Page 59 - 2020 JSOM Winter

training. 22–25 Unfortunately, we are unable to report success Emergency War Surgery book, and the Joint Trauma System
rates given data set limitations. (JTS) clinical practice guidelines (CPGs) throughout their cur-
riculum to ensure that MOs and medics have the most up-to-
There is some reporting of LSIs from the battlefield and Role 1 date medical information to lower the preventable death rate
setting. Lairet et al. identified that out of 2,106 patients evacu- on the battlefield. The JTS CPGs and Emergency War Surgery
ated from Role 1 to a higher role of care, providers at the receiv- book differ from what is currently recommended by CoTCCC.
ing facility identified 360 (17%) missed LSIs, including 56 (3%)
airway interventions, 24 (1%) chest procedures, 57 (3%) hemor- Documentation of medical care in the prehospital setting is
rhage control interventions (of which six were tourniquets), 160 a well-known limiting factor for improving battlefield med-
(8%) vascular access interventions, and 63 (3%) hypothermia icine. 9,33–35 We found that documentation rates were signifi-
prevention opportunities. The two most commonly performed cantly higher among casualties treated by MOs than medics.
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interventions were establishing vascular access and hemorrhage This may be in part due to the extensive emphasis placed on
control. Our findings also demonstrate that hemorrhage control documentation throughout clinical training for physicians and
and intravenous (IV) access/fluids were the most common ther- PAs. Moreover, the MOs are likely at the BAS, which is a more
apies instituted by MOs and medics. Gerhardt et al. performed well-controlled and safer setting. Medics at the POI may be
an analysis on LSIs by MOs and medics at the POI and battalion caring for patients in poorly lit conditions with an emphasis
aid station (BAS). Similar to our findings, MOs were associated placed on rapid evacuation. Therefore, delays in evacuation
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with more advanced interventions, including 89% of the needle for documentation may not be feasible and ex post facto doc-
or tube thoracostomies, 100% of the ETIs, and 75% of the sur- umentation via TCCC AARs may not be well emphasized
gical cricothyroidotomies. Although MO level of training may among unit leadership. Additionally, this may suggest that
explain the greater incidence of complex procedures such as ETI nonmedical personnel should be trained to support the medics
and tube thoracostomy, several of the interventions captured in at the POI by documenting at their direction.
our study are within the scope of practice of medics and we found
that MOs performed more of these LSIs than medics. We suspect While 87% of combat deaths occur in the prehospital setting,
this may be partially explained by the MO typically leading a re- efforts to improve prehospital care are limited. Mabry and De
5
suscitation team comprised of six to eight medics within the con- Lorenzo outlined major challenges to improving prehospital
trolled environment of the BAS, while some medics may have been care. Commanders of maneuver units own the battlespace and
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at or near the POI delivering care alone with only their aid bag. by proxy the medical care that is provided. Despite this, the ser-
vice medical commands maintain control over the training and
Medication administration and adherence to the TCCC guide- doctrine associated with prehospital healthcare. Another chal-
lines have been poor over the course of the conflicts in Af- lenge in improving prehospital combat medicine is the system
ghanistan and Iraq. 9,28–32 In this study, MOs had higher rates that assigns MOs to deploying units. It is important that military
of antibiotic administration. This is consistent with a previous physicians maintain competency through patient care, which
analysis we performed of DoDTR data that demonstrated of many times requires them to work in a hospital as opposed to
297 prehospital antibiotic administrations, 73.4% were by performing staff duties with a unit. Additionally, physicians that
an MO, however only six (2.4%) were recommended within have limited understanding of their medics’ abilities and scope
TCCC guidelines. MOs also administered morphine and hy- of practice may impede adherence to TCCC guidelines. 28–32,37–39
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dromorphone more frequently than medics. Although hydro- In a recent study, 41% of medical providers had not completed
morphone was unlikely to be issued to medics going out on TCCC training. The military would benefit from more phy-
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missions, the same cannot be said of morphine and antibiotics. sicians with an operational medicine focus and subject matter
The lower rates of drug administration among medics may expertise in battlefield medicine. 35,36,41 Our study demonstrates
be attributed to working on their own at the POI, in which that physicians were frequently involved in the chain of care for
interventions addressing more immediate life-threats, such as casualties in forward staged areas, further supporting the need
tourniquets and tranexamic acid, take priority. for them to be appropriately trained (e.g., a military specific
curriculum during graduate and post-graduate training).
Many MOs and senior medics in the US Army have attended
the Tactical Combat Medical Care (TCMC) Course at Fort Within the US Army, combat medics have constantly changed
Sam Houston, Texas, before deployment. The course is offered guidelines and tasks lists. The current version, the Individual
by the Health Readiness Center of Excellence and is one week Critical Task Lists (ICTLs), is not always well aligned with the
in duration. It focuses on Role 1 care, but there is also discus- TCCC guidelines. The variations between ICTLs and TCCC
sion on Role 2 care. The course is based on known trauma may cause confusion for the medic providing care at the POI.
resuscitation methods, lessons learned from past and current The ICTLs must be tested annually, which is likely more often
combat environments, and from newly developed technology. than TCCC. In addition to ICTLs, combat medics use the Sol-
Additionally, TCMC teaches MOs and senior medics the injury dier’s Manual and Trainer’s Guide (STP 8-68W13-SM-TG),
patterns of combat casualties and the constraints in delivering which outlines the required tasks that must be trained on
medical care on the battlefield and in urban environments. quarterly to annually, for skill levels ranging from 10-30.
While the TCMC course is mostly offered to MOs, it does While the STP is not all-inclusive of the training needed to
encourage the MOs to bring their medics for a team approach make a combat medic more effective during battlefield medi-
to patient care. Another source of predeployment training is cine and while conducting DNBI treatment, it does provide a
the Brigade Combat Team Trauma Training (BCT3) Course. foundation. When noncommissioned officers (NCOs) conduct
This course focuses on Role 1 and Role 2 care. The BCT3 the training needed to assess the level of proficiency of their
course is offered to maneuver unit medical sections. Typically, medics, they use the STP and ICTLs. However, the problem
the deploying medical team will attend the course together. that arises is that the STP and ICTLs do not always align with
Both TCMC and BCT3 use current CoTCCC guidelines, the the most current CoTCCC guidelines. The STP is published by

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