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«FINAL REPORT 30 January 2013 U.S. Central Command Pre-Hospital Trauma Care Assessment Team Russ S. Kotwal, MD MPH COL, MC, USA Director of Trauma ...»

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Saving Lives on the Battlefield

A Joint Trauma System Review of Pre-Hospital Trauma Care

in Combined Joint Operating Area – Afghanistan (CJOA-A)


30 January 2013

U.S. Central Command

Pre-Hospital Trauma Care Assessment Team

Russ S. Kotwal, MD MPH


Director of Trauma Care Delivery, Joint Trauma System

Committee Member, Committee on Tactical Combat Casualty Care

Frank K. Butler, MD

CAPT, MC, USN (Ret) Director of Pre-Hospital Trauma Care, Joint Trauma System Chairman, Committee on Tactical Combat Casualty Care Erin P. Edgar, MD COL, MC, USA Command Surgeon, US Central Command Stacy A. Shackelford, MD Col, MC, USAF Deployed Director, Joint Theater Trauma System – Afghanistan Donald R. Bennett, MD CAPT, MC, USN Deployed Director, Joint Theater Trauma System – Afghanistan Jeffrey A. Bailey, MD Col, MC, USAF Director, Joint Trauma System This report in its entirety was reviewed by the U.S. Central Command Communications Integration Public Affairs Office and the Operational Security Office on 24 January 2013 and determined to have an “Unclassified” classification with no limit for distribution.

Unclassified “I hoped that something that I would say or do would save the life of at least one Ranger. If I accomplished that much I would consider myself successful.” – COL Ralph Puckett


From 2001 to 2011, combatant commanders assumed the risk of warfare at an average cost of approximately one life per day…notable is that every fourth day, the death was potentially preventable. With this point of reference, the following are questions to


1. What makes military medicine unique?

2. Why do military medical providers exist?

3. What is the leading cause of death on the battlefield?

4. Where do most military service members die on the battlefield?

5. Where can we make the greatest difference in military casualty outcomes?

6. Do medical priorities, resources, and efforts match mission requirements?

7. What is the standard for pre-hospital battlefield trauma care?

8. Does our pre-hospital casualty response system meet or exceed standards?

9. How do we determine best practices in pre-hospital battlefield trauma care?

10. How do we develop clinical expertise in pre-hospital battlefield trauma care?

11. How do we train providers in trauma who do not routinely practice trauma?

12. Who is the advocate for medics and pre-hospital battlefield trauma care?

–  –  –

A. Background During the Vietnam conflict, many U.S. casualties died because they failed to receive prehospital trauma care interventions as simple as placing a tourniquet on a bleeding extremity. A paper from the Vietnam era noted that: “...little if any improvement has been made in this (prehospital) phase of treatment of combat wounds in the past 100 years.” This statement continued to be true until the development of Tactical Combat Casualty Care (TCCC) in 1996.

TCCC is a set of pre-hospital trauma care guidelines customized for use on the battlefield.

One example of the lifesaving potential of TCCC guidelines is renewed focus on pre-hospital tourniquet use. Until recently military medics were taught that a tourniquet should be used only as a last resort to control extremity hemorrhage, yet a study of 2600 combat fatalities incurred during the Vietnam conflict and a study of 982 combat fatalities incurred during the early years of conflict in Afghanistan and Iraq noted death from extremity hemorrhage was relatively unchanged at 7.4% and 7.8% respectively. After the global implementation of the tourniquet recommendations from the TCCC guidelines, a recent comprehensive study of 4596 U.S.

combat fatalities from 2001 to 2011 noted that only 2.6% of total combat fatalities resulted from extremity hemorrhage. This dramatic decrease in deaths from extremity hemorrhage resulted from ubiquitous fielding of modern tourniquets and aggressive training of all potential first responders on tourniquet application.

Currently, if you are a U.S. or Coalition casualty on the battlefield of Afghanistan and you arrive alive to a Role 3 Medical Treatment Facility (MTF), your chance of survival is greater than 98%.

