Tactical combat casualty care ( TCCC )

[medicineman]

It is simply trying to keep the standing orders for the providers to a minimum and simplified.  There is always the temptation to teach more than is really needed and the students as a rule (and their CoC) are always trying to learn more - they expect to be doctors or paramedics in 5 days of class room instruction and 5 days of field practice.

What the trauma surgeon and a few others on our TP board were saying was that the Americans weren`t seeing alot of the closed tensions we were expecting from primary blast trauma in Iraq.  Hence, it was decided to go with penetration injuries only - go with the evidence that was out there.

There is also going to be an analgesia protocol as well - pill packs for all and some sort of narcotic analgesic will be made available for providers to use.  Question is, will the narcs be for medics or for medics and TCCC providers and of course, what kind.  Watch and shoot kiddies.

MM

 

[herseyjh]

Well that is good news then.  If blast trauma is not showing the incidents of tension pneumo as one would expect, rather penetrating trauma is, then it is a win-win situation.  You don't have to worry about about excluding the blunt trauma strictly from a false-positive error perspective, as statically the chances are small that you will have one. 

Hmm now on to analgesia.  I like the pill idea as it is simple and straight forward.  I like the idea of oral transmucosal fentanyl even better.  There was a good article in the Annals of Emergency Medicine on this.  It was a small study, 22 patients in Iraq, but it is showing promise.  They had to reverse on patient with Narcan, so this could still prove to be a risk.  For now I think the NSAID or COX-2 route would be the way to go.  Speaking from a non-medic administration point of view.  From the medic point of view I would like to think soldier comfort would take president and a variety of medications would be made available.  The concept of 'ALS' pain control is common in most EMS systems, and I would hope this concept will be embraced and afforded to the field medic.  Having some poor guy yelling his head off, and chocking it up to the old saying that 'pain' never killed anyone drives me mad.  I could go on here, but perhaps I will stop, as I am sure many people share my view in this department.

 

[medicineman]

I think the analgesia thing will be forever debated.  I always remember being told medics carried morphine on a battlefield as much for pain relief as for shutting people up (or speeding people along).  We are there, after all, not only to conserve manpower, but also to boost morale and confidence.  A good start would be pain relief.  I guess time will tell.

MM

 

[Armymedic]

I am bringing this topic forward, as it is more relevent then ever.

 

[Bruce Monkhouse]

...and to go with the "more relevent than ever" theme, here is a post quoted from another thread that drives home the point.

Late reply, I know, but I can't sit at my computer all day (Hurts my legs).. with that said...

The TCCC should be manditory for all combat troops. 

When I was hit with shrapnel (from the A-10) and I was crawling for my rifle (thought we were under attack) a fellow soldier found me, rolled me over and applied tourniquets to my legs... which stopped the bleeding from my femoral vein (not artery, thank god)... when the medic inspected the tourniquets, he said "these were done perfectly... text book"
When I arrived at KAF, the docs there said that tourniquet probably saved my life.

We were all trained, by our TCCC's and medics from 2FA how to apply Tourniquets, Isreali Bandages (which they applied to the wound going through my arm) and quick clot, all of which was used the day I was wounded and the day before.

The level of professionalism demonstraited by the soldiers on the battle field in treating the casualties could only be described as absolutely amazing.  The less wounded were treating the more wounded.  And it is true what the article said about everyone pitching in; when I looked up from the stretcher, I was surrounded by a medic, an engineer, a sniper and a at least 2 others from the battalion. Everyone around me was calm and professional.

Anyway, enough ranting... to sum up; yes, the training provided was useful... it saved lives... may have saved mine.  Which is why, since I've been back home and close to my home regiment (RHFC) I have been pimping the idea of educating more reservists in TCCC.  Because we will probably be sending more reservists over seas with combat units, and the more they can be trained at home unit, the easier it will be for them to work with the Battalions.

C

 

[Scoobie Newbie]

I told many people that of all the training they needed to pay close attention to this one (well before knowing I was going).  I PRAY I won't need to apply this to me or anyone else.  I even signed for one while on leave to practise (the only one left in BN).  I also managed to snag another one from one of the guys back as well as 2 Israeli bandages.

