Tactical combat casualty care ( TCCC )

[Grunt_031]

The Medical Pers (Med Techs) were sent on a PHTLS Instructor course proir to the TCCC being run and then instructed to the Candidates. The PHTLS was intergrated into the course content. All the candidates where given certifcation by Canadian College of Emergency Medical Services.

This was a trial run using this civilian qualification and probably will not be run this way in the future. Once the Militray version of PHTLS being developed in the US becomes available they may revist the idea.

 

[Armymedic]

We are improvising with intergrating BTLS with military medicine...PHTLS just has a chapter in its manual, whereas BTLS does not.

I think the CFMG version will teach based on BTLS, but final decisions on the matter are well above my pay grade.

 

[ModlrMike]

All the candidates where given certifcation by Canadian College of Emergency Medical Services.

Which is a private civilian school, not to be confused with an National oversight agency.

 

[MedCorps]

Grunt_031,

Did you do the course?  How did you like it?  What would you add / delete?  Do you feel more comfortable at responding to a trauma in your section now, without a Med Tech?

Interested to know. 

Army Medic... there has been some throught at CFMGHQ / Med Trg to go with the PHTLS as opposed to the BTLS.  Why... the only reason anyone can give is that PHLTS in the 5th edition (2003) put a chapter (16) on military medicine.  In the last version of BTLS (5th Ed 2004) they did not.  We will have to see what the giant head comes up with on this one.

Cheers,

MC

 

[Armymedic]

There is simple reasons for no military chapter in the BTLS book. 1. No military contributors, dispite having military chapters(branches) in the BTLS community. 2. Also, John Campbell wants the medical knowledge to be widespread, not how to apply the knowledge. There are still military based senarios in BTLS testing, but its left to the instructors to instruct.

The PHTLS just took concepts from US Army pams and put it into a civilian book (why? I don't know). I have both texts and with the exception of a few chapters (the military chapter being one), the concepts and skills are very similar. BTLS, IMHO, has better assessment "drills" then PHTLS.

 

[MedCorps]

Army Medic,

Having done both courses in the last little while (and getting IP on both :smile I agree that the BTLS has better drills.  I will give you that for sure.  I also think that much of the stuff from the military chapter was taken from other stuff (the scenarios are from Military Medicine in around 2000). 

I also think that PHTLS has a military chapter because of the active involvement of the US military to assist in authoring the text.  The US military kicked up a team of 8 people to assist in writting the text.  In terms of man-hours / cost of labour that is big bucks for a publisher.  They did not kick up bottom feeder either.  I know three of the people who were on the writing team.  All three are ER docs and two are Capt(N) (read: full Col) and one is from USASOC and is a doc who is a LCol (although he was expecting to get promoted soon, and might be a Col now).

Cheers,

MC

 

[Armymedic]

I think if you would have had highly trained free instructors from across the street,   ;D

there would be a MCpl who would have loved to give you the gears to see you earn that IP    >

Anyway, pulling back to topic.

If CFMG were to start this course in Petawawa, I believe some of the first instructors should be BTLS instructors with much Cbt arms/fd experience. When 2 Fd ran the short course for ISAF roto 0, the brigade surg went to the BTLS cadre and pulled all the senior ones to teach.

 

[Donut]

One other consideration for PHTLS vs BTLS, is that BTLS requires a medical director, while PHTLS doesn't need to be run with physician oversight.  Given the shortage of MO in the CF, and cost associated with hiring Medical Directors, this is a valid concern.

The flip side is that, especially when our instructors may not be all that current on trauma, do we want to do away with the oversight that provides?  I know that running our courses, with our Bde Surg as the med director, helps him get a feel for the various skill levels of his medics.  The first question he or the HCC ask when he's reading a medic emerg report is "how'd he do on the last BTLS?"

Now, out here we pay $800 a day for a civi med director, and $400 a day for the civi instructors. Big bucks, and if we can save that and keep the standards high enough, we clearly should.