Although the overall case fatality rate in the ongoing conflict is lower in comparison to previous conflicts, significant challenges still remain. The comprehensive study of 4596 U.S. combat fatalities incurred in Afghanistan and Iraq from 2001 to 2011 mentioned above also found that 87% (4016/4596) of deaths occurred prior to reaching a MTF. This percentage remains relatively unchanged from the 88% noted from the Vietnam conflict. Additionally, of the pre-MTF fatalities, a panel of military medical experts determined that 24% (976/4016), or 1 in 4 of these deaths, were potentially preventable. Surgically correctable torso hemorrhage, junctional hemorrhage, airway compromise, and tension pneumothorax remain as significant challenges and causes of preventable death in the pre-hospital battlefield environment.

A recent study of combat casualties from the 75th Ranger Regiment, U.S. Army Special Operations Command, between 2001 and 2010 documented that 0% of their pre-MTF fatalities and 3% of their total fatalities were potentially preventable. This is largely attributable to the Ranger Casualty Response System, a Tactical Combat Casualty Care (TCCC) based program that is aggressively taught to all unit personnel. This casualty response system is a commanddirected program that was in place prior to the onset of hostilities in Afghanistan in 2001. It has been continuously updated throughout the current conflict as guided by a unit-based trauma registry and by the expert recommendations from the Committee on TCCC. The unprecedented low incidence of preventable deaths achieved by the Ranger Casualty Response System is a model for improving pre-hospital trauma care and saving lives on the battlefield.

The Ranger system provides an example of how command ownership, comprehensive TCCC training at all levels, casualty data collection, and process improvement using Joint Trauma System principles can save lives when implemented. This system offers key insights into how

Unclassified Unclassified

future improvements in battlefield trauma care and casualty survival can be made throughout the DoD. The 1993 Battle of Mogadishu provided invaluable lessons learned and led to dramatic changes in Ranger pre-hospital trauma care that have subsequently saved many Ranger lives on the battlefield. The current conflict has also provided invaluable lessons which can save lives now and on future battlefields if these techniques are uniformly implemented, well-trained, and well-executed by U.S. military forces.

B. Mission Assess pre-hospital trauma care within the Combined Joint Operations Area - Afghanistan (CJOA-A) and provide recommendations to reduce preventable combat death among U.S., Coalition, and Afghan forces to the lowest incidence achievable.

C. U.S. Central Command Pre-Hospital Trauma Care Assessment Team COL Russ S. Kotwal, MC, USA – Director, Trauma Care Delivery, Joint Trauma System CAPT Frank K. Butler, MC, USN (Ret) – Chairman, Committee on Tactical Combat Casualty Care COL Erin P. Edgar, MC, USA – Command Surgeon, U.S. Central Command Col Stacy A. Shackelford, MC, USAF – Outgoing Deployed Director, Joint Theater Trauma System, U.S. Central Command CAPT Donald R. Bennett, MC, USN – Incoming Deployed Director, Joint Theater Trauma System, U.S. Central Command Col Jeffrey A. Bailey, MC, USAF – Director, Joint Trauma System

D. Itinerary

5-6 Nov: Bagram Airfield: Role III (USAF, USA), Role II (USA) 6-7 Nov: Salerno FOB: Role II (USA, USAF), Role I (USA), TACEVAC (USA) 7-10 Nov: Bagram Airfield: Role I (USA), TACEVAC (USA) 8-9 Nov: JTTS Theater-Wide Trauma Conference ( 130 medical providers from AFG, DEU, FRA, NOR, UK, USA, USAF, USMC, USN) 10-11 Nov: Kandahar Airfield: Role III (USN), Role I (USA) 11 Nov: Tarin Kowt: Role II (USN), Role I (USN, AUS) 12-14 Nov: Bastion: Role III (UK, USA), Role I (UK, USA, USMC, USN), TACEVAC (UK, USAF) 14-17 Nov: Bagram Airfield: TACEVAC (USAF), JTTS, JC2RT E. Selected Observations

1. Throughout the course of hostilities in Afghanistan, TCCC has gone from being used by only a few USSOCOM and 18th Airborne Corps units to being used throughout the battle space. This evolution has, however, occurred unevenly and sporadically.

–  –  –

3. One reason for the apparent randomness of advances in pre-hospital trauma care is the lack of a clearly responsible organization for developing best-practice pre-hospital trauma care recommendations to the Services and Combatant Commanders.

4. A second reason for the apparent randomness of advances in pre-hospital trauma care is a matter of ownership, and the potential for decisions in this area to be made or not made by any number of different senior military leaders and at multiple levels within the chain of command of each service.