 

[vonGarvin]

As an aside (hopefully relevant), as MM said, the medics are not only there to treat, but also to provide morale.  EFFECTIVE first aid (as the TCCC apparently is), is vital.  As I told the candidates this summer, that no matter what, TWO things were given out in Patrol Orders (even after the 80th patrol when most things were "as per SOP"):  they were:
Action on PW (Geneva Convention application)
Action on casualties.

If they failed to give either, I told them that they would receive an incident chit, and perhaps a fail on the assessment.  (reason why it wouldn't be an automatic failure?  No one single assessment factor will pass/fail; however, if someone forgets to give PW/Med, then they probably forgot alot of other stuff too).  The key was the incident chit (as a minimum), and depending on the situation, they were told that they could go to higher counselling, up to and including PRB.  (It is the commandant who removes people from training, not the course officer, not the candidate: the commandant only).  As it turns out, everyone remembered the actions on PW and action on Cas.

Here's hopoing that the TCCC becomes baseline for medical training for our soldiers...

 

[Armymedic]

Ref your patrol orders:

Did they read something like this?

Action on casualty: self aide: If you are wounded, provide self aide to yourself, stop major bleeding with direct pressure or a tourniquet, communicate that you are wounded, and retrieve your rifle to protect yourself.
Buddy aide: If a member of the patrol is wounded: provide aid to casualty as soon as possible, communicate to ptl comd the status of cas and thier ability to carry on with patrol.

COAs upon cas: 1. Attempt CASEVAC and carry on with mission, 2. Abort mission and attempt CASEVAC, 3. Bring cas with patrol and carry on with msn, or 4. Leave cas in place and carry on with msn.

 

[vonGarvin]

Ref your patrol orders:

Did they read something like this?

Action on casualty: self aide: If you are wounded, provide self aide to yourself, stop major bleeding with direct pressure or a tourniquet, communicate that you are wounded, and retrieve your rifle to protect yourself.
Buddy aide: If a member of the patrol is wounded: provide aid to casualty as soon as possible, communicate to ptl comd the status of cas and thier ability to carry on with patrol.

COAs upon cas: 1. Attempt CASEVAC and carry on with mission, 2. Abort mission and attempt CASEVAC, 3. Bring cas with patrol and carry on with msn, or 4. Leave cas in place and carry on with msn.

Not quite like that.  But it was self aid followed by buddy aid, with the mission being paramount.  There was a go/no-go point for the ptl comds (eg: if you suffer x % cas, you will abort the patrol.  Given by the OC, and varied by mission). 
One point: cas were never to be left alone: always with someone (never leave anyone unattended: bad for morale and a whole bunch of other reasons).  So, if it were en route, then they "could" be left in place, with someone else, and retrieved on the way back.

 

[Armymedic]

Jokingly....I have to say I agree with them... ;D

In reality....WTF? My comments to follow.


http://cnews.canoe.ca/CNEWS/War_Terror/2007/04/11/pf-3982853.html

April 11, 2007

Military says only brightest soldiers should have advanced first-aid training

By MURRAY BREWSTER

OTTAWA (CP) - As the casualties in Afghanistan mount, the army wants many more soldiers trained in highly realistic battlefield first aid, but military doctors are resisting.

A recent report into a friendly-fire incident, in which an American plane accidentally strafed Canadian troops in Afghanistan last September, recommended more soldiers be qualified in this specialized care, a step above the standard combat first-aid course given to all troops deployed overseas.

"This incident illustrates the requirement to have as many soldiers as possible . . . qualified," said the document, obtained by The Canadian Press under the Access to Information Act.

"The training is considered critical given the (combat operating environment). Combat first aid should be a consideration like firepower when considering the building blocks of the forces."

The Sept. 9 report recommended that two soldiers in each section be trained in combat casualty care to help save lives. Currently, the army requires only one soldier per section to be certified in advanced battlefield first aid, known as Tactical Combat Casualty Care.

The need for first-aid training came brutally into focus Easter Sunday with the roadside bombing that killed six soldiers and injured four others. One of the wounded - Cpl. Shaun Fevens - managed to instruct another soldier on what to do in order to save Fevens' own life.

The friendly fire review, completed in the immediate aftermath of the Labour Day incident that killed one soldier and wounded 36 others, has since been greeted with skepticism by Ottawa-based medical staff.

All soldiers heading into war zones receive combat related first-aid training, a two-day course on how to stop bleeding, apply bandages and tourniquets and use QuickClot, a powder that quickly dries up bleeding.

