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11. Three Things I Would Change About TCCC: CDR Lanny Training architecture by PEO STRI that will help to list and
Littlejohn is the Senior Medical Officer at the Naval Special classify training simulation methodologies in the DoD in or-
Warfare Development Group. The “Three Things I Would der to help optimize how we train for trauma care.
Change About TCCC” presentations are an ongoing feature – COL Jim Geracci gave the group an overview of the very
at CoTCCC meetings and are designed to offer trauma care successful TCCC training program that was used during
experts an opportunity to identify areas in which TCCC could his time as III Corps Surgeon and was organized around the
be improved. CDR Littlejohn is an emergency medicine phy- Army’s Medical Simulation Training Center at Ft. Hood.
sician with extensive operational experience, both in Special He noted that III Corps is not Special Operations and that
Operations and in support of USMC units. there is a disconnect between CoTCCC recommendations
His recommendations for things to consider changing and how trauma care is being trained and executed in the
about TCCC are as follows: conventional forces. COL Geracci’s approach at III Corps
was TCCC for everybody: physicians, PAs, and Medics.
1. Fluid Resuscitation for Hemorrhagic Shock—CDR Little- – Dr Peter Rhee shared some thoughts about new directions in
john highlighted the importance of continuing to pursue the treatment of tension pneumothorax. He stated that nee-
the fielding of dried plasma across the force. Whole blood dle decompression fails about 50% of the time using current
may be better but will be logistically impractical for many techniques. He has been working on a prototype needle de-
units and in many areas of operations. We also need to im- compression system that uses a modified Veres needle with a
prove our training methodology for whole blood admin- 3mm lumen, a pop-up indicator that tells the provider when
istration and add a standardized whole blood transfusion the needle enters the pleural space, and a one-way valve.
protocol as a TCCC knowledge product. Work is ongoing to finalize this system and have it cleared
2. Improvisation—There should be an increased focus on im- by the FDA for the treatment of tension pneumothorax.
provisation in combat casualty care, for example in areas
such as extremity tourniquets and junctional tourniquets. Thursday, 7 September 2017
3. Tension Pneumothorax—We need to relook at how we 14. Senior Leader Remarks: MG Brian Lein, the commanding
identify and treat tension pneumothorax in TCCC. There general of the US Army Medical Command, shared his per-
are too many needle decompressions being performed on spective that military medicine needs to increase its focus on
our casualties. There is an ongoing change proposal for combat casualty care. He thanked the attendees at the meet-
TCCC on that topic at the moment and CDR Littlejohn ing for being one of the most effective groups in the DoD in
was immediately recruited to help the team that is author- advocating for advances in battlefield trauma care. But he also
ing that change.
noted that it is the senior leadership in military medicine that
needs to engage to bring about significant and lasting advances
12. Joint Trauma System Preventable Death Review: Dr Jud in combat casualty care throughout the US military. The health
Janak provided an update on the ongoing JTS effort to more care benefit is important, but caring for our wounded warriors
precisely define when a combat death should be classified as needs to be the top priority. MG Lein also noted that we are
“preventable.” Although the 2016 National Academies of Sci- not training and using our combat medics in ways that best
ence, Engineering, and Medicine report on trauma care was prepare them to treat the wounded on the battlefield. Likewise,
entitled “Zero Preventable Deaths” and adopted that as its trauma training for surgeons is not optimized at the present by
goal in trauma care, neither the civilian sector nor the DoD providing them a robust trauma experience at Level 1 trauma
has a standardized, prospective system for classifying a par- centers. He also provided a cautionary note by saying that the
ticular injury or combination of injuries as either survivable current system is not prepared for a large scale conflict and that
or nonsurvivable. The initial step of this JTS effort has been the DoD would run out of Role 4 CONUS trauma beds very
to perform a review of the medical literature to identify and quickly if there is a large-scale ground war in Korea.
compare both civilian and military preventable death method-
ologies and reported preventable death rates in order to under- 15. TCCC: It All Adds Up: Dr Jeff Howard from the JTS
stand how preventable deaths are being reviewed and reported discussed prehospital factors that affect survival. On 15 June
at present. 2009, then-Secretary of Defense Robert M. Gates mandated
Dr Janak’s preliminary observations include:
that combat casualties must be transported to a treatment fa-
1. There is considerable heterogeneity in the methodology cility with a surgical capability within 60 minutes. A recent ar-
used. ticle by Kotwal et al. in JAMA Surgery found that the KIA rate
2. A decision will need to be made about whether to use an among US casualties with an ISS > 25 before this mandate was
Expert Panel Review or a Trauma Scoring System Thresh- 16.0%. After 2009, the KIA rate dropped to 9.9%. The case-
old—or a combination of the two. fatality rate was 13.7% before 2009 and 7.6% after that time.
3. Preventable combat deaths must also take prehospital con- While rapid evacuation to the care of a surgeon is unques-
siderations into account, which is a challenge considering tionably important in determining casualty outcomes, other
the current poor level of documentation in prehospital factors may also influence survival. Dr Howard and colleagues
care. conducted a secondary analysis of 4,542 battlefield trauma pa-
4. There is added complexity in battlefield trauma from non- tients injured in Afghanistan from 1 September 2001 through
medical considerations. 31 March 2014 using data in the DoD Trauma Registry.
5. There should be an identification of what aspects of care These figures show: 1) “The Cost of Time”—the in-
could be improved and opportunities for improvement. crease in fatalities among combat casualties over time; and
2) a graphic presentation of what the number of KIAs would
13. New Business have been expected to be with the injury patterns, transport
– Dr Howard Champion provided an introduction to the times and elements of care prior to 2009. The incremental sav-
planned development of a DHA Integrated Medical Synthetic ings in lives are displayed for each of the following factors:

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