 

[Armymedic]

But the TCCCS is meant for Army soldiers in a reg force brigade. In which case you have a Fd Amb, which has more then one or two MO's and I have yet to meet a young Capt who wasn't interested in assisting in instruction of their Med Techs.

Also the $ issue for instructors. A certain large CFMG organization has lots of $ to hire instructors from Toronto to come up and teach...A smaller unit has instructors, coordinators, and instructor trainers avail who travel to places like Trenton and Ottawa to teach for the cost of TD.

My point is if there is a will there is a way. But BTLS should be the basis of the medical standard.

 

[Donut]

Quick note to add to this thread:

Just last week I was asked (yet again) to submit my civi quals up the chain.   Included in the latest spreadsheet of quals was TCCC Instructor, right next to the ACLS and BTLS instructor columns.

As well, with instructors who teach for the cost of TD, there'd be a lot more of them if the CF would fund some instructor courses, and maybe establish regional instructor cadres.  When I pay out of pocket for membership in a professional organization, licensing fees, instructor qualifications, instructor updates, etc, and then the army assumes I will lower my fees by over 70% to teach the course to a class that's twice the size it should be, my GAFF drops precipitously.

 

[Fraser.g]

Doug,

There is a fine line between use of civi qualifications and abuse of same. If the army wants to use you as a BTLS instructor then they should pay your dues. They do mine! I suspect that the regular force members of this forum and BTLS Instructors have DND pay their memberships.

I believe that this should go for CPR, SFA, BTLS, ACLS, ATLS and TCCC if it is licenced from an external agency other than DND.

As you said, they ask us to teach classes that are larger than recommended, get paid less for doing it, and expect us to maintain the certifications on our own time and nickle. Not on bro!

I have my unit pay for my instructor papers and they have never questioned them. I simply pay my dues and then submit a CF 52 for the expenditure.

Grant

 

[Armymedic]

Doug,

There is a fine line between use of civi qualifications and abuse of same. If the army wants to use you as a BTLS instructor then they should pay your dues. They do mine! I suspect that the regular force members of this forum and BTLS Instructors have DND pay their memberships.

I believe that this should go for CPR, SFA, BTLS, ACLS, ATLS and TCCC if it is licenced from an external agency other than DND.

As you said, they ask us to teach classes that are larger than recommended, get paid less for doing it, and expect us to maintain the certifications on our own time and nickle. Not on bro!

I have my unit pay for my instructor papers and they have never questioned them. I simply pay my dues and then submit a CF 52 for the expenditure.

Grant

Oh heck YEAH, I got my BTLS Intructors for free, as do all the students I teach...We only charge $20 per person for BTLS ontario so every student gets the appropriate card. Books are bought and held by the 2 Fd Amb...

Quick note to add to this thread:
As well, with instructors who teach for the cost of TD, there'd be a lot more of them if the CF would fund some instructor courses, and maybe establish regional instructor cadres. When I pay out of pocket for membership in a professional organization, licensing fees, instructor qualifications, instructor updates, etc, and then the army assumes I will lower my fees by over 70% to teach the course to a class that's twice the size it should be, my GAFF drops precipitously.

This is exactly what has happened in Petawawa for the last 5-8 yrs....We have a system in place where every yr or two we certify new BTLS instructors from the courses we ran, currently roughly 20. The military paid for us to be qualified and we don't earn any $ by teaching....BTLS Ontario allows us to have this group because of all the potential students in Pet, Ottawa, Kingston, Trenton, and Borden.

If I were you I'd get the CF to pay (reimburse) for any future courses you take if they want you to teach.

Anyway, this is pulling off track....more to the MCSP thread then TCCCS....

If there is no "Official" TCCC course yet in CFMG's eyes...how can anyone become an instructor yet?

 

[MedicMW]

The use of free instructors is not appropriate. Units should be reimbursing instructors who maintain instructor qualifications and use them within the military environment.

