«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 ...»
(BAF Role I – CJSOTF; Tarin Kowt Role I – NSW; Role I – 75th Ranger Regiment) Centralized packaging of CWPP medications with extended shelf life would prove beneficial for some units.
245. Many intraosseous infusion devices are found to be non-functional upon arrival at the Role II and Role III facilities. (JTTS Deployed Director)
246. In addition to Cox-1 NSAIDs, other medications to include selective serotonin reuptake inhibitors (SSRIs) may also inhibit platelet function. (BAF Role I – 1st Infantry Division) Medications being administered to combatants in theater should be reviewed for their possible effect on coagulation and prescribed only when the therapeutic benefit is perceived to outweigh the increased risk of death from hemorrhage if the individual is wounded.
247. Potential platelet donors at the Kandahar platelet apheresis center are rejected if they have been on recent aspirin, ibuprofen, or other NSAIDs. (KAF Role III)
248. Evacuation aircraft carry compressed gas cylinders with oxygen to use for casualty care.
(BAF Role I – Shadow DUSTOFF; Bastion Role I – UK MERT; Bastion and BAF Role I – USAF Pararescue personnel)
249. Medics noted that the FAST IO is very slow when blood is being infused. The EZ-IO humeral is faster but is much more easily dislodged. (Tarin Kowt Role I – NSW)
250. SEAL IFAK is very complete; includes 2 x SOFT-T tourniquets, TCCC Card, NPA, combat wound pill pack (Mobic 15mg, Tylenol 650mg, Moxifloxacin 400mg), 2 HALO chest seals, 14 GA 3.5” Needle for chest decompression, and 2 x combat gauze. (Tarin Kowt Role I – NSW)
251. The SEAL medics interviewed preferred the SOFT-T tourniquet to the Combat Application tourniquet. One medic suggested that a hybrid tourniquet be developed that incorporates the best features of the CAT and the SOFT-T. (Tarin Kowt Role I – NSW)
253. Each SEAL operator carries a morphine 10mg IM auto-injector for battlefield analgesia.
SEAL medics noted that OTFC works better than IM morphine and is often given in conjunction with IM morphine. SEAL medics do not routinely carry ketamine. (Tarin Kowt Role I – NSW)
254. In light of the recent Green on Blue occurrences, it is essential that all Afghan casualties be searched prior to admitting them to the hospital. (Role III – KAF Commander)
255. It is imperative that a thorough security check to include a complete search of the casualty’s person be done on all Afghan casualties before they are loaded onto evacuation platforms. (Bastion Role I – UK medics and physicians)
256. In terms of mobility, to what extent have our military forces sacrificed the situational awareness and flexibility of former vehicle platforms for the heightened protection provided by current vehicle designs? (Salerno Role I – CJSOTF) Too much PPE can create a defensive posture and negate the tactical advantage of an offensive posture. (Salerno Role I – CJSOTF;
Role I – 75th Ranger Regiment Combatant Leader)
257. The quantity, severity, and mechanism of injury of combat casualties vary by unit role on the battlefield. (e.g. Battle space owner versus assault element – deny terrain versus offensive operations.) (Role I – 75th Ranger Regiment Combatant Leader)
258. Build strength in the force, not resilience. Strength is proactive, whereas resilience is reactive. (Role I – 75th Ranger Regiment Combatant Leader)
259. Human performance programs are paramount. If tailored to the individual, the unit, and the mission, these programs will play a major role in injury prevention, injury tolerance, and injury recovery. (JTS Trauma Care Delivery Director)
260. The medical community exists to provide the line with confidence. (Role I – 75th Ranger Regiment Combatant Leader)
261. Multiple 75th Ranger Regiment combatant leaders and first responders made themselves available to the pre-hospital assessment team in Afghanistan. This underscores the fact that these personnel view themselves as an integral part of the pre-hospital casualty response system. (JTS Trauma Care Delivery Director)
262. Here is what SEAL units need to improve combat trauma care in theater: 1) a Forward Surgical Element dedicated to CJSOTF operations; 2) maintain good SEAL SOCM medics; 3) we need better definition, quantification, and treatment of TBI – both blast vs blunt trauma; and
4) optimized physician medical leadership in combat trauma care. (Tarin Kowt Role I – NSW Combatant Commander)
263. All UK ground forces are wearing protective undergarments to protect against urogenital injury from dismounted IED attacks. (Bastion Role I – UK medics)
and a nurse. The MTB is basically an armored container box that is protective against small arms fire. It requires a Logistic Vehicle System Replacement (LVSR) to move. While the concept of moving the MTB close to the battle to provide life-saving casualty care as quickly as possible may be very useful in classic USMC maneuver operation, it has been difficult to employ effectively in the counterinsurgency and village stability operations currently being conducted in Afghanistan. (Bastion Role – USMC/USN physician)
I. 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. The JTS should remain the source for best-practice trauma care guidelines to be recommended to the services.
