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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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40. Many decisions about the specific aspects of battlefield trauma care are made at the brigade or battalion level. (BAF Role I – 1st Infantry Division, BAF Role I – Shadow DUSTOFF)

41. Multiple SEAL medics have commented on the robust nature of the Ranger Casualty Response Program. Ranger leaders assume risk for pre-hospital trauma care initiatives, training, and innovation. They also embolden their medics. (Tarin Kowt Role I – NSW Physician Assistant)

42. Some of the unit-based pre-hospital trauma care protocols reviewed were clearly in error.

One was noted to call for copious irrigation of an eye with suspected penetrating ocular injury.

(CoTCCC Chairman) Also, several pre-hospital protocols recommend 2 liters of LR for casualties in shock, which is at odds with current concepts of hemostatic resuscitation that call for minimizing the use of crystalloids during resuscitation. (JTTS Deployed Director)

43. Some medics in other services have been noted to carry their tourniquets in lower leg or ankle locations. This is a bad practice since the lower leg is often lost in dismounted IED attacks. (Bastion Role I – USMC/USN corpsmen)

44. A note on teaching trauma care to new corpsmen: “Don’t go for the ugly – go for the bleeding.” (Bastion Role I – USMC/USN corpsmen)

45. UK hospital personnel discussed a recent pediatric IED casualty. The patient suffered bilateral globe injuries as well as bilateral TM injuries. Role I personnel should understand that IED casualties may not be able to either see or hear after the injuring event. (Bastion Role III – UK physicians)

–  –  –

up in the urethra and resulted in a ruptured urethra. Additionally, this patient came in without IV access. (KAF Role III – Trauma Surgeon)

47. There was a recent case of a casualty who suffered rhabdomyolysis. The casualty had a tourniquet that had been left in place for an estimated 7-8hrs. There was an evacuation delay due to enemy fire. The casualty did not lose the leg but had renal injury as a result of the rhabdomyolysis. (KAF Role III)

48. Almost all tourniquets are effective, but some are placed very high on the extremity.

Ketamine is fantastic for pain, but limits the neurological exam more than opioids. One point about tourniquets is that care should be taken to not get the skin flap caught under the tourniquet. Reinforce the TCCC point about removing items from cargo pants pockets. Combat medics are doing a great job of saving DCBI casualties. Blast boxers are making a tremendous difference in preserving external genitalia in blast injuries. This success is largely due to the great job done by the previous 82nd Airborne Division Surgeon in spearheading this initiative.

(KAF Role III – Trauma Director)

49. COL Rob Russell, a prominent UK military physician with extensive personal experience with using TXA in theater, on TXA recommendation for trauma care: “Give it to all evacuation platforms. Give it to Casualty Collection Points and Battalion Aid Stations. Give it to medics if they may be doing extended field care. Quote me.” (Bastion Role III – UK)

50. The military medical community has Role III MTFs in Afghanistan that provide trauma care that rivals world-class civilian trauma centers. The greatest improvement in trauma care survival can be realized by directing more effort toward Role II and Role I. A paradigm shift in focus is required. Physicians and nurses understand and are comfortable with hospital and clinic care;

however, military physicians and nurses also need to understand and be comfortable with prehospital care, especially as it pertains to the battlefield. Trauma care delivery between Role I and Role II/III is currently not seamless. (JTS Trauma Care Delivery Director)

51. The Joint Trauma System (JTS) and the DoD Trauma Registry are as described, Joint and DoD. As such, the JTS must perceive and be perceived as a Service-neutral entity. The JTS must operate with agile access and accessibility to the Services and the COCOMS. Under the current construct, having the JTS operate as a component of the Joint Surgeon's Office best meets these requirements. However, the JTS should maintain its current operating location.

