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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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161. Basic training units should have a standard TCCC POI that trains first responders to proficiency. Training can be conducted to a level of familiarization, proficiency, or mastery.

Training to a level of familiarization will not save lives under the stress of combat. (BAF Role I – 1st Cavalry Division)

162. Best practices and procedures should be cross-leveled and standardized between all military medical simulation training centers (MSTCs), as currently too much variability exists between sites. MSTCs should receive central certification. MSTCs should serve as a TCCC training materiel and equipment distribution site. MSTC trainers need to be subject matter experts, regardless of military versus civilian status, and they must train to a standard not to a time. (BAF Role I – 1st Cavalry Division, 1st Infantry Division, 173rd ABCT)

Unclassified Unclassified

163. Senior ground medics expressed concerns for the current inequity of opportunity for paramedic training when compared to flight medics and civilian counterparts. A ceiling exists that limits the technical education and growth of ground medics. (Role I – 1st Infantry Division, 3rd Infantry Division, 101st Airborne Division (AASLT), 173rd ABCT)

164. If combat casualty care is a training priority and a requirement, combatant commanders need to formally place all levels of casualty response training on short and long term training calendars. (Role I – 1st Infantry Division, 3rd Infantry Division, 101st Airborne Division (AASLT), 173rd ABCT)

165. A medical rapid fielding initiative should include subject matter experts to provide “train the trainer” instruction. (Role I – 3rd Infantry Division)

166. Civilian contracted TCCC and tactical first responder courses vary in quality. They provide either great training or a means to check the block for training. Who inspects, certifies, and ensures quality control of these programs? (Tarin Kowt Role I – NSW)

167. Oftentimes training occurs during deployment, rather than pre-deployment. (Tarin Kowt Role I – Australian Forces)

168. All UK forces are taught Battlefield First Aid (BFA), initially and refresher once a year.

(Bastion Role I – UK Forces)

169. Live tissue training (LTT) is paramount and saves lives. (Role I – USA, USAF, USMC, USN)

170. Field Medical Training Battalion (FMTB) course is 8 weeks with combat trauma management as a 2 week portion taught toward the end of the course. All elements include LTT in pre-deployment training (PDT). LTT is essential – most currently use swine model. FMTB approves curriculum for LTT vendor courses. All contracted and based on TCCC; however, companies vary on how skills are taught (e.g. “high and tight” tourniquets, improper location for needle decompression). Consider cost and benefit of contract versus organically provided training. (Bastion Role I – USMC/USN)

171. Marine Corps and BUMED directives mandate TCCC training for HMs but not physicians.

Combat Trauma Training should be a theater requirement. (Bastion Role I – USMC/USN)

172. Physicians typically go to a combat trauma course put on by a private contractor that includes LTT. USMC medical officers get the same course as corpsmen and riflemen. The course is 1 day of lectures and 1 day of application (LTT). It is billed as a Combat Lifesaver course and incorporates TCCC, although it may not have the latest updates to TCCC. (Bastion Role I – USMC physician)

173. The Combat Casualty Care Course (C4) conducted for medical officers is hit and miss. All interns are supposed to get the C4 course at the Defense Medical Readiness Training Institute (DMRTI). This is a 10-day course, of which 3 days is TCCC. Not all interns actually attend this training. Additionally, this is a one-time only initial training – no sustainment training is provided.

Are we training military medical officers and employing them in the right manner or are we stuck in an old paradigm? As physicians receive initial and sustainment training in ATLS, there should be a universal requirement for military physicians to receive initial and sustainment training in combat casualty care. (Bastion Role I – USMC/USN) Unclassified Unclassified

174. It is a MEF requirement for all medical officers to go to the Naval Trauma Training Center prior to deployment. The training is good but the trauma is different from that seen in theater.

