Page 103 - JSOM Summer 2020

– The concomitant use of benzodiazepenes and opioid anal- Calculated time to teach all slides, videos, 1028 min
gesics. Midazolam as a single agent carries an FDA Black and skills sheets
Box warning about respiratory depression. The use of mid-
azolam in conjunction with opioids such as oral transmu- Plus
cosal fentanyl citrate (OTFC) increases that risk and has Fund of TCCC knowledge test: 60 min
caused respiratory arrest in combat casualties on at least Fund of TCCC Knowledge Test Review 60 min
two occasions. TCCC Critical Decision Case Studies Test 60 min
– Pressure-patching an open globe eye injury. Pressure patch- TCCC Critical Decision Case Studies Test Review 60 min
ing of the eye is absolutely contraindicated in casualties Course Survey 60 min
who have sustained penetrating trauma to the eye because
of the risk of causing iatrogenic expulsion of intraocular Plus
contents and preventable blindness, yet pressure patching Estimated time for Graded Trauma Lanes 960 min
of suspected open globe injuries was erroneously taught by and Autologous Blood Transfusion Training
the US military in the past and eye dressings designed to
help facilitate this improper care were in the military equip- Total Course Time Needed 2288 min
ment system until 2014. Pressure patching of eyes with (38.1 hr)
known or suspected open globe injuries must be avoided;
these eyes should be covered by a rigid eye shield followed There are at present no JTS-approved, scripted casualty sce-
by emergent surgical repair of the open globe. 26–28 narios that are designed to be presented to TCCC students
– All casualties with torso trauma or polytrauma need to be during trauma lane training to assess their ability to integrate
monitored closely for respiratory distress and/or hypoten- all of the TCCC concepts that they have been taught into effec-
sion that may be caused by an unrecognized tension pneu- tive management of a severely injured casualty or casualties.
mothorax. Always perform needle decompression (NDC) Scenarios developed at the unit or instructor level may vary
when a tension pneumothorax is suspected and always do considerably in the injuries presented, the points of empha-
bilateral NDC for a casualty with torso trauma who loses sis provided by the instructors, and the pass-fail criteria used.
vital signs on the battlefield. Failure to do so has contrib- Similarly, a JTS-approved autologous blood training session
uted to a number of potentially preventable deaths in US needs to be developed. This training could be done in parallel
casualties. 26,29 with the graded trauma lanes noted above.

All of the items contained in the Direct from the Battlefield When the totality of the curriculum as developed by the JTS
module represent errors in combat casualty care made in the is used and an additional 2 days are added for graded trauma
past that must not be repeated in the future. Yet three of the lanes and autologous blood training, the required time for
four TCCC-MP courses appraised omitted this presentation. TCCC-MP training would be approximately 5 days.

Omitted Post-Course Test Metrics The Need for Structured, Ongoing Quality Assurance in
A list of CoTCCC-recommended post-course metrics for TCCC Training
TCCC-MP courses was developed by the CoTCCC in 2018 The observations above serve to reinforce the previously doc-
and includes a 50-question fund of knowledge test using umented concerns about the quality of TCCC training, 5,15 and
CoTCCC-developed questions. The recommendation is for the need for this oversight is being increasingly recognized.
22
TCCC-MP course administrators to use a random test ques- This is especially true since the responsibility for TCCC train-
tion generator to select 50 questions from a bank of JTS- ing is distributed between the Defense Health Agency (which
developed TCCC test questions. This prevents courses from oversees tri-service basic Medical Education and Training),
using a single test, which lends itself to becoming known to the Service Surgeons General (e.g., the Army SG has oversight
the student population with the resultant production of an- of 68W medic training), and line combat units (which have
swer keys, as has happened in the past. Only one of the four oversight of medical sustainment training for medics attached
courses appraised conducted testing in this manner. Likewise, to combat units). Organizational prerogatives are jealously
the CDCS should be presented to the students in random or- protected and attempts of outside organizations to impose ad-
der. None of the four courses appraised conducted this testing. ditions or modifications to that training are not necessarily
welcomed, however helpful they might potentially be.
Reconsidering the Length of Time Required to
Conduct TCCC-MP Training The units that were contacted as potential participants in this
Finally, the TCCC-MP course has, in the past, been considered series of TCCC course appraisals were understandably cau-
a 2-day (16-hour) course. The time required to present this tious at first, considering that this type of DoD-wide Qual-
material was found on these appraisals to be significantly lon- ity Assurance on combat medical training is a novel concept.
ger than that. Also, as previously noted, the current curriculum However, owing to the spirit of cooperation encountered at
contains no time for graded trauma lanes (simulated casualty the instructor level and to the assurances of the appraiser that
management with moulaged patients or manikins) and no time the intent of this effort is to continue to build on previous
for training in autologous whole blood transfusions. 20,21 recommendations for improvement in combat casualty care
provided by the CoTCCC and the JTS, the process proceeded
The calculations below are our estimation of what the cor- smoothly. In general, the instructors appreciated the feedback
rect time for the TCCC-MP course should be when ALL of that they received and it was stated frequently that this process
the JTS-developed curriculum is used; ALL of the knowledge offers the training sites an opportunity to provide real-time
transfer metrics are employed; and additional time is added for feedback to the CoTCCC that may be considered for incorpo-
graded trauma lanes and autologous blood training is added. ration into the curriculum, as TCCC continues to be refined

Quality Assurance in TCCC Training | 101