Page 102 - JSOM Summer 2020

TABLE 3 Time Spent on Module Slides and Videos Plus Skill FIGURE 1 Needle decompression performed at incorrect anatomical
Sheets* sites.
Total Time – Time for
Modules & Skill Modules Time for Skill
Site Sheets (minutes) (minutes) Sheets (minutes)
Site A 712 422 290
Site B 956 761 195
Site C 832 512 320
Site D 1118** 798** 320**
*Note that the times shown are based on incomplete use of the JTS
recommended curriculum.
**Slides shown were mostly of non-JTS origin.

and seeks to identify the factor(s) responsible for those out-
comes. Adverse outcomes in battlefield trauma care may be
caused by a lack of TCCC training; failure of TCCC con-
cepts to benefit a particular casualty; tactical exigencies that
preclude the rendering of needed care; combat equipment
shortages or deficiencies; or improper execution of TCCC rec-
ommendations. Another possibility that has been encountered
in the past, however, is that the unit may have received TCCC
training, but that that training might have contained incorrect (Photo courtesy Dr Warren Dorlac.)
messaging. If the needles used for needle decompression are
found to have been inserted in the wrong locations (Figure
1), did that occur because the individual was taught to place
them in the wrong place? Or was the medic taught the correct
placement of the needles in NDC, but failed to perform that
procedure correctly when required? To address the management of a group of selected tactical ca-
sualty situations that are representative of those incurred in
the recent combat actions in the Middle East, the casualty sit-
Omitted “Critical Decision Case Studies” Presentation uations in the Scenarios Presentation of the TCCC curriculum
The Critical Decision Case Studies (CDCS) section of the were developed by the CoTCCC and the recommended man-
TCCC-MP curriculum was added in 2017 after an import- agement of each casualty scenario is discussed. This approach
ant observation by COL (Ret) Bob Mabry, a charter mem- is invaluable in learning how to combine good tactics with
ber of the CoTCCC and the former Joint Special Operations good medicine. The “Scenarios” presentation, however, was
Command (JSOC) Surgeon. COL Mabry observed that the omitted in all four courses appraised.
TCCC curriculum at that point in time provided a great deal
of information about the types and pathophysiology of com- Omitted “Direct from the Battlefield” Presentation
bat injuries and how to perform the battlefield trauma care For over 15 years, the JTS, the CoTCCC, and the Armed
interventions needed to treat these conditions. There was less Forces Medical Examiner System have reviewed the injuries,
emphasis, however, on WHEN to perform these interven- treatments, and outcomes of casualties sustained by the US
tions, especially in the context of a severely injured casualty and partner nation militaries. When significant opportunities
in a specific tactical situation. Knowing when these lifesaving for improvement in battlefield trauma care have been noted,
interventions should be performed is an essential component especially when these opportunities are judged to be of high
of optimal combat casualty care. The TCCC CDCS were importance in obtaining a good outcome for the casualty,
accordingly developed to help illustrate which intervention these items have been compiled into a “Direct from the Battle-
to perform at a particular point in time for a casualty in a field” presentation in the TCCC-MP curriculum. The items in
specific wounding scenario. Omission of this section of the this presentation may fairly be considered as the most import-
curriculum when training TCCC-MP, therefore, means that ant lessons learned from previous casualties and the care they
the course graduates may not have demonstrated the ability received – or to put it more plainly, these were mistakes made
to make the correct treatment decisions in scenarios where that should NOT be repeated.
making the incorrect decision would likely result in the death
of the casualty. Examples include:
– Reinforcing the need to recheck extremity tourniquets af-
Omitted “TCCC Scenarios” Presentation ter they have been in place for 2 hours to determine if other
The original 1996 TCCC paper recognized that battlefield means of hemorrhage control are feasible. Forgetting this im-
trauma care may need to be modified or deferred, depending portant step may cause limb ischemia and result in limb loss
on the particulars of the specific tactical situation that the unit that could have been avoided with better execution of TCCC.
that has sustained the casualty is confronted with. To quote: – The importance of avoiding opioid analgesics in casualties
“Having established a general plan with which to approach who are in – or judged to be at significant risk for – hem-
injuries that occur in a tactical environment, let us now return orrhagic shock. The most common cause of preventable
to the casualty scenarios presented earlier and examine what death in combat casualties is hemorrhagic shock and opi-
tactical considerations and modifications to the basic manage- oids may increase that risk. Ketamine is the recommended
ment plan may be required for each particular scenario.” 3 option for analgesia for these casualties. 25

100 | JSOM Volume 20, Edition 2 / Summer 2020