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based on feedback from both users and the published medical report. DG and FB participated in the drafting and revisions
literature, as it has been for over 20 years. 1,13 of this report.

Conclusions References
1. Butler FK. Two decades of saving lives on the battlefield: Tacti-
1. TCCC-MP courses as currently conducted in the DoD are cal Combat Casualty Care turns 20. Mil Med. 2017;182:e1563–
not presenting all of the course material recommended by e1568.
the JTS, despite such training being mandated by the DoD 2. Butler FK. Tactical Combat Casualty Care – beginnings. Wilder-
ness Environ Med. 2017;28:S12–S17.
for all US military medical personnel. 3. Butler FK, Hagmann J, Butler EG. Tactical Combat Casualty
2. Some of the material omitted (e.g., TCCC CDCS, TCCC Care in special operations. Mil Med. 1996;161:3–16.
Scenarios, Direct from the Battlefield) is of critical impor- 4. Butler FK. Introduction to TCCC. In: Butler FK, Giebner SD,
tance to ensuring proficiency in TCCC concepts. Pons P (editors). Prehospital Trauma Life Support Manual, ed 9
3. There was incorrect messaging presented in the TCCC-MP (Military). Burlington, MA: Jones and Bartlett Learning; 2019.
courses that were appraised, some of which, if actually per- 5. US House of Representatives letter (17 Members) on TCCC train-
formed on the battlefield, would likely result in adverse ca- ing dtd 4 Dec 2018.
sualty outcomes. 6. Butler FK, Smith DJ, Carmona RC. Implementing and preserv-
ing advances in combat casualty care from Iraq and Afghanistan
4. Some of the messaging contained in the appraised TCCC- throughout the US military. J Trauma. 2015;79:321–326.
MP courses that is not in the current TCCC Guidelines 7. Eastridge BJ, Mabry R, Seguin P, et al. Death on the Battlefield
may be good potential additions to TCCC, such as mod- (2001–2011): implications for the future of combat casualty care.
ifying the method of TXA administration (slow IV push J Trauma Acute Care Surg. 2012;73:S431–S437.
vs a 10-minute infusion) and should be considered by the 8. Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating pre-
ventable death on the battlefield. Arch Surg. 2011;146:1350–1358.
CoTCCC for incorporation into the TCCC Guidelines. 9. Kragh JF, Walters TJ, Baer DJ, et al. Survival with emergency
(This proposed change to the TCCC-MP curriculum is in tourniquet use to stop bleeding in major limb trauma. Ann Surg.
fact being considered by the CoTCCC at the time of this 2009;249:1–7.
writing.) Another example is the need for medics to tape 10. Butler FK, Holcomb JB, Giebner SG, et al. Tactical Combat Casu-
CAT Gen7 tourniquets in place after placement to prevent alty Care 2007: evolving concepts and battlefield experience. Mil
the encircling band from loosening. Med. 2007;172(suppl 11):1–19.
5. There were a number of excellent videos of actual TCCC 11. Tarpey MJ. Tactical Combat Casualty Care in Operation Iraqi
Freedom. US Army Med Dep J. 2005;38–41.
interventions being performed that are not currently part 12. Department of Defense Instruction 1322.24: Medical Readiness
of the JTS-developed TCCC-MP curriculum. These vid- Training. 16 March 2018.
eos should be forwarded to CoTCCC staff and the JTET 13. Butler FK. Leadership lessons learned in Tactical Combat Casu-
for consideration as potential additions to the TCCC-MP alty Care. J Trauma Acute Care Surg. 2017;82:S16–S25.
curriculum. 14. Butler FK, Blackbourne LH. Battlefield trauma care then and
6. Additional training modalities such as advanced simula- now: a decade of tactical combat casualty care. J Trauma Acute
Care Surg. 2012;73:S395–S402.
tors, moulaged casualties, graded trauma lanes, and autol- 15. Gross KR. Establishing a DoD standard for TCCC training. Joint
ogous blood transfusion training should be considered for Trauma System White Paper; 11 Sept 2015.
incorporation into the TCCC-MP curriculum. 16. Goforth C, Antico D. TCCC standardization: the time is now. J
7. Post-course written testing using the standardized TCCC Spec Oper Med. 2016;16:53–56.
fund of knowledge and TCCC Critical Decision Case Stud- 17. Shiffman J. Special Report – Military knew about bizarre meth-
ies questions developed by the JTS should be administered ods of doctor hired to train troops. Reuters News Service article;
17 June 2015.
at the completion of all TCCC-MP courses. 18. Amos J. Policy Guidance for Combat Trauma Training (CTT)
8. The 16-hour training time currently prescribed for that Includes Live Tissue Training (LTT). Marine Corps Combat
TCCC-MP training is too short, even for the academic ma- Development Command letter; 26 June 2007.
terial presently contained in the curriculum. The findings 19. Brown BD. Combat trauma training in Special Operations forces.
from this study and the need to add graded trauma lanes US Special Operations Command letter; 9 December 2005.
and autologous blood training to the course suggest a rec- 20. Fisher A, Carius B, Corley J, et al. Conducting fresh whole
ommended time of 5 days for the TCCC-MP course. blood transfusion training. J Trauma Acute Care Surg. 2019;87:
S184–S190.
9. There is a need for systematic and standardized quality as- 21. Donham B, Barbee G, Deaton T, et al. Risk associated with au-
surance program to ensure that TCCC training programs tologous fresh whole blood training. J Spec Oper Med. 2019;19:
are carried out in accordance with the JTS-recommended 24–25.
TCCC curriculum. This appraisal program would best be 22. Butler FK. TCCC Updates; Tactical Combat Casualty Care for
performed as a new component of the CoTCCC mission Medical Personnel (TCCC-MP) guidelines and recommended
with dedicated TCCC course appraisers. post-course metrics 2018. J Spec Oper Med. 2018;19:136–146.
23. CRASH-2 Collaborators. Effects of tranexamic acid on death,
vascular occlusive events, and blood transfusion in trauma pa-
Limitations tients with significant hemorrhage (CRASH-2): a randomized,
placebo-controlled trial. Lancet 2010;376(9734):23–32.
The major limitation of this study is its small size. A larger 24. Morrison JM, Dubose JJ, Rasmussen TE, et al. Tranexamic acid
study needs to be performed, followed by a more informed decreases mortality following wartime injury: the Military Appli-
discussion of how to establish and maintain ongoing, struc- cation of Tranexamic Acid in Trauma Emergency Resuscitation
tured oversight of TCCC-MP courses going forward. Study (MATTERS). Arch Surg 2012;147:113–119.
25. Butler FK, Kotwal RS, Buckenmaier CC III, et al. A triple-option
analgesia plan for Tactical Combat Casualty Care. J Spec Oper
Author Contributions Med. 2014;14:13–25.
DG performed all course appraisals. LH provided the data 26. Butler FK, Giebner SG, Montgomery HR. Tactical field care.
analysis and participated in the drafting and revisions of this In: Butler FK, Giebner SD; Pons P (editors). Prehospital Trauma

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