Two days of TCCC is taught as part of the NTTC course. (Bastion Role I – USMC physician)

175. Medical officers assigned to USMC units attend the 2-week Field Medical Service Officer (FMSO) Course at one of the two FMTBs. This course provides an introduction to Marine Corps medical support structure and function, Marine combat operations, and the basics of field medical care. Basic TCCC concepts are covered but this portion of the course is not formalized and there is no certification provided. (Bastion Role I – USMC physician)

176. Stress training is essential. Trauma center rotations (TCRs) and Navy Trauma Training Center (NTTC) are both desirable. The Navy Medical Education and Training Command should require and provide both TCR and LTT – not either/or, but both. Cadaver lab is not the same as LTT – it does not provide the same stress and realistic training. (Bastion Role I – USMC/USN)

177. There is an uneven application and implementation of pre-hospital and TCCC protocols within and between services. There is also a significant delay of data and protocol integration at the service schoolhouses. (Bastion Role I – USMC/USN)

178. The content of some TCCC courses taught to U.S. military personnel does not accurately reflect the recommendations made by the Committee on TCCC as published in the PHTLS Manual and posted on the PHTLS and Military Health System web sites.

(Role 1 – USMC/USN)

179. There was unanimous agreement that LTT is very helpful in preparing corpsmen to manage combat casualties. There was a recommendation that the USMC, USSOCOM, and USCENTCOM do a joint letter to address this issue. There is a need to optimize the use of LTT models to teach the required procedures and there should be more objective metrics for LTT.

(Bastion Role I – USMC/USN physicians and corpsmen)

180. There is currently no requirement to make HMs EMT-B qualified. Naval hospitals want corpsmen to have this certification so they can use them on ambulance transports. The Navy tried to incorporate this requirement, but it was resource intensive. EMT-B training was noted to be not really helpful for managing combat trauma. (Bastion Role I – USMC/USN corpsmen)

181. Special Forces medics reliably get updated TCCC training and equipment as a result of the Special Operations Medical Skills Sustainment Course; and both medical and non-medical Special Forces personnel receive TCCC training prior to combat deployment during Pre-Mission Training (PMT). (BAF Role I – CJSOTF)

182. Physicians assigned to Special Forces units as Battalion Surgeons do NOT reliably get TCCC training before deploying to combat theaters. (BAF Role I - CJSOTF)

183. Battlefield trauma training must be a reportable item and receive command attention. (KAF Role I – 3rd Infantry Division)

184. Combat medics MUST have Live Tissue Training. (KAF Role I – 3rd Infantry Division)

–  –  –

185. Combatant units would like to get an update package whenever changes are made to TCCC. (KAF Role I – 3rd Infantry Division)

186. The 3rd ID is working to increase the skill level of their flight medics to paramedics. (KAF Role I – 3rd Infantry Division)

187. All Medical Officers in the 3rd ID went to TCMC, and all medics went to either BCT3 or TCMC. However, units from other divisions are deployed under our command and may not have the same strict training requirement. (KAF Role I – 3rd Infantry Division)

188. All SEALs receive TCCC training as part of the SEAL Qualification Training course and again as part of Tactical First Responder (TFR) training in preparation for deployment.

Physicians assigned to NSW units do not necessarily get formal TCCC training. (Tarin Kowt Role I – NSW) This creates the remarkable potential for NSW physicians to know less about battlefield trauma care than non-medical SEAL operators.

189. Tactical First Responder (TFR) training for SEALs is a 3-day course. It is contractor-run and varies in quality depending on the contractor chosen. It does not necessarily include the latest updates in TCCC. TCCC training should be the responsibility of the UNIT senior combat medical leader. Casualty response drills that include TCCC are part of this training. Live tissue training is excellent and is an important part of this course, but needs to be done in the context of TCCC principles and should be a culminating event. TFR should be done at the start of platoon pre-deployment training. (Tarin Kowt Role I – NSW)

190. The Special Operations Combat Medic (SOCM) course is now almost 8 months long and teaches both TCCC and the USSOCOM Tactical Medical Emergency Protocols. (Tarin Kowt Role I – NSW) The expanded SOCM course may be the clinical equivalent of Navy IDC school with respect to trauma care and emergency medicine in deployed environments. (Tarin Kowt Role 1 – NSW Senior Medic)

191. SEAL medics had very strongly positive feedback about SOCMMSC training. The quality of instruction is excellent and it provides re-certification and trauma refresher training all at once.