The PHTLS course is similar to BTLS. I found that PHTLS expected the Care Provider to be immediate in treatment and determination of injuries. I found the scenarios to be much more appropriate with the military module (in place since 1974). The PHTLS course assumes the knowledge of Anatomy and Physiology is already in place and there has been experience.

The TCCC course is a PHTLS specialization, (PHTLS does require a medical director for program to run) and was originally proposed by Major (ret.) Dan Voriout (mis-spelled) and Capt. (ret.) Roger King from 1 CMBG. Dr. King still fills in at the Base Hospital and is usually fairly even tempered and helpful. Major Barry Ellis is the current Medical Director for the program and seeking ways to effectively implement it CF wide.

 

[Armymedic]

The use of free instructors is not appropriate. Units should be reimbursing instructors who maintain instructor qualifications and use them within the military environment.

How?

They pay for me to become qualified, why do I require reimbursement to teach?

If I pay for the course, I get 80% reimbursement thru BPSO....military still pays me....(rules on course reimbursement currently changing, see PEP thread in current events)

What more can they do?

The PHTLS course is similar to BTLS. I found that PHTLS expected the Care Provider to be immediate in treatment and determination of injuries. I found the scenarios to be much more appropriate with the military module (in place since 1974). The PHTLS course assumes the knowledge of Anatomy and Physiology is already in place and there has been experience.

The TCCC course is a PHTLS specialization, (PHTLS does require a medical director for program to run) and was originally proposed by Major (ret.) Dan Voriout (mis-spelled) and Capt. (ret.) Roger King from 1 CMBG. Dr. King still fills in at the Base Hospital and is usually fairly even tempered and helpful. Major Barry Ellis is the current Medical Director for the program and seeking ways to effectively implement it CF wide.

Thanks for the background,
That being said...TCCC could easily be adapted with BTLS medical protocols and extra expense and time would not have to be wasted re qualifying your SMEs in another prehosp technique so that they can teach TCCC to nonmedical pers. In Petawawa, where the largest concentration of MA's are there are 0 (I say again none) PHTLS instructors here that I am currently aware of. If they want to implement it CF wide, then standardizing the medical protocols with what the current standards are is the next most appropriate action.

When I see Maj Ellis at the OP Med at the end of the month , I am sure this topic will come up.

 

[Donut]

PHTLS and BTLS have a reciprocity agreement in place, so converting BTLS instructors to PHTLS Instructors shouldn't be too difficult.

As for PHTLS being the creator of TCCC, I've seen documents and powerpoints written by a Capt Frank Butler of USN Spec Ops Command, I think, that may or may not predate the PHTLS program.  I'm not saying PHTLS doesn't have a TCCC, just as BTLS has an Access and Pediatrics courses, but I'm fairly certain the original TCCC came from the US.

As for instructor reimbursement, DND hasn't bought me a BTLS qual since 1997.  I'm out of pocket $1400, including travel and upgrades, for a qualification I took to further my CIVI career. PEP isn't available because I have a degree, nowhere in my job description does it say BTLS Instructor, Coordinator, or Paramedic, yet because I have these I'm expected to provide these services within my salary.

 

[MedCorps]

Some light reading from Iraq.  CLS is like TCCC providers are for the CF, more or less (some delta in skill set, but same idea).

Enjoy

MC

Operation Iraqi Freedom (OIF)
CAAT II Initial Impressions Report (IIR)

Chapter 4: Combat Service Support
Topic F: Health Service Support

Subtopic 3: Combat Lifesavers (CLS)


Observation Synopsis

Ensure unit's combat lifesavers (CLS) are fully trained and understand their role in the medical treatment process. Once-yearly training is insufficient to ensure they can perform necessary duties in a critical situation. There was at least one incident on the road where the targeted unit was rendered ineffective in terms of medical treatment by an improvised explosive device (IED) attack that resulted in several casualties. Another unit passing by stopped and took control of the situation, including providing medical care to the wounded. Specifically, CLS need extensive training in starting intravenous (IV) lines and providing appropriate first responder aid. Starting IVs is a skill that is difficult to do in controlled settings for the inexperienced (like the vast majority of combat lifesavers), and almost impossible to do in an emergency without prior proficiency. All vehicles traveling in a convoy should have at least one combat lifesaver with their bag. Vehicle first aid kits, though useful for minor injuries, are not sufficient for major traumas associated with IED, small arms, or rocket-propelled grenade (RPG) attacks on convoys. On more than one occasion, combat lifesavers did not have their bags available or in their possession because they were kept locked up or in storage to keep from losing them or to maintain accountability.