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.
6. Implementation of a TCCC Rapid Fielding Initiative should include a rapid fielding team of subject matter experts that conduct visits to deployed and deploying forces, issues and transitions supplies and equipment, and provides hands-on training and testing of knowledge.
7. A battlefield death, KIA and DOW, registry must be initiated and maintained.
8. The Joint Trauma System (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.
Consider realignment of the JTS under the Joint Surgeon's Office, or equivalent Joint solution, in order to meet these requirements and optimize mission success. However, maintain current operating location at the Battlefield Health and Trauma Research Institute. This location facilitates relationships with a Joint medical research complex as well as a Joint Level I Trauma and Burn Center.
Service and Combatant Commanders:
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.
9. Casualty response systems should be measured as a combatant unit priority for combat deployment, as well as an enduring requirement for training and readiness. A “go / no go” criteria with command attention should be enacted and reflected on a Unit Status Report (USR) or an equivalent reportable mechanism.
10. Point of injury pre-hospital trauma care documentation should be obtained for all casualties using a redundant data capture system that includes: 1) documenting care when tactically feasible during a mission using the TCCC Casualty Card (DA Form 7656 or DoD equivalent), 2) documenting care within 72 hours following a mission using the JTS TCCC AAR system, and 3) establishment of unit-based registries in order to provide near real time feedback to commanders.
11. As conventional forces of the future are chartered to become more SOF-like, and to conduct more unconventional missions, other major commands should review USSOCOM Directive 350-29, Special Operations Forces Baseline Interoperable Medical Training Standards, and USASOC Regulation 350-1, Appendix G, Medical Sustainment Training.
Requirements and practices depicted in these documents should be considered by other major commands as applicable.
12. Human performance programs are paramount. If tailored to the individual, the unit, and the mission, these programs will play a major role in injury prevention, injury tolerance, and injury recovery. Review and consider USSOCOM human performance programs as a model for expanded efforts throughout the U.S. military.
Medical instructors should also be embedded in the structure of basic combat arms centers and schools in order to accommodate basic pre-hospital lifesaving skills and ideology applicable to all first responders. Non-AMEDD leadership schools at all levels should also integrate medical instructors to optimize TCCC and pre-hospital casualty response training for leaders.
14. Services should monitor TCCC and combat medical training courses to ensure that content and variations from CoTCCC recommendations are approved by service medical leadership and based on best practices and appropriate levels of evidence.
15. Combatant Commanders and Surgeons outside of CENTCOM should review this report, implement applicable recommendations for readiness and contingency planning prior to an outbreak of conflict in their area of operations, and be prepared to perform recommended tasks as provided to CENTCOM. Lessons learned are not lessons learned unless we learn them.
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)
3. Implementation of initiatives to develop advanced tactical evacuation capabilities for the critically injured should consider three components: 1) Medical capabilities (advanced training, provider teams, forward damage control resuscitation techniques - blood, plasma, other), 2) ground vehicle and aircraft capabilities (configuration, markings, ground and airframe, technology, weapon systems), and 3) pilot and crew capabilities (advanced ground and flight training, weapons training). All methods and facets of tactical evacuation should be explored to optimize successful mission accomplishment. A dedicated aircraft should not dictate the mission requirement; the mission requirement should dictate a dedicated tactical evacuation capability.
An intelligent tasking algorithm and matrix should be developed.
4. Professionalize the force; review and refine a career pathway for military pre-hospital medics. Although a senior medical NCO should be a master of his craft, current advancement opportunities are weighted toward non-medical attributes and skills. Consider technical advancement and autonomy of practice for senior medics (both flight and ground) through Emergency Medical Technician-Paramedic training. (e.g. United Kingdom model) Consider commensurate compensation for maintaining paramedic credentials (e.g. Jump, Dive, Flight status model), as well as a paramedic tab to readily identify and denote achievement of the advanced paramedic skill level (e.g. Ranger Tab model).
5. Review and refine a career pathway for military pre-hospital physician assistants. Significant prior combat medic experience should be a major selection factor for the interservice physician assistant program. Historically, experienced prior service medics were selected for physician assistant training and then served for extended periods of time in combatant units. They were the center of gravity, medical continuity, and pre-hospital expert in a combatant unit. Over the past two decades, the selection criterion for physician assistant training has changed to
accommodate lesser to no prior medical experience, and extended assignments with combatant units are now discouraged. Pre-hospital career paths should be encouraged and pre-hospital subject matter experts should be created and sustained. Additional training opportunities should include critical care, trauma, and emergency medical systems fellowships.