Page 156 - JSOM Spring 2020

two recorded cases to date with one of them being a fail- support special operations forces led to the development
ure. He felt the failure was due to poor training on how to of a new paradigm for combat casualty care on the battle-
administer the product. field.” (28) The core principles of Tactical Combat Casu-
alty Care (TCCC) were based on the premise of eliminating
4. TCCC Update(s): preventable deaths and combining good medicine with
Dr Butler Presented COL (Ret) Jim Geracci with the 2019 good tactics. . . . These early iterations of TCCC guidelines
TCCC CAPT Frank K. Butler Award. Dr Geracci served recommended immediate application of limb tourniquets
as a unit surgeon at all levels of the conventional Army as the first-line treatment of extremity hemorrhage. Over
from battalion to corps and has been instrumental in im- the ensuing decade, the US military gradually adopted
plementing a number of TCCC initiatives over the last de- widespread implementation of extremity tourniquets for all
cade. From fielding junctional tourniquets to the updated deployed forces, ultimately resulting in an 85% decrease
DD1380 to corps-level TCCC training initiatives, his name in deaths attributed to limb hemorrhage. (20) This battle-
has been synonymous with making TCCC happen in the field lesson was subsequently translated to the civilian pop-
Army. He integrated TCCC training as a requirement for ulation, fostered by the strong advocacy of the Hartford
physician credentialing and privileging at MTFs support- Consensus (29, 30) and by the evolution of community
ing III Corps. As a CJTF Command Surgeon, he ensured bleeding control courses, “Stop the Bleed.” (31,32)
that our joint and coalition forces were well-supported
medically and that the US military sustained the advances Another recent paper by Howard et al published in JAMA
in battlefield trauma care that TCCC has helped to pioneer. Surgery examined the impact of various interventions and
He has been involved with the DHA-sponsored deployed their relative contributions to the marked reduction in case
medicine project to enhance TCCC curricula and utilize fatality rate in the 56,763 US military casualties injured
modernized web-mobile applications to improve training in battle in Afghanistan and Iraq from October 1, 2001,
and has advocated for TCCC recommendations through all through December 31, 2017. In achieving a 44% total re-
levels of the US Army. duction in mortality, 474 deaths were found to have been
prevented by tourniquet use; 873 by blood transfusion, and
Dr, Butler discussed the US Air Force Surgeon General’s let- 275 by shorter prehospital transport times.
ter of 13 August 2019 that mandated TCCC for Medical
Personnel training for all active duty 4N0X1 and 4 N1X1 5. Ketamine Use in Prehospital
personnel within 18 months and directed that – until the Dr Margaret M. Moore, LSU Health New Orleans, in-
DHA-approved TCCC curriculum is finalized – this train- troduced “Ketamine use in the Prehospital and Hospital
ing should be obtained through the National Association Treatment of the Acute Trauma Patient: A Joint Position
of Emergency Medical Technicians (NAEMT) educational Statement” with the caveat that this version is a DRAFT
infrastructure. She also encouraged TCCC training for and has not yet been officially approved or endorsed by
physicians, physician assistants, nurse practitioners, nurses, any organization.
dentists, and optometrists.” • Dr Moore began with the ketamine position statement:
• Uniform guidance on the use of ketamine in the care of
The TCCC for All Service Members Course was released
on 1 August 2019. It is designed for military personnel who the trauma patient.
are not expected to be combatants but may be called upon o Includes prehospital and in-hospital
to treat trauma victims as lay individuals, as in the civilian • Based on peer-reviewed published evidence and expert
“Stop the Bleed” program. TCCC-ASM is a 6-hour course opinion.
and will be taught as part of basic training by all of the Target audience:
armed services. o EMS personnel, EMS medical directors, emergency
physicians, trauma surgeons, nurses and pharmacists.
Mr Dominque Greydanus recently conducted a pilot se-
ries of four Tactical Combat Casualty Care for Medical **NOT a comprehensive discussion of pain control op-
Personnel (TCCC-MP) course appraisals and found that tions in the trauma patient.
TCCC-MP courses are not presently presenting all of the Dr Moor discussed two cases where ketamine was used
course material recommended by the JTS, despite TCCC successfully. Case 1 was a 19-year-old male patient who
training being mandated for all US military personnel. was climbing a wrought iron fence, slipped and fell while
Some of the material omitted is very significant. Further, trying to get back to his airbnb. The patient was brought
there was incorrect messaging presented in the TCCC-MP into the ED/trauma bay with a patent airway but was agi-
courses that were appraised, some of which, if actually per- tated and intoxicated. He had two 4cm lacerations on his
formed on the battlefield, could reasonably be expected to right chest with diminished breath sounds and low BP and
result in adverse casualty outcomes. Further, post-course O saturation. He had no sensation or motor below the
written testing was found to be inadequate in all courses. 2
nipples. He had received 50mg of ketamine by EMS.
In Texas, it’s now a state law in Texas that – if you have a
school – then you have to have “Stop the Bleed” kits. The Case 2 was an 18-month-old boy with a GSW to the head.
tourniquets contained must be “approved for battlefield He had a GCS score of 9 and was moving all four extrem-
trauma care by the Armed Forces of the United States.” ities with stable vital signs. He had received 25mg of ket-
amine by EMS prior to arrival.
A recent paper by Eastridge, Holcomb, and Shackelford Some of the key take-aways they have observed in the ad-
published in Transfusion noted that “A turning point in ministration of ketamine:
military prehospital trauma care came in 1996 when a re- • Few absolute “contraindications.”
view of battlefield deaths and the medical requirements to
o Children <3 months of age

150 | JSOM Volume 20, Edition 1 / Spring 2020