Page 60 - 2020 JSOM Winter

the Army’s Publishing Directorate and can take a long time to concern. Another limitation which may impact our findings
9
be updated. The Army is currently in the process of moving is the time until evacuation to a higher echelon of care or if
many of the STPs, Training Circulars (TCs), and ICTLs to the evacuation even occurred. The less severely wounded may be
Central Army’s Registry (CAR) for ease of access and updat- treated at the BAS and then returned to duty (RTD). It is possi-
ing. More recently, ICTLs were created for MOs. However, ble that the MOs provided care and interventions to casualties
unlike the ICTLs for medics, which have steps or checklists, with minor wounds that were RTD, whereas the medics’ pa-
the ICTLs for MOs are expectations of the skills they should tients required a higher role of care. In addition, urgent surgi-
possess. This constant flux is a source of frustration for those cal evacuations bypassed the Role 1 BAS and went straight to
who have to perpetually modify their training to meet the a Role 2 or 3 facility with surgical capability. In this study, we
goals of an unknown body. To further complicate the situa- also do not know the indications for which interventions were
tion, this analysis of medic requirements only applies to the US performed. It is possible that patients underwent interventions
Army. The other components also have requirements and to that were not indicated. Conversely, we do not have data of
provide an analysis of each is beyond the scope of this report. when a procedure was indicated but was not performed. It is
also possible that medics collocated with MOs at the BAS and
In 2011, the Defense Health Board made the recommendation performed some of the interventions credited to MOs. Fur-
for TCCC training for deploying personnel. Later, this would thermore, it is also possible that medics at the POI performed
42
become a mandate for all deploying personnel to the US Cen- an intervention, evacuated a casualty to the BAS in which an
tral Command area of operations. At the time of this study, MO was located, and credit for the intervention was given to
43
TCCC training is conducted during the intern year. However, the MO. In other words, we must clearly state that we only
as outlined in Gurney et al., only 46% of the units mandated know who was involved in the registry data chain of care. We
TCCC training. Furthermore, the study noted that providers’ do not delineate the training level of the specific individual
40
confidence in their medics was associated with medics success- and we do not have clear evidence of who performed each
fully completing TCCC training. In 2018, the Department of procedure despite our need for categorization. Although our
40
Defense (DoD) published DoDI 1322.24, which mandated that study design required that we categorize each encounter, the
all service members and DoD expeditionary civilian personnel registry data does not delineate the training level of the indi-
receive standardized TCCC training and maintain proficiency vidual (MO or medic) who performed specific portions of the
in providing first responder care. Though each service re- trauma casualty’s prehospital care.
44
tained the ability to increase the medical readiness training
requirement based off of anticipated mission requirements, it Conclusion
remains unclear to what extent this was implemented.
More than half of casualty encounters in this study listed an MO
This is a convoluted area of military medicine. Even with as a prehospital battlefield care provider. The percentage of in-
TCCC as the standard for Role 1 care, the training is varied terventions performed differed between MO and medic encoun-
across services, by level of training, and within the different ters, which may highlight differences in provider skills, training,
levels of training. For instance, in the US Army, if TCMC and and equipment, or that interventions were dictated by differ-
BCT3 are using materials and guidelines from Role 2 and 3, ences in mechanisms of injury. Future efforts to align guidelines
it is difficult to establish the benefit and usefulness of TCCC and recommendations across the military roles of care may offer
and MOs in the far forward setting. At a minimum, if TCCC is a more standardized solution for the Role 1 setting.
the standard for Role 1 care, then courses should teach to that
standard. Moreover, it is challenging to note whether outcomes Acknowledgments
truly varied beyond that of mortality. Many interventions, such We would like to thank the Joint Trauma System Data Analy-
as wound prophylaxis for open fractures, are unlikely to have sis Branch for their efforts with data acquisition.
a mortality benefit and rather the benefit would likely come by
way of long-term reduced complications. Most importantly, we Funding
must reiterate the inherent bias of the registries. The DoDTR We received no funding for this effort.
only captures casualties that survived long enough to make it
to a facility with surgical capabilities. Thus, the DoDTR would Disclaimer
not capture casualties that died in the prehospital setting, which Opinions or assertions contained herein are the private views
likely represents the casualties that could have benefited from of the authors and are not to be construed as official or as re-
medical personnel with more advanced levels of care. Specific flecting the views of the Department of Defense or its Services.
to the PHTR, data capture for this registry is based on com-
pletion of TCCC cards or TCCC AARs. Previous studies show Disclosures
abysmally low completion rates and are inherently evident by We have no conflicts to disclose.
the totality of only 1,357 casualties captured throughout nearly
16 years of war. 9,45 Given this, we cannot state that there are Ethics
no differences in outcomes since we do not have adequate data The USAISR regulatory office reviewed protocol H-19-018 and
capture, nor do we have sufficient sample size. As such, we determined it was exempt from IRB oversight. We obtained
can only demonstrate that MOs play a major role in combat only deidentified data. We executed data sharing agreement
casualty care and thus their training needs to reflect this reality. 19-2186 prior to data transfer.

Limitations of this study include that it is observational and Author Contributions
retrospective; therefore, we can only demonstrate correlation ADF, SGS, JFN, and MDA performed data collection, data
and not causation. Prehospital documentation is often limited analysis, data interpretation. SGS, ADF, JFN, MDA, DT, and
or missing, therefore the accuracy of the reporting may be of RSK prepared the manuscript with critical input.

58 | JSOM Volume 20, Edition 4 / Winter 2020