Page 39 - JSOM Summer 2025

Combat Casualty Care in Arctic or Extreme Cold Environments

Considerations for the Army Health System

David J. Reynhout, PA-C *; Stephen E. Meyer, PA-C ;
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Titus J. Rund, DO ; Michael T. Colesar, MD 4
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ABSTRACT
The Department of the Army’s 2021 strategy to “Regain Arctic environment. Our objective is to illustrate the effect the Arctic
Dominance” highlights the operational necessity of sustain- region has on these systems and provide recommendations to
ing combat readiness in Arctic or extreme cold environments improve them. Adapting to the extreme cold through equip-
(AoECE). Presented are five scenarios inspired by casualties ment adjustments and modifying existing techniques will
that illustrate capability gaps and best practices as the Army enable TCCC practitioners to preserve the standard of care
Health System applies tactical combat casualty care (TCCC) expected from previous conflicts.
in austere, frigid climates: (1) adapting TCCC to the AoECE
as a unique environment; (2) technological limitations in the Methods
prevention and treatment of hypothermia; (3) freezing cold in-
jury (FCI) and non-freezing cold injury (NFCI) treatment and Five scenarios were created to describe the medical treatment
the institutional need for a cold injury center; (4) a proposal challenges that military providers encounter in the AoECE.
for a FCI rule-out pathway to preserve the fighting force; (5) These scenarios are based on real-world injury patterns en-
carbon monoxide poisoning and logistical constraints. These countered by the authors while providing medical support in
scenarios emphasize the need for research, procurement, and the Arctic region.
doctrine tailored specifically to the AoECE, as environmental
exposure and equipment capability will be a decisive factor in
casualty survivability and force regeneration. Adapting TCCC to the Arctic as a Unique Environment
Scenario 1
Keywords: cold environments; tactical combat casualty care; A 24-year-old mechanic is crushed by a wheeled vehicle
non-freezing cold injury; freezing cold injury; cold weather; during a routine training exercise in remote Alaska. A
Arctic; Army Health System; frostbite; hypothermia North Atlantic Treaty Organization (NATO) 9-line medi-
cal evacuation (MEDEVAC) is immediately requested,
and a medic begins to perform a primary assessment in
Introduction accordance with TCCC guidelines. The medic exposes
the casualty to assess for injury and identifies a flail chest
In 2021, the Department of the Army outlined a new plan to and signs of hemorrhagic shock. Subsequently, the ex-
“Regain Arctic Dominance.” This strategy underlines the im- posed casualty shows signs of moderate hypothermia. A
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portance of maintaining capabilities in Arctic or extreme cold hypothermia prevention and management kit (HPMK) is
environments (AoECE). Reprioritizing for this environment applied to the casualty, but the chemical heater will not
and preparing to conduct multi-domain operations (MDO) activate in the frigid environment. The medic is unable
against a near-peer threat requires an assessment of current to provide the TCCC-recommended medications imme-
medical capabilities and identification of capability gaps. As diately because they have frozen in his aid bag. Without
part of this renewed emphasis on the Arctic environment, sev- the ability to actively rewarm or provide appropriate
eral gaps have been identified as tactical combat casualty care medications, the casualty becomes unconscious before
(TCCC) practitioners support exercises in the harsh Arctic MEDEVAC arrives.
climate.
The characteristics of AoECE have forced TCCC practitioners
While cold weather injury patterns are not new to military operating in these regions to modify existing techniques.
operations, we suggest that a lack of emphasis on the region Trauma casualties are treated according to the MARCH al-
during the Global War on Terrorism has resulted in a loss of gorithm: massive hemorrhage, airway, respiratory, circulation,
institutional knowledge for effective large-scale treatment of hypothermia/head injury. This standardized pathway priori-
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these injuries in austere and far-forward environments. Mod- tizes injuries that the Joint Trauma System (JTS) has identified
ern practices in TCCC have exhibited deficiencies in the pre- as leading causes of mortality on the battlefield. In the AoECE,
vention and treatment of cold-weather injuries, and medical hypothermia prevention should persist throughout casualty
equipment sets (MES) require supplementation for the frigid care. Hypothermia’s role in the trauma diamond of death—a
*Correspondence to david.reynhout@gmail.com
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1 CPT David J. Reynhout, CPT Stephen E. Meyer, and MAJ Michael T. Colesar are affiliated with the 2nd Brigade, 11th Airborne Division, Fort
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Richardson, AK. MAJ(P) Titus J. Rund is affiliated with the 207th Aviation, Alaska Army National Guard, JBER, AK.
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