5. Combat medics serving at Role I are generally very familiar with TCCC principles. This is not reliably true for physicians, physician assistants, and nurses, since there is no DoD-wide requirement for them to receive this training.

6. Even Role I combat medical personnel who are familiar with TCCC techniques and equipment may not receive up-to-date TCCC training and equipping prior to deployment.

7. The lack of pre-hospital care documentation is a major obstacle to advancing pre-hospital trauma care. If you cannot document what was done, then you can’t make evidence-based improvements. You can’t improve what you can’t measure, and you can't measure without data.

8. A clear opportunity for improvement exists in the area of providing an advanced casualty evacuation capability for severely injured casualties.

9. The key elements of an advanced casualty evacuation capability are: 1) a multi-provider team; 2) air and ground platforms that can support this team and its casualties; 3) the ability to perform Damage Control and Hemostatic Resuscitation with 1:1 PRBCs to plasma; 4) the ability to perform an array of advanced airway interventions; and 5) the ability to administer tranexamic acid (TXA).

10. A continuous review of all deaths in CJOA-A conducted as a combined effort of the Joint Trauma System and the Office of the Armed Forces Medical Examiner is needed to identify potentially preventable deaths among U.S. combat fatalities and enable necessary performance improvement efforts to be made in a timely manner.

F. Selected Recommendations (Sustains and Improves):

Secretary of Defense:

1. Command-direct an on-going 100% preventable death review and analysis of all combatrelated fatalities to be conducted by a joint team from both the Armed Forces Medical Examiner and the Joint Trauma System.

2. Command-direct an on-going review and analysis of preventable deaths in CJOA-A as they relate to tactics, techniques, and procedures (TTPs), tactical trends, personal protective equipment (PPE), evolving injury patterns, and OPTEMPO through a consolidated registry of findings from formal tactical investigations and theater-wide tactical operations interfaced with the DoD Trauma Registry

–  –  –

3. Support designation of the Joint Trauma System (JTS) as a DoD Center of Excellence and as the lead agency for Trauma Care and Trauma Systems

4. Support TCCC realignment under JTS with POM support, and strengthen its role in providing best-practice pre-hospital trauma care recommendations

5. Develop a TCCC Rapid Fielding Initiative to fast-track new TCCC techniques & technology to deployed and deploying combatant units as requested.

Service and Combatant Commanders:

1. Line commander priority, emphasis, and understanding of their tactical casualty response system is critical to success (e.g. 75th Ranger Regiment Casualty Response model)

2. Train all combatant unit personnel in basic TCCC initially, annually, and within 6 months of combat deployment (e.g. USSOCOM Directive 350-29 model). This should be a requirement for deploying to a combat theater.

3. Train all medical personnel (physicians, PAs, nurses, medics) in instructor-level TCCC courses initially and within 6 months of combat deployment. This should be a requirement for deploying to a combat theater.

4. Integrate TCCC-based casualty response into battle drills, small unit tactics, and training exercises at all levels (e.g. 75th Ranger Regiment Casualty Response model).

5. Support enduring sustainment hands-on trauma training for all pre-hospital medical personnel (Live Tissue & Trauma Center Rotations) (e.g. USASOC Regulation 350-1 model)

6. Advance pre-hospital care and improve performance through Point-of-Injury (POI) care documentation (TCCC Casualty Card, JTS AAR, unit-based registries) directed by line commanders (e.g. 75th Ranger Regiment Casualty Response model)

7. Advance pre-hospital evacuation care and improve performance through TACEVAC care documentation (TCCC Casualty Card, Run Sheets) directed by line commanders

8. Emphasize contingency planning to ensure evacuation capabilities in non-permissive environments.

Service Surgeons General:

1. Sustain and expand initiative to train and sustain all tactical evacuation medics as Critical Care Flight Paramedics (e.g. 160th Special Operations Aviation Regiment (Airborne) model;

AFSOC model; newly implemented AMEDD model)

2. Support and expand USFOR-A initiatives to develop an advanced tactical evacuation capability for the critically injured – blood, plasma, advanced airway interventions, advanced provider teams (e.g. UK MERT model)

–  –  –

Research and Development Commanders:

1. Elevate the priority of pre-hospital trauma care research and funding and emphasize the need for advances in non-compressible hemorrhage control and resuscitation of casualties in shock in the pre-hospital environment

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