The proposal to put more troops through the advanced two-week course has been endorsed by army brass, saying it benefits all ranks, not just non-commissioned officers to whom the program is currently restricted.

"This would allow the army to build a critical mass of qualified soldiers" in order to make it part of regular career training for combat arms soldiers, says an Oct. 3 memo from Land Forces Command.

But the director of the military's health services branch, Col. Maureen Haberstock, has criticized the proposal, saying combat casualty care is training that should be reserved for "exceptional" soldiers.

"Some of the skills taught, if performed unnecessarily or incorrectly can be harmful, or even fatal," she wrote in an Oct. 31 memo.

Her assessment is supported by other senior medical staff at Defence Department headquarters.

"Typically, any time (the army) finds something that is good, if a little is good a lot is better," Lt.-Cmdr. Ian Torrie, a physician and expert in combat casualty training, said in an interview.

"The people who are going to get this extra training, you really want your brightest person. You really don't want everybody to have it."

Since the lessons-learned document was written, the army has increased the number of soldiers qualified for casualty care, but Torrie refused to discuss numbers, citing security concerns.

The soldiers given higher level first aid use elaborate mannequins. A variant of the course given only to full-fledged medics involves the controversial but limited use of injured live animals, specifically pigs.

"What we're doing is very carefully scrutinized and goes through an animal ethics board," said Torrie. "Yes, we do use live animals. They are treated very humanely."

He said the pigs are sedated and given spinal blocks so they don't feel pain.

"We all find it very difficult to deal with live animals, but recognize the value and it actually is saving lives," said Torrie.

The Canadian Forces first adopted combat casualty training after the first friendly-fire incident in 2002, which left four soldiers dead and eight wounded when an American pilot accidentally bombed Canadian troops in a training exercise outside of Kandahar Airfield.

 

[Armymedic]

So here it is from me on both sides of the argument.

Tactical combat casualty care involves skills and knowledge that should be taught to every soldier in the cbt arms as part of their basic trade/MOC training, it should rate as important as the skills of shooting your rifle and physical fitness. What is more precious then your or your buddies lives? Too often it is officers in the Health services (and usually not actual doctors or nurses) who have never gotten their boots dirty who decide what level of tng is sufficient for the nonmedical troops to provide to their peers. Our CF medical system must acknowledge that when it comes to medicine, more with clearly defined limits is better, and the limits that our system places on the NCO medical providers and the cbt arms soldiers are currently to restrictive and not in line with what our allies (the US) is learning and doing in the field. "They" (the Crystal Place they) are more worried about CYA and legal implications, then ensuring our Med Techs and soldiers have to skills to save lives. We as a military should be pressing ahead with MILITARY MEDICINE and not restricting knowledge skills and equipment.



Too often our training is done "check in the box style" and not with the time or effort actually required to maintain an acceptable skill level. To have and maintain these skills is not something you can only do once a yr as part of a IBTS or predeployment work up schedule, nor can you say, "I had a course 3 yrs ago, and I did it once". Constant practice and refreshing are needed to maintain a minimum standard of competency. Accordingly, medical skills are costly in both time and resources to teach and maintain. The CF has difficulty in getting all its medical pers onto the courses and training they themselves need to get all their required training. To be able to do this an individual must be motivate to learn and maintain, and be given permission and opportunity by the CoC to do so. In our training, do we practice casualty procedures and initial CASEVAC skills in most iterations on every exercise? Are the medical plans including proposed CCPs included in the Service Support portions of every order? If the Army wishes to convince the Medical group that it is truly serious about TCCC and wants its soldiers trained to a higher standard, then there is much work to do.

 

[a_majoor]

The title alone says it all.

Would you really want to be standing next to the dimmest soldier when you get hit? How do you determine where the brightest guy is going to be when casualties occur? What happens when the brightest guy is hit?

Just like marksmanship with the rifle; advanced first aid training needs to be taught and practiced by every serving member.

 

[Gardiners1]

The title alone says it all.

Would you really want to be standing next to the dimmest soldier when you get hit? How do you determine where the brightest guy is going to be when casualties occur? What happens when the brightest guy is hit?

Just like marksmanship with the rifle; advanced first aid training needs to be taught and practiced by every serving member.