(Tarin Kowt Role I – NSW)

192. SEAL medics recommended that a trauma rotation be available for all SEAL SOCM Medics. There is currently a rotation at Spirit of Charity Trauma Center in New Orleans that is available for some units, but not all. (Tarin Kowt Role I – NSW)

193. Trauma Center rotations are available when requested by SOF units for their medics and can be coordinated through their chain of command. (Tarin Kowt Role 1 – NSW Senior Medic)

194. LTT should be optimized to train the best life-saving skills. (Tarin Kowt Role I – NSW Combatant Leader) Both USSOCOM and Headquarters USMC have issued letters on how to optimize this training. (CoTCCC Chairman)

195. NSW physicians get relatively more training in submarine and dive medicine during Undersea Medical Officer (UMO) training, and relatively less training in SEAL operations, both land warfare and diving. The SEAL support portion of UMO training needs to be expanded significantly and include field experience in NSW operations. This training should also include an overview of the entire scope of USSOCOM component organizations and their missions, an understanding of deployed SOF missions, and deployed SOF task force structure/function.

Unclassified Unclassified There should also be TCCC, LTT, and selected SOCMSSC items in the course. (Tarin Kowt Role I – NSW)

196. We can’t send a PJ to war unless all of his certifications are current; otherwise how would we assure skills maintenance? We need an EMT-M (Military). (Bastion Role I – USAF CRO)

197. LTT has saved many lives. It will be a travesty if we lose it. LTT should include tactical scenarios. It is taught by contract vendors and there is variation in the quality of the courses.

(Bastion Role I – USAF CRO and Senior PJ)

198. PJs have a robust internal network for following new developments in TCCC and do not necessarily need a TCCC Transition Initiative provided by an outside organization. (Bastion Role I – USAF Senior PJ)

199. PJs need hands-on trauma experience at trauma centers as well as paramedic and other required recertifications. PJs train using LTT at least every 2 years. This training is in addition to current PJ deployment frequency – every other 3 month period. (BAF Role I – USAF Senior PJ)

200. Many potential military and civilian first responders routinely play popular combat video games (e.g. Halo, Call of Duty, Gears of War). Partner with the makers of these games and integrate accurate first responder treatment protocols for casualties in the game, based on injuries and injury requirements. (JTS Trauma Care Delivery Director)

Equipment, Medications, Research, Technology

201. Army physicians and medics are well-informed about the basic tenets of TCCC techniques and technology but were found to lack recommended equipment items and medications – no TCCC cards, no OTFC, no ketamine. (BAF Role I – 1st Infantry Division; Salerno Role I – 101st Airborne Division (AASLT))

202. The impact of pre-hospital opioid analgesia on casualty outcomes has not been welldocumented. (CoTCCC Chairman)

203. Special Forces, Rangers, 160th SOAR, and Pararescue units are now carrying TXA. SEAL units do not carry TXA. (Tarin Kowt Role I – NSW) PJs have had TXA since the TCCC recommendation was made. (Bastion Role I – USAF Senior PJ)

204. There is a moral obligation to treat pain. Effective analgesia also helps to decrease the risk of PTSD. Opioids are overused at present. Ketamine is not really a new option, but there is relatively little ketamine use in theater at present. The use ratio of ketamine with opioids is about 1:25. This ratio should approximate 1:1. One to three mg of midazolam is useful for ketamine side-effects. Ketamine should not be given IV push, but injected over 1 minute. (Theater Trauma Conference – V Corps Command Surgeon)

205. TF Med A theater clinical operations has been tasked to obtain single dose vials of ketamine (currently only available in very concentrated multi dose vials) and a ketamine autoinjector. (Theater Trauma Conference – TF Med A Commander)

–  –  –

shock in that it is a late sign. Current research at the USAISR is focusing on cardiovascular reserve index as determined by computerized analysis of the arterial pulse wave character.

Also, there is a need to expedite fielding of the 731 ventilators. The ventilator’s calibration device is currently awaiting an FDA determination, but could be calibrated by forward positioned company representatives. Maintenance training for biomedical equipment technicians is also required prior to fielding. (Theater Trauma Conference – BAF Role III Trauma Surgeon)

207. Evacuation in conventional units may be delayed beyond the 3-hour cut-off for TXA use in casualties at risk for death from hemorrhage. Conventional evacuation units should have access to TXA. Prophylactic TXA should be considered. (Theater Trauma Conference – V Corps Command Surgeon)

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