(Joint Trauma System Director)

Data and Performance Improvement

52. “An after action review (AAR) always followed a training exercise. When appropriate I compared my combat experience to what the regiment was doing. I suggested improvements and used combat examples where violations of fundamentals had resulted in unnecessary casualties. 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, Words of Wisdom: A Professional Soldier’s Notebook, 2007) AARs should always immediately follow a training exercise or combat mission. Role I personnel should use “Casualty AARs” to capture and share information for performance improvement of fundamental combat tactics, casualty response systems, and trauma care delivery. (JTS Trauma Care Delivery Director)

Unclassified Unclassified

53. 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 to enable necessary performance improvement efforts to be made in a timely manner. (JTS Director)

54. Combatant leaders have requested better availability of information concerning the status of recently injured members of their units. (Role I – 25th Infantry Division Combatant Leader, 101st Airborne Division (AASLT) Combatant Leader) USSOCOM has liaisons collocated with Role III, Role IV, and Role V MTFs to assist with this issue. (BAF Role I – CJSOTF)

55. Combatant unit commanders and medical providers desire feedback on their pre-hospital trauma care performance, documentation, and evacuation. (Role I – 1st Infantry Division, 3rd Infantry Division, 101st Airborne Division (AASLT), 173rd ABCT, CJSOTF, 75th Ranger Regiment) Consider providing feedback by region, service, and unit command.

56. 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.

(Military EMS and Pre-Hospital Medicine Fellowship Director)

57. Evidence-based best-practice protocols improve outcomes, standardization improves outcomes. (BAF Role III Trauma Surgeon) Outcomes are measured through morbidity and mortality.

58. Little to no medical records are received from most Role I units and personnel. (BAF, KAF, Bastion Role III – multiple medical providers)

59. Documenting POI casualty care is too difficult and should not be expected. (Multiple Role I, II, III providers)

60. Tactical evacuation is often occurring too quickly to complete POI TCCC interventions and TCCC card. (Kandahar Role I – 3rd Infantry Division)

61. The 75th Ranger Regiment obtained POI casualty care documentation (TCCC Card and/or Casualty AAR) for 74% of casualties in Afghanistan and Iraq from 2001 to 2010. [Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield.

Archives of Surgery 2011, 146(12): 1350-8.]

62. For FY 2012 in Afghanistan, nearly 100% of 75th Ranger Regiment combat casualties had POI documentation (TCCC Card and/or Casualty AAR); however, only 14.7% of total combat casualties entered into the DoD Trauma Registry during the same time frame had POI documentation available. You cannot improve performance without measuring performance;

you cannot measure performance without data. Data collection and analysis comes with an initial cost – Mandate, Monies, and Manpower. However, in the long run it is cost-effective as data and timely data analysis will improve command decisions and direct procurement appropriately for personnel, training, and equipment. (JTS Trauma Care Delivery Director)

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hospital casualty care documentation solutions must be available to all potential first responders and not just medical providers. (Role I – 75th Ranger Regiment Combatant Leader)

64. The weekly JTS trauma teleconference is well-attended by all providers in the spectrum of combat casualty care, except POI providers. Additionally, nominal input and data is received from Role I providers for this conference. As 87% of pre-hospital death occurs in the pre-MTF environment, with 24% potentially preventable, strongly recommend increase in POI provider involvement in this conference. (JTS Trauma Care Delivery Director)

65. The weekly JTS trauma teleconferences on occasion note that casualties who are given opioids are either in shock when the medication is administered or become hypotensive subsequently. No studies have been published from the current conflict that review outcomes in combat casualties as a function of the type and route of analgesia used in combat casualties as well as the type and severity of wounds sustained, and physiologic parameters indicative of circulatory or respiratory status. (CoTCCC Chairman)

66. Significant amounts of static tactical and medical information and data is being generated on the battlefield by multiple units in multiple forums on multiple systems. Email messages are a prime example of static information. This information must become dynamic. Information Technology systems must be employed to optimize the consolidation, synthesis, and analysis of information and data for tactical and medical performance improvement. (JTS Trauma Care Delivery Director)

67. Combatant units and Role I personnel utilize classified telecommunications and computer systems routinely at home station and extensively while deployed. MTF personnel have more limited access, especially at home station, which diminishes communication ability with Role I personnel for casualty updates and transfer of information.