I can only echo your thoughts as you have pretty much spelled them out.  Pity the poor soldier who gets hit and beside him is not one of the "brightest".  What concerns me is what constitutes being the brightest?  If a guy is average intelligence that means he isn't eligible for advanced first-aid?  So if I get hit I have to hope and pray there is a PH.D nearby to save my hide?  I think every soldier should be able to take advanced first aid.

 

[geo]

uhhh.... would you want the dumbest troops to be deployed?
or retained as rear guard (or released?)

Only sharpest and brightest should be at your side - and they should have the advanced first aid trg.

 

[COBRA-6]

Why does this come to mind: 

 

[Journeyman]

So now I'll wear a velro patch with my blood group...and those around me wear one with their IQ 

"Sorry, but I'll wait out this open pneumothorax sucking chest wound until someone with a higher IQ comes along." :

No, the training isn't easy, and not everyone can get it (but your mom will still think you're special). But CF Health Services casually suggesting that most* are too stupid is arrogant to the point of harmful for the troops' well-being. 



* Based on my shaky knowledge of statistics indicating that 50% are below average.

 

[Colin Parkinson]

When the Coast Guard started the Rescue Specialist program with first Aid training to Advanced Occupational Level II, the senior management said they didn’t want us “deckapes” to be caring for a pregnant woman because we were to rough. Took about 5 years to kill that attitude. Either the soldier will pass the course or not, if the soldier fails basic first aid, don’t send them on a advanced course. It’s not rocket science.

 

[medaid]

huh... that's an interesting article. DO I agree with it? Not really. I mean after all, what do you call the last person to graduate from Med School? 'Doctor'. There are some of the 'brightest' people I have ever seen fail miserably on trauma calls when they are on the road, and some who freeze when they do their rotations at the hospital. Does it really mean that they're below average? Nope. They were high enough to get through some of the courses to get there in the first place, but just cant do it when brown, sticky stuff hits the fan. I agree with some of the previous thread.

TCCC = for most combat/support soldiers
Med Tech skills = Med Techs

et voila problem solved on their high and mighty comments about 'bright and 'dim' troop. But honestly, there are those within the CF H Svc I would never let touch me. I'm sorry, but your CF provided training at times just scare me and makes me question allot of things with regards to training and doctrine. ESPECIALLY the 'check the box' type examinations that we do. But that's just my 2 rupees.

 

[medicineman]

Funny thing about first aid - it's pretty much a  hands on skill and about 95% is just common sense (I know that I say it's been bred out of the gene pool, but hear me out).  I've taught people on civvy street the old standard course before it got really dumbed down to people that only had a grade 4 education and could barely read the test, much less answer it.  Give them a task though, absolutely no problems.

The soldier I want learning this is the one who is most motivated - the one that wants to be on the course, who is responsible enough to carry and maintain and use the equipment - not necessarily the smartest.  The one who wants to be there will do well on the course and in the field for real.  Let's face it - in the end, we're training the guys and gals that are going to have to keep US alive if WE get smacked - do you want the one that was sent there against their will, didn't care and barely paid attention to anything in class looking after you?

The pilot course we ran in Gagetown had alot of people that were just tossed there as filler at the end of the PCF cycle.  Having said that, a fair number really wanted to be there and did quite well on the training - and not all of them were MENSA members.  As far as I'm concerned, if we're not going to teach everyone, then the troops should be screened vounteers, not voluntolds.  What they should have is an aptitude, and by the way, that doesn't necessarily equal brains (though that helps).

My two pieces of copper.

MM

 

[Armymedic]

This part I am surprised was put out into the media:

The soldiers given higher level first aid use elaborate mannequins. A variant of the course given only to full-fledged medics involves the controversial but limited use of injured live animals, specifically pigs.

"What we're doing is very carefully scrutinized and goes through an animal ethics board," said Torrie. "Yes, we do use live animals. They are treated very humanely."

He said the pigs are sedated and given spinal blocks so they don't feel pain.

"We all find it very difficult to deal with live animals, but recognize the value and it actually is saving lives," said Torrie.

Animal labs are used extensively in the US (pigs mostly, 18D also use goats) for the hands on portions of their courses. The value added in working with live tissue is indescribable. There is nothing like pouring Quikclot on a real femoral bleed or tubing a real tension pnuemothorax on a pig. I am glad the CF has gone down that road.

Is Cdr Torrie the "SME" for cbt related first aid, or whatever we are calling TCCC now?