Page 133 - JSOM Spring 2021

Why trAIn MIssIon coMMAnders In tActIcAl MedIcIne? Officer of SEAL Team Four. It is very much in keeping with
The Tactical Medicine course as taught in Naval Special the philosophy noted in the original paper that the best medi-
Warfare provides a rationale for why mission commanders cine on the battlefield is fire superiority. The fact that control
need training in this area. While it is true that a corpsman of hemorrhage is the top priority is emphasized by pointing
usually takes care of the casualty, the mission commander out that exsanguination from extremity wounds is the number
runs the mission and what is best for the casualty and what one cause of preventable death on the battlefield. Hemorrhage
is best for the mission may be in direct conflict. The question from extremity wounds was the cause of death in more than
is often not just whether or not the mission can be completed 2500 casualties in Vietnam who had no other injuries. 13
successfully without the wounded individual(s); the issue may The need for immediate access to a tourniquet in such
well be that continuing the mission may adversely affect the situations makes it clear that all SOF Operators on combat
outcome for the casualty. If the mission is to be successfully ac- missions should have a suitable tourniquet readily available
complished, the mission commander may have to make some at a standard location on their battle gear and be trained in
2,3
very difficult decisions about the care and movement of casu- its use. Mission commanders are reminded that since this is
alties. Additional reasons to train SEAL mission commanders an equipment item for every man in the unit, it is the mission
in tactical medicine include: 1) the importance of having the commander’s responsibility to ensure that a tourniquet is part
commander know that the care provided in TCCC may be of the routine pre-mission equipment check. As a final point
substantially different than the care provided for the same in- of emphasis, the story of the death of General Albert Sidney
14
jury in a non-combat setting; 2) the unit may be employed in Johnston at Shiloh on 7 April 1862 is presented. General
such a way that there is no corpsman, medic, or PJ immedi- Johnston was one of the senior commanders in General Rob-
ately available to the injured individual; and 3) the corpsman, ert E. Lee’s army. His command surgeon, Dr. David Yandell,
medic, or PJ may be the first team member shot. had directed that tourniquets be issued to the troops prior to
the battle. During the battle, General Johnston sustained a
hoW PeoPle dIe In Ground coMbAt fatal hemorrhage from a popliteal artery injury that presum-
This portion of the course was adopted from a presenta- ably could have been controlled by a tourniquet. The General
tion given by COL Ron Bellamy to the Joint Health Services forgot that he had one available and bled to death with his
Support Vision 2010 working group. It is critically important tourniquet in his pocket.
12
that mission commanders be aware that the individuals with the Since some of the mission commanders may have had
most severe wounds are not necessarily the ones who should be some basic medical training, a few other major points of de-
treated first. An understanding of which deaths are avoidable is parture from civilian care are emphasized. Does the cervical
enhanced by emphasizing COL Bellamy’s important concept of spine not need to be immobilized before moving a trauma
focusing on the causes of preventable death on the battlefield. patient with a head or neck injury? The findings of Arishita
15
These are summarized in Figure 3. Air warfare, combat swim- et al., answer this question convincingly. They reviewed the
mer missions, shipboard warfare, and other types of combat issue of cervical spine immobilization (CSI) in penetrating
would, of course, be expected to have different injury patterns. neck injuries in Vietnam and found that in only 1.4% of pa-
tients with penetrating neck injuries would CSI have been of
possible benefit. Time to accomplish CSI was found to be 5.5
bAsIc coMbAt trAuMA MAnAGeMent PlAn
The three phases of care proposed in the TCCC paper are minutes, even with experienced EMTs. Their conclusion was
2
shown in Figure 4. “Care Under Fire” is defined as the care that potential hazards to both patient and provider in a com-
rendered by the medic or corpsman at the scene of the injury, bat environment outweighed the potential benefit of CSI for
while he and the casualty are still under effective hostile fire. penetrating neck injuries. The distinction between penetrat-
The available medical equipment is limited to that carried by ing trauma and blunt trauma is reviewed, since parachuting
the individual Operator or by the corpsman, PJ, or medic in injuries, fast-roping injuries, falls, and other types of trauma
his medical pack. “Tactical Field Care” is the care rendered resulting in neck pain or unconsciousness should be treated
by the corpsman, PJ, or medic once the unit is no longer un- with CSI unless the danger of hostile fire constitutes a greater
der effective hostile fire. This term also applies to situations in risk in the judgement of the treating corpsman, PJ, or medic.
which an injury has occurred on a mission, but there has been
no hostile fire. The available medical equipment is still limited tActIcAl FIeld cAre
to that carried into the field by mission personnel. Time prior The outline of Tactical Field Care as shown in Figure 6
to evacuation to an MTF is very variable. “Combat Casualty is presented. The Mission Commanders course omits much of
Evacuation Care” or “CASEVAC” care is the care rendered the medical literature discussion contained in the longer (6-
once the casualty (and usually the rest of the mission person- hour) BUMED-approved course taught to SEAL corpsmen.
nel) have been picked up by an aircraft, vehicle, or boat. Per- The second major change from the protocol presented
sonnel and medical equipment that may have been previously in reference two deals with the fluid resuscitation of patients
staged in these assets will now be available. with penetrating trauma of the chest or abdomen who are los-
ing consciousness. Several such casualties were discussed at
the workshop on urban warfare casualties workshop. There
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cAre under FIre
Once these terms have been reviewed, the protocol out- was a clear consensus in the expert panel that should a casu-
lined for the Care Under Fire phase as shown in Figure 5 is alty with uncontrolled hemorrhage have mental status changes
presented and discussed. The care in this phase is the same or become unconscious (blood pressure of 50 systolic or be-
as outlined in reference two except for the important added low), he should be given either an empiric bolus of 1000cc of
recommendation that the casualty continue to return fire if Hespan or enough fluid to resuscitate him to an end point of
able to do so effectively. This change from the original pro- improved mentation (systolic blood pressure of 70 or above.)
tocol was proposed by then-CDR Pat Toohey, Commanding A Tactical Field Care battlefield triage plan has been pro-
posed for mission commanders and is shown in Figure 7.

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