68. There is currently no review or preventable death analysis done on casualties who are killed in action and never admitted to a Role III facility. (Role III – KAF)

69. The medical community must continue to improve its ability to utilize, analyze, and distribute information, data, and trends in near-real time in order to optimize timeliness of performance improvement initiatives that save lives.


70. The Tactical Evacuation (TACEVAC) phase of care includes both Casualty Evacuation (CASEVAC) and Medical Evacuation (MEDEVAC). “At the tactical level, organic, or direct support CASEVAC and/or MEDEVAC resources locate, acquire, treat, and evacuate military personnel from the point of injury or wounding to an appropriate MTF.” (Source: Joint Publication 4-02, Health Service Support, 26 July 2012)

71. A clear opportunity for performance improvement exists in the area of providing an advanced casualty evacuation capability for severely injured casualties. (Forward Aeromedical Evacuation “FAME” study pending publication)

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to perform an array of advanced airway interventions; and 5) the ability to administer tranexamic acid (TXA).

73. The Medical Emergency Response Team (MERT) is the UK combat air ambulance. The MERT was started in 2006 during Operation Herrick 4 in Afghanistan. The concept was first put into place by Col Martin Nadin. Currently, MERT provides 24/7 area coverage (15 minute notice during the day; 30 minute notice at night) with two dedicated casualty evacuation platforms and two groups of 17 personnel. Each group consists of 8 MERT medical personnel, 4 Force Protection personnel, and 5 crew personnel. The 8 MERT medical personnel provide two teams of 4 personnel, with each 4-man team consisting of an emergency medicine physician or anesthesiologist, an emergency medicine flight nurse, and two paramedics. The 4 Force Protection personnel are gunners (riflemen) who are trained to the team medic level and who rotate between QRF, MERT, and Tower duties; one is a commander lance corporal or corporal, and the others are senior air craftsmen. The 5 crew personnel consist of two pilots, two sidedoor gunners, and a tail gunner who also serves as the “loadie” crew chief. (Bastion Role I – UK MERT)

74. The USAF Pedro & Guardian Angel Team primarily provides Combat Search and Rescue (CSAR) support and secondarily provides casualty evacuation (CASEVAC) support. In support of the CASEVAC mission, two aircraft will deploy with 7 personnel on each aircraft. The team consists of two pilots, two gunners, and two Pararescue Jumpers (PJs) and one Combat Rescue Officer (CRO) on the lead aircraft and three PJs on the trail aircraft. The CRO is an aircrew member who is qualified on the aircraft and provides communications, command, and control with his own radio, not the aircraft radio. PJs train and sustain at the EMT-P level. CROs receive initial and annual TCCC training, and some also receive EMT-B training depending on the unit. Medical equipment includes Propac electronic monitors, Golden Hour boxes, 2 D cylinders of oxygen, blood components or Hextend (no LR or NS); hypothermia prevention through Ranger Rescue Wrap (heavy sleeping bag, 360 degree access, active heating pads) and wool blanket; they use ketamine liberally and consider it the best option for analgesia in combat casualties. (Bastion Role I – USAF Pararescue)

75. Category A evacuations currently comprise 70% of all evacuations in CJOA-A. (Shadow DUSTOFF) Need to ensure that evacuations are categorized correctly. Many evacuations are assigned a priority higher than what is actually required for their wounds. (JTTS Deployed Director) To help ground medics to better advise their mission commanders, who typically call in the 9-lines, a list of evacuation categories and examples of injury patterns each has been compiled by the JTTS Deployed Director and included in the revised TCCC curriculum.

76. It was also noted that some evacuations may be assigned a higher category than their injuries would normally warrant because of tactical considerations and follow-on mission requirements. Consider adding an evacuation category for “Tactical” mission requirements.

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