Joint Tactical Medicine
The evolution of combat medical training has been driven by evidence-based guidelines influenced greatly by data collection in recent years of U.S. wartime engagement.
By MAJ Walter Engle
As Overseas Contingency Operations (OCO) slow, are we medically trained for future conflicts? In a world that is filled with uncertainty and conflict, it is important to be adequately prepared for future engagements. The United States Military witnessed the lowest prehospital, battlefield casualty fatality rate (CFR) 2012-2014 at <9%. Once the casualty reaches a surgical asset, the CFR is <3%. This observation is directly related to the evidence-based medicine guidelines of Tactical Combat Casualty Care (TCCC), developed by the Committee on Tactical Combat Casualty Care (CoTCCC) and the Institute for Surgical Research (ISR). These successful guidelines are based on battlefield casualty data collected by the Joint Trauma System (JTS). The trend for 2015 data shows the CFR (KIA + DOW/KIA + WIA) is rising. Historically, the CFR is higher at the beginning of a conflict than what it was at the end of a previous conflict. JTS gathers data from TCCC cards and TCCC after action reports (AAR) recovered from OCO casualties. Data is also gathered at the Armed Forces Medical Examiner when casualties do not survive their injuries.
COMBAT CASUALTY CARE COURSE
The solution to maintaining the medical advances achieved from OCOs is continued emphasis on tactical medicine training. Where can service medical teams, commanders, and command surgeons send medical personnel for realistic, centrally-funded, standardized TCCC training? Good medicine and good tactics are nested at the Combat Casualty Care Course (C4); located at Camp Bullis, San Antonio, Texas.
C4 provides initial pre-deployment, or sustainment Tactical Combat Casualty Care (TCCC) curriculum. This eight-day course trains Tri-Service medical personnel to apply medical knowledge in an austere continuum of care from point of injury (POI), to Role II, and evacuation. C4 closes two gaps in medical care on the battlefield identified by the CoTCCC and ISR: first, military medical providers are not familiar with TCCC; second, they do not understand or employ the scope of practice for a medic or corpsman. C4 is a centrally-funded course executed by DMRTI with the Combat Medicine Branch in the lead.
Additional courses are offered by the Tactical Medicine Branch (Advanced Burn Life Support, TCCC, Basic Life Support, Advanced Trauma Life Support Operational Emphasis (ATLS-OE), Trauma Nursing Core Course (TNCC), and Pre-Hospital Trauma Life Support (PHTLS)) and the Contingency Operations Branch (Emergency Preparedness Response Courses, Joint Medical Operations Course, Joint Medical Planning Tool Course, Hospital ICS Courses).
Based on the student’s medical profession, they will attend a professional program (ATLS-OE, TNCC, or PHTLS) and upon passing the written and scenario test, will receive the appropriate certification and continuing education credits. C4 introduces medical personnel to the three phases of TCCC (Care Under Fire, Tactical Field Care, and Tactical Evacuation Care) and the concept of prolonged field care in an austere environment with delayed medical evacuation. Students are placed into an austere environment – Forward Operating Base (FOB), and issued body armor, helmets, and M4 carbine simulators adding to the realistic training experience. In addition to the protective gear, each platoon is issued two stocked aid bags, a Warrior Aid and Litter Kit (WALK), and a SKED rescue system.
Students are placed into three platoons led by Primary Instructor cadre (PI), who have extensive deployment history, acting as Platoon Sergeants for accountability and instruction of subject matter expertise on tactical medicine. Each medical exercise has additional cadre to maintain an efficient student-to-instructor ratio. Students are challenged by being placed into leadership positions and required to make timely, decisive, tactical decisions. Each student Platoon Leader is given an Operations Order (OPORD) outlining the events of the week. Each evening a fragmentary order (FRAGO) is given detailing the next day’s events. Leadership is paramount to good medicine and good tactics.
Students demonstrate tactical medicine proficiency and decision making in six mission oriented exercises that stress the guidelines and phases of TCCC. Each exercise begins with a briefing and ends with an AAR. Casualty documentation and packaging for movement are stressed during each medical exercise. The C4 cadre instructs students on the importance of battlefield injury data collection to form the TCCC guidelines. These guidelines frame C4 and the medical exercises conducted throughout the evolution.
