Page 140 - JSOM Fall 2021

Tactical Combat Casualty Care Scenario

Management of a Gunshot Wound to the Chest in a Combat Swimmer

2
1
3
Frank Butler, MD *; Lanny Littlejohn, MD ; Terence Byrne, SOTM ;
4
Enrique Martino, IDMT ; Harold Montgomery, ATP ; Brendon Drew, DO 6
5

ABSTRACT
Tactical Combat Casualty Care (TCCC) has always empha- unit members while still on the battlefield. Though the TCCC
sized the need to consider the tactical setting in developing Guidelines provide an evidence-based trauma care approach
a plan to care for wounded unit members while still on the to specific injuries that may occur in combat, they do not ad-
battlefield. The TCCC Guidelines provide an evidence-based dress how the care of the casualty may have to be modified
trauma care approach to specific injuries that may occur in for the particular tactical setting in which the casualty may
combat. However, they do not address what modifications be sustained. Different tactical settings may require markedly
might need to be made to the basic TCCC guidelines due to different casualty re sponse plans for the same injury or con-
the specific tactical setting in which the scenario occurs. The stellation of injuries.
scenario presented below depicts a combat swimmer operation
in which a unit member is shot while in the water. The unit In small unit operations, in addition to considerations based on
casualty response plan for a combat swimmer who sustains a where the unit is located (e.g., in the desert, in mountainous
gunshot wound to the chest while on a mission is complicated terrain, diving, etc.), care of the casualty or casualties may also
by the inability to perform indicated medical interventions for vary based on other mission-specific factors. What is the impor-
the casualty while he is in the water. It is also complicated by tance of the mission and what is the time-sensitivity? At what
the potential for ballistic damage to his underwater breathing phase of the operation did the casualty occur? Who are the indi-
apparatus and the need to remain submerged after wound- viduals injured and what skill sets do they possess? Can the mis-
ing for at least for a period of time to avoid further hostile sion proceed without them? Will the mission continue to pursue
fire. Additionally, there is a potential for a cerebral arterial gas its tactical objective after the casualty has been sustained, or
embolism (CAGE) and/or a tension pneumothorax to develop will it need to be aborted? Will this be because the mission has
while surfacing because of the decreasing ambient pressure on been compromised, or because the casualties that have been sus-
ascent. The tactical response may be complicated by limited tained preclude the successful completion of the mission?
communications between the mission personnel while sub-
merged and by the vulnerability of the mission personnel to From 1996 through 2001, as TCCC concepts were first being
antiswimmer measures if their presence is compromised. presented to military leaders (both medical leaders and line
combat commanders) and at medical conferences, a paral-
Keywords: TCCC; Tactical Combat Casualty Care; gunshot lel effort explored how a variety of tactical settings and en-
wound; GSW; combat swimmer; cerebral arterial gas embo- vironments might impact the unit’s casualty response. This
2
lism; tension pneumothorax was done through a series of six separate workshops, each of
which lasted a full day. An expert panel approach was used
to facilitate discussion of each of the casualty scenarios being
considered, with each panel member being assigned to present
Introduction
a scenario. The rest of the panel and the audience were invited
The original TCCC paper was published in 1996 after a 3-year to comment after the proposed care plan was reviewed.
joint research effort conducted by US Special Operations
Command medical personnel and the Uniformed Services Uni- One of the environments considered was the combat swimmer
versity of the Health Sciences, Bethesda, Maryland. 1 setting, in which the injured combatant will be either on the
surface of the water when the injury is sustained, submerged
From the outset, TCCC has emphasized the need to consider on a dive, or on land but needing to make a swimming or
the tactical setting in developing a plan to care for wounded submerged transit to extract from the mission. This workshop
*Correspondence to fkb064@yahoo.com
1 CAPT (Ret) Frank Butler is an ophthalmologist and served as a US Navy SEAL platoon leader, the command surgeon at the US Special Opera-
tions Com mand, and chair of the Joint Trauma System’s Commit tee on TCCC for 11 years. CAPT Lanny Littlejohn is an emergency medicine

2
3
physician in the US Navy and the Force Surgeon for the Naval Special Warfare Command. SO1 Terence Byrne served as a platoon medic and
4
breacher for the US Naval Special Warfare Group One. HMCS Enrique Martino is an instructor at the Naval Special Warfare, Special Opera-
5
tions Tactical Medic School House at Stennis Space Center, MS. MSG (ret) Harold Montgomery is a retired Special Operations medic and is cur-
6
rently the program coordinator for the Committee on TCCC of the Joint Trauma System division of the Defense Health Agency. CAPT Brendon
Drew is the Chair of the Joint Trauma System’s Com mittee on TCCC and currently serves as the 1st Marine Expeditionary Force Surgeon.
138
138