.revmedx.com/).

148 | JSOM Volume 18, Edition 1/Spring 2018