MILITARY OPERATIONS ON URBAN TERRAIN
The Military Operations on Urban Terrain (MOUT) medical exercise introduces the students to basic close-quarters-battle tactics utilizing a “glass house” training tool which mimics the floor plan of the target building. The Casualty Collection Point (CCP) concept on a dismounted recovery mission facilitates this TCCC scenario.
Students are organized into eight-person squads and given specific leadership and medical roles to execute. The mission is casualty recovery from a helicopter down scenario, forcing the squad to make entry into the target building. Stressors include limited visibility, loud battlefield noise, sounds of distress, and gunfire. Utilizing M4 carbines with “smart” magazines, basic squad tactics, and a Virtual Trainer Firearms Simulator, students engage an interactive screen displaying enemy combatant avatars. Once fire superiority is gained, the squad recovers the casualties and establishes a CCP. Tactical Field Care interventions begin and are complete once each casualty is packaged for movement with documentation. Each casualty is moved to a simulated evacuation point manually.
VILLAGE STABILITY OPERATIONS
The Village Stability Operations (VSO) medical exercise introduces the student platoon to planning for a medical capabilities operation. Utilizing a sand table, students use the 1/3 planning and 2/3 execution concept. Security, infiltration, indigenous medical care, and exfiltration plans are discussed. The village resembles structures from the Southwest Asian Area of Operations (AO).
The platoon approaches the village in tactical formation to conduct a key leader engagement. The medical personnel begin to treat role players masquerading as villagers. The operation comes under direct and indirect attack; students’ progresses through the phases and treatments of TCCC. The scenario ends at the rally point with the Quick Reaction Force (QRF).
TACTICAL MEDICINE LANE
The Tactical Medicine Lane (TML) medical exercise is set in an African AO. Squads develop a plan as part of the QRF to recover casualties from a convoy attacked with an Improvised Explosive Device. The platoon must plan ground movement to the disabled vehicles and extricate casualties to a friendly village.
Roles are assigned and medical personnel treat each casualty as the squad maneuvers through various obstacles. Leadership determines the route and evacuation mechanism, TALON litter in the WALK or a SKED. In addition to employing leadership and tactical medical treatment, the exercise reinforces the need to evacuate to higher echelons of care as the combat situation permits. Good tactics and timely evacuation are vital as medical supplies are exhausted.
The Mass Casualty MASCAL medical lane exposes the students to the chaos of multiple casualties with limited supplies to treat at a Role I facility. MASCAL situations are common in a deployed and garrison setting. Planning allows students to react in an organized manner. The lane is initiated with a simulated Vehicle-Borne IED (VBIED) at the FOB entry control point. Casualties arrive and the students triage, treat, and package for evacuation. The scenario continues to present more casualties, stressors mount until the students are nearly overwhelmed. Cadre monitors students for timely and appropriate decision making and casualty care.
The Role II medical exercise extends the course instruction into the prolonged field care concept. Students apply ATLS-OE, PHTLS, or TNCC training from earlier course training to casualty care. Students are introduced to Role II scenarios complete with ancillary service assets (i.e. radiology, lab, blood), but lacking surgical augmentation.
Simulated casualties present different trauma cases. Students are assigned to a five person trauma team and delegated roles. Each bed and mannequin is proctored by a medical professional and simulation operator. Trauma teams rotate to each case bed and delegate new roles for maximum treatment exposure.
Students are introduced to Role II capabilities at the Air Force Expeditionary Medical Support (EMEDS) training site. Students observe the EMEDS tent structure, ancillary services, and patient flow through the Emergency Room, Operating Room, and the Intensive Care Unit.
TACTICAL EVACUATION CARE (TEC)
The TEC medical exercise is a new addition to C4. The cadre creates emphasis to the TEC phase of TCCC to expand the prolonged field care concept. Students receive instruction on basic flight physiology, in-flight emergencies, aircraft familiarization, and TEC. Utilizing a UH-60 Blackhawk simulator, students initiate a 9-line request and mark a hasty landing zone.
TEC demonstrates continued continuum of care beyond a facility and dispels impressions of limited casualty responsibility once loaded onto an evacuation platform.
Photo courtesy of WALK.