Page 25 - JSOM Spring 2024

unit, there can be different curricula and definitions of “medic.” nations using tourniquets in the prehospital system reconsider
“Combat medics” may refer to individuals with a medical how tourniquet reassessment and conversion is protocolized
background and higher levels of training, but “company med- and taught. Any changes to the guidelines must not be overtly
ics” have less training and do not currently convert tourniquets complex and should be applicable to the systems in which they
per protocol. Current in-country programs to qualify “combat function.
medics” last, on average, 2 weeks. Regular Servicemembers
who have no specific medical duties typically receive 1 or two Priorities: Revisit TCCC Core Tenets in Training
2 of training that cover the basics of tactical medicine with a and Appropriately Adapt Guidelines
heavy focus on the use of tourniquets as the main means of In Ukraine, the authors have observed (and participated in) the
controlling external bleeding. Sources report that training was enthusiastic teaching of the benefits of tourniquets and skill-
often condensed ahead of rapid deployment times for some based training to practice application in high-risk environ-
units, and tactical training took precedence among inexperi- ments. Civilians and military personnel have fully embraced
enced service personnel. Some units received as little as 2 hours the life-saving benefit of tourniquets. The next phase of support
of tactical medical training prior to deployment (anonymous must emphasize familiarity with assessment of life-threatening
personal communication, Ukrainian physician, Ukraine, 2023). hemorrhage, reassessment of tourniquets, and appropriate
A small number of advanced medics received SOF-level train- conversion of tourniquets in a tactical environment.
ing and now operate in specialized units. Additionally, NGOs
provide training, largely based on existing guidelines and As conversion did not occur frequently in the field during the
within the scope of national protocols (Figure 2). GWOT, the majority of limb injuries arrived at a facility with
tourniquets in place. As a result, the number of GWOT-era
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FIGURE 2 NGO-led training on TCCC, instruction on tourniquet use. personnel with direct experience in field tourniquet conversion
is likely small. This potentially translates into a training cur-
riculum and personnel gaps. Relying on the presence of field
medics with sufficient training near the POI may result in in-
creased morbidity and mortality in near-peer conflicts, includ-
ing the current war in Ukraine. Ukrainian physicians directly
report that their battlefields are more similar to World War I
with trenches, heavy artillery shelling and land mines, compli-
cated evacuation patterns, insufficient resources, and lack of
access to trained medics within the first hour of injury (anony-
mous personal communication, Ukrainian physician, Ukraine,
2023).

As noted by Walters et al. in 2005, “the most effective method
of limb salvage is early successful conversion of a tourniquet to
a less damaging means of hemorrhage control.” This strategy
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relies on the following competencies and skills: appropriate
tactical training to recognize CUF versus TFC, correctly recog-
nizing life-threatening hemorrhage versus minor trauma and
In comparison, the regimented training protocols in the U.S. appropriately reassessing and converting tourniquets when
DoD are the result of decades of refinement. All service per- appropriate. Results of one study from the early TCCC era
sonnel receive, at minimum, a 1-day ASM-level training prior suggest that among soldiers who completed ASM training, less
to combat deployment. Enlisted medical personnel undergo at than half could correctly recognize and treat life-threatening
least 16 weeks of training, and advanced SOF medic operator hemorrhage. 26
courses require at least 26–54 weeks of training “at least” ne-
gates the need for “minimum” (and suffer attrition over 70%). Based on our collective experiences of practicing and/or teach-
Both conventional and SOF medics are required to attend re- ing these principles, we stress that the medical skills taught in
fresher courses. TCCC take extensive practice to master or even reach a degree
of comfort. “Life-threatening hemorrhage” is not a concept
When considering the low mortality rates by the end of the with which a layperson will typically have any degree of famil-
GWOT, it is important to understand the context of the exten- iarity, and medical personnel who do not routinely take care
sive training and selection processes. It took no less than 10 of traumatic injuries may not have any level of comfort with
years and a large-scale conflict to push through a system-wide hemorrhage. In the studies referenced above, it was highly
focus on process improvement and a centralized curriculum trained U.S. and IDF Servicemembers applying tourniquets at
promoting best practices, incurring heavy debate and doubt high rates and without a medical indication. The simple act of
during the process. 17,33,38 While not feasible to expect partner unwinding the windlass on a tourniquet, hours away from a
nations engaged in conflict to have the resources or infrastruc- facility and away from medical personnel with equipment and
ture to develop a similar system on an accelerated timeline and training, can be an overwhelmingly intimidating act even in a
under duress, efforts should continue to implement and expand tactically secure situation. Similarly, cursory training in hem-
standardized training throughout all levels of medical care. orrhage control techniques such as wound packing may not
Still, systemic differences have been anticipated and noted. translate to competency in the field.

In the reality of the war in Ukraine, and likely future large- The issue that should be immediately addressed is how to best
scale combat operations, we recommend that entities and emphasize the core tenets of evidence-based practices in TCCC

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