Page 98 - JSOM Summer 2020

combat medical personnel into the TCCC change development Recent events have demonstrated that this training
process; (4) having a standing body (the CoTCCC) charged is not being satisfactorily accomplished. The two
with monitoring the success of current battlefield trauma care USCENTCOM/Joint Trauma System assessments of
recommendations and recommending updates as needed; and prehospital trauma care in Afghanistan documented
(5) enabling everyone on the battlefield – not just medical inconsistent or absent TCCC training in combat
personnel – to effectively manage external hemorrhage and forces deployed to CENTCOM.
perform basic trauma airway maneuvers. 1,13,14 The CoTCCC,
working in concert with the more inclusive TCCC Working Secondly, the Joint Trauma System Performance Im-
Group, composed of both military and civilian subject matter provement process has noted adverse casualty care
experts in trauma care, updates TCCC recommendations as events associated with failure to perform standard
needed on an ongoing basis. 1 TCCC measures. These events occurred even in units
that had reportedly been trained in TCCC as a result
of misinformation provided during that training.
The first standardized TCCC curriculum developed by the
CoTCCC was done at the direction of the Navy Medical Ed- Finally, recent reports in the media have noted that
ucation and Training Command in 2008, during the time that US Service Members have been exposed to inap-
the CoTCCC was still part of the Navy Operational Medicine propriate and potentially dangerous training events
Institute (NOMI). Since that time, TCCC curricula have been during courses that were intended to provide bat-
updated as needed to reflect new changes to the TCCC Guide- tlefield trauma care training. One physician lost his
lines. The TCCC curriculum has been an approved knowledge medical license in Virginia as a result. These occur-
product of the JTS since the CoTCCC was transferred to the rences document a clear opportunity for the DoD
JTS in 2013. to improve in its methods of conducting TCCC
training.” 15
The Need for Quality Assurance in TCCC Training
Ensuring that TCCC training is carried out in a standard- This JTS White Paper went on to recommend that the service
ized, high-quality and appropriate manner, however, has been Surgeons General recognize that:
a recurring problem. 5,15,16 Instances of incorrect messaging
in non-standard TCCC courses have been documented on “1. A lack of standardization for TCCC training is a
numerous occasions and have been directly associated with problem that needs to be resolved;
adverse outcomes in combat casualties, including a leg am- 2. A standardized educational infrastructure such
putation from prolonged tourniquet use and respiratory ar- as that developed by the NAEMT that supports
rest from using midazolam after fentanyl lozenges. Some the teaching of the Joint Trauma System-devel-
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“TCCC” courses have also been found to contain inappro- oped TCCC curriculum and provides a TCCC
priate training such as the iatrogenic induction of hypotension card recognized by the JTS, the NAEMT, the
in student volunteers to demonstrate the signs and symptoms American College of Surgeons Committee on
of shock as well as administering powerful analgesic medica- Trauma, and the CoTCCC is the optimal way
tions to students to illustrate the cognitive impairment that forward for the services; and
they cause. These activities place TCCC students at risk and 3. the course be coordinated for military units
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are not appropriate for any training evolution. through the Military Training Network.”
The need to improve quality assurance in TCCC training
These types of deficiencies in TCCC training courses were
identified and addressed over a decade ago by both the US courses led two USMC authors to address this topic as well in
Special Operations Command and the US Marine Corps, with 2015. These authors also recommended that TCCC be taught
both organizations mandating improved quality assurance in courses that use the JTS-approved TCCC curricula but are
of TCCC training courses. 18,19 At present, however, there is offered through the NAEMT educational infrastructure with
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no systematic, comprehensive quality assurance program for the quality assurance mechanisms that that system provides.
TCCC training throughout the DoD.
The need for improved quality assurance in TCCC was further
recognized by 17 Members of the US House of Representa-
The JTS again addressed the issue of Quality Assurance in
TCCC training in 2015, in light of continued reports of inap- tives in 2018. In their letter to then-Secretary of Defense James
propriate material in combat trauma training courses that pur- Mattis, these members stated in part that: “[TCCC] training
ported to be teaching TCCC. The following is a quote from is not being satisfactorily accomplished. The two US CENT-
the JTS White Paper on TCCC Training from that year: COM/Joint Trauma System assessments of prehospital trauma
care in Afghanistan documented inconsistent or absent TCCC
training in combat forces deployed to CENTCOM. Second,
“The implementation of the battlefield trauma care the Joint Trauma System Performance improvement process
concepts embodied in Tactical Combat Casualty Care has noted adverse casualty care events associated with failure
has been a major factor in the US Military achieving to perform standard TCCC measures. These events occurred
the highest casualty survival rate in its history during even in units that had reportedly been trained in TCCC as a
the Afghanistan and Iraq conflicts.
result of incorrect messaging contained in that training. Fi-
All of the Services have directed that their members nally, recent reports in the media have noted that US Service
obtain training in TCCC. Further, TCCC training Members have been exposed to inappropriate and potentially
has been specifically recommended by the Defense dangerous training events during courses that were intended
Health Board and the Assistant Secretary of Defense to provide battlefield trauma care training. One physician lost
for Health Affairs. his medical license in Virginia as a result. These occurrences

96 | JSOM Volume 20, Edition 2 / Summer 2020