Lessons Learned

* Convoy commanders need to ensure a sufficient number of CLS providers are included in the personnel of each convoy.
* Prior to deployment, all combat lifesavers need to be trained and certified, have possession of their CLS bags, and exhibit confidence in using the enclosed medical supplies.

DOTMLPF Implications

Training: Recommend at least quarterly hands-on training, especially an IV starting workshop, and not just a paper or lecture review of basics to â Å“check the block

 

[Donut]

I found the section on the movement of casualties in a non-linear battlespace interesting, as well as the description of equipment shortfalls, both with the jump bags and with the stretchers.

Has anything like this been reported from Op Athena?  I don't suppose we're having to decontaminate our stretchers with nearly the regularity that the US is having to, but still...

I did like the M577 CP amb conversion.  Can you say headspace! (and, I suppose, big @#^$%*  profile, too for a tactical environment)

 

[MedicMW]

Re: BPSO reimbursement of Instructor fees.

As a reservist I am not eligible for those same reimbursements (16 days short of four years cumulative class B service). My unit does reimburse under the MCSP requirments for maintenance of my registration. Initially they did pay for me to become qualified and I instructed frequently for the first three years. After my re-certification (not reimbursed) my RSS staff ensured I was rewarded within the unit alternatively.

I suppose it comes down to the consistency and competence of leadership to make me happy. Their occasional benevolence doesn't hurt either.

Re: PHTLS may be a US thing.
PHTLS is a US thing. The physician that developed PHTLS and the TCCC module is American and can be socialised with every year at the PHTLS world conferences in The US. I believe this year it is in Phoenix. It is an excellent opportunity to meet military medical personnel from around the world (last year there were Israeli, French, German, American and Italian medics all over the place). Dr. Houston in Edmonton will have more information on the conference this year.

Williams, M.

 

[Donut]

MW, what I said was that a variant of Tactical Combat Casualty Care was developed by the US Spec Ops Command which predates the PHTLS course of the same name(can't find the course on the PHTLS website, though).  Similarly, CONTOMS, the US Counter Narcotics Tactical Operations Medical Support could make a claim to be the originator, through their EMT-T program.

I have found, at the US AMedd site (www.amsc.amedd.army.mil/Doc/ PA/TACTICAL%20COMBAT%20CASUALTY%20CARE.doc ), a paper which cites both PHTLS 4th&5th edition texts (use of Hetastarch blood expanders and fluid resuscitation) and the paper by Dr FK Butler et al entitled Tactical Combat Casualty Care in Special Operations, published in Military Medicine in 1996.

Further, according to Specialoperations.com, the first TCCC protocols were included in PHTLS in 1999, from existing US Naval Spec Ops directives, approved in 1997, and based on a requirement identified in 1993.

Last I heard, TCCC had been endorsed by the American College of Surgeons, the source of ATLS and the program that both BTLS and PHTLS try to keep in line with. 

St John Ambulance teaches CPR and to elevate the legs of the shocked patient; I'm pretty sure they never invented external chest compressions or had Trendelenburg working for them, either.

BTW, is this Dr Houston an anaesthesiologist?  I suspect I worked with him a decade or so ago in Edmonton.

 

[MedicMW]

Doc Houston is Emergency Spec. and Anaesth. So you might have worked with him. As an aside I just participated in an Edmonton Police Services Tac EMS course and it has some nice components to it as well. They really stress the immediate threat factor.