Page 60 - JSOM Summer 2018

Old Tricks for New Dogs?

John Caddy and the Victorian Origins of TCCC

P.S. Reynolds, PhD

ABSTRACT
The success of Tactical Combat Casualty Care (TCCC) in organizational characteristics: (1) clear specification of imme-
reducing potentially preventable combat deaths may rely on diate care priorities; (2) a simple, practical, evidence-based,
both specific interventions (such as tourniquets) and the sys- and standardized methodology; and (3) expansion of training
tematized application of immediate care. Essential elements of to include nonmedical personnel. 6
a combat care system include clear specification of immedi-
ate care priorities, standardized methodology, and inclusion Of interest to students of military medicine is that these basic
and training of all nonmedical personnel in early response. concepts for managing combat injuries may have been antic-
Although TCCC is fairly recent, the construct is similar to ipated by almost two centuries. In the 1855 edition of The
that first suggested during the mid-nineteenth century by John Lancet, John Turner Caddy (1822–1902) outlined a concise
Turner Caddy (1822–1902), a British Royal Navy staff sur- and practical approach to first responder casualty care, On
geon. Although naval warfare engagements at the time were Immediate Measures to Be Adopted in Battle for Stanching
relatively infrequent, casualties could be numerous and se- Bleeding From Gun-shot Wounds, and for the Temporary
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vere and often overwhelmed the small medical staff on board. Adjustment of Fractures. Caddy was a Royal Navy surgeon,
Caddy recognized that nonmedical personnel properly trained with an active career spanning more than 30 years, from the
in the fundamentals of combat injury management would re- Victorian Age of Sail to the transition to steam-powered ships.
sult in lives saved and greatly improved morale. The novelty His approach to combat casualty care was brief, prescriptive,
was in his attempt to make procedures simple enough to be explicitly systematic, and, unusually for the time, featured in-
performed by nonmedical personnel under stress. However, corporation of nonmedical first responders as an essential part
Caddy’s guidelines were completely overlooked for nearly two of an integrated medical response. Caddy’s contribution was
centuries. The principles of best practice for managing combat to systematize and streamline descriptions of well-known in-
trauma injuries learned in previous wars have often been lost terventions for the most prevalent combat injuries, in order to
between conflicts. Understanding the historical roots of com- make actions simple enough to be performed by nonmedical
bat first responder care may enable us to better understand personnel under stress. However, Caddy’s paper was ignored
and overcome barriers to recognition and retention of essen- in his own day, and its principles were overlooked for almost
tial knowledge. 160 years. Identifying barriers to implementation may inform
us as to how we can best sustain the advances made by mili-
Keywords: combat casualty care; Crimea; hemorrhage; mili- tary medicine and prevent the erosion of knowledge and skills
tary medicine; tourniquets; wounds and injuries gained in past conflicts. 1,8

Caddy’s stated purpose in proposing his guidelines was to up-
Introduction hold primary directives to naval medical officers to promote
combat readiness through streamlined medical assistance. By
The proportion of active duty service personnel dying of po- the early nineteenth century, at least 10% of Royal Navy per-
tentially preventable combat-related wounds is now the low- sonnel (primarily officers) was expected to be proficient in first
est in the history of warfare. Partial credit can be attributed aid (including tourniquet use). However, with the establish-
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to the systematized training of personnel in TCCC principles ment of British naval supremacy at the end of the Napoleonic
and skillsets. First instituted by Special Operations Forces campaigns in 1815, naval conflicts were relatively infrequent.
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(SOF) in the 1990s, TCCC is now used by all branches of This meant that naval medical officers were unprepared for
the US military, the armed forces of the United Kingdom, and war and relatively inexperienced in treating large numbers of
most NATO and coalition countries. TCCC guidelines have casualties. During engagements, the medical staff was usu-
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also been incorporated into many civilian and law enforce- ally located in a secure area below decks, and the wounded
ment first responder protocols. Critical skills center on early were transported there; this arrangement reduced interference
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and aggressive control of severe life-threatening hemorrhage with ship combat operations and provided a safer area for the
(still the major cause of potentially preventable death among surgeon to treat casualties. 10,11 However, as a result, care was
military casualties), airway management, and shock. Al- delayed, even for injuries that required immediate attention.
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though revival of tourniquet use has saved many lives, the A second problem was that emergent casualties could be so
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undoubted success of TCCC may rely as much on three basic numerous that they overwhelmed the small medical staff on
Correspondence to PReynolds@anest.ufl.edu
Dr Reynolds is affiliated with the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL.
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