A unit of a 14-person, six-vehicle military convoy is moving through a village in northern Afghanistan. As the convoy pulls out on open road at the end of that village, an improvised explosive device (IED) discharges under the second vehicle manned with two soldiers. Intensive sniper fire follows and the rest of the convoy is busily engaged in suppressing it. The non-armored disabled vehicle is right side up and not on fire. You are the medic of the unit and you are in an armored vehicle, next to the demolished vehicle with the two victims. As you arrive at the vehicle, you find two casualties: Casualty #1 is the driver of the vehicle. He sustained bilateral mid-thigh traumatic amputations, as well as a penetrating injury of the pelvis and the abdomen. Furthermore, there is a large open head wound in which mangled gray matter is clearly visible. There are no vital signs—he is obviously dead. Casualty #2 is the front-seat passenger. He sustained a below-knee amputation of his left leg with heavy arterial bleeding from the stump, as well as multiple injuries to the left side of his face. He has significant soft-tissue trauma, and has sustained a visible comminuted fracture of the mandible. You note moderate bleeding from the left facial injury. The soldier is conscious and has a good radial pulse but the airway appears compromised due to disrupted airway anatomy (maxillofacial trauma) and bleeding into the airway.
Immediate trauma care on the battlefield varies in many respects from pre-hospital trauma care as practiced in the civilian setting. First, the causes, types, and severity of injury differ; second, in combat settings, the incidence of hostile fire, dark environments, limited medical equipment, and prolonged evacuation times is greater. Therefore, treatment guidelines developed for the civilian setting do not necessarily work well in the military setting. The need for reconsideration of trauma care guidelines in the tactical setting has long been recognized.1–3 The Tactical Combat Casualty Care (TCCC) project was initiated by the US Naval Special Warfare Command in 1993, and later continued by the US Special Operations Command (USSOCOM). Within the framework of this project a bundle of tactically appropriate battlefield trauma care guidelines were developed.4 These TCCC guidelines combine “good medicine” with “small-unit tactics.”
TCCC has three goals for trauma care in the tactical setting: (1) treat the casualty; (2) prevent additional casualties; and (3) complete mission. TCCC is divided into three phases:
Care under Fire
Tactical Field Care
Tactical Evacuation Care
TCCC is performing the correct intervention at the correct time in the continuum of field care (Figure 58–1). In the Care under Fire phase, medical personnel and casualties are under effective hostile fire and tactical considerations predominate. The medical care is limited to extremity hemorrhage control with tourniquets. In the Tactical Field Care phase, more extensive medical care can be provided, because there is no effective hostile fire. In the Tactical Evacuation Care phase, the casualties are transported (air, ground, or sea) to a medical facility with the opportunity to provide additional medical personnel and equipment to further increase the level of care. The TCCC guidelines will be updated periodically by the Committee on Tactical Combat Casualty Care (CoTCCC). Furthermore, the TCCC guidelines are currently adapted into civilian Tactical Emergency Medical Service (TEMS) systems.
TCCC was introduced in the Canadian Forces (CF) first to their Special Operation Forces in 1999 and to the conventional forces before the initial deployment of Canadian soldiers to Kandahar/Afghanistan in 2002. In July 2011 Canada ended its combat mission in Afghanistan. More than 1000 CF members have been injured and more than 150 have been killed. During the Afghan war the CF gained substantial experience delivering TCCC to wounded soldiers on the battlefield. Compared to past conflicts, this conflict has seen a dramatic reduction in the number of soldiers killed from combat wounds: the current case fatality rate is 8.8%, whereas the rate during World War II was 22.8%.5,6 Savage et al.7 conclude in their publication on lessons learned from the Afghan war, that “though this success is multifactorial, the determination and resolve of CF leadership to develop and deliver comprehensive, multileveled TCCC packages to soldiers and medics is a significant reason for that and has unquestionably saved the lives of Canadian, Coalition and Afghan Security Forces.”
ASSESSMENT OF THE PATIENT
According to the TCCC guidelines, you are in the phase “Care under Fire.” Limited medical care should be attempted while the casualty and the unit are under effective hostile fire. The major considerations during this phase of care are the following:
Suppression of hostile fire.
Moving the casualty to a safe position.
Treatment of immediate life-threatening hemorrhage.
Casualty treatment during the “Care under Fire” phase is complicated by several tactical factors8: first, the medical equipment carried by the individual soldier and rescuer is limited; second, the unit’s personnel will be engaged with hostile forces and, especially in small-unit engagements, will not be available to assist with casualty treatment and evacuation. Third, the tactical situation prevents the medic or medical provider from performing a detailed examination or definitive treatment of casualties.
It is commonly said that “the best medicine on the battlefield is fire superiority.” It is the best way to prevent risk of injury to other personnel or additional injuries to the casualty. As soon as the rescuer is directed or able, his/her first major objective is to keep the casualty from sustaining additional injuries. The casualty is directed to move to cover. If the casualty is not able to move, the casualty has to be dragged or carried by rescuers to a safe position.
Extremity hemorrhage is the most frequent cause of preventable battlefield deaths.9 Because of their effectiveness at hemorrhage control and the speed with which they can be applied, tourniquets are the best option for temporary control of life-threatening extremity hemorrhage in the tactical environment.10 Based on the experience of combat medics on the battlefield of Iraq and Afghanistan, the use of hemostatic agents was reconsidered and is not recommended for this phase of care. The requirement to hold direct pressure on the bleeding site after application of a hemostatic agent for at least 3 to 5 minutes was felt tactically not feasible when the casualty and the responder are under effective hostile fire. Once the casualty is under cover, a hemostatic agent can be a highly effective option in life-threatening non-extremity wounds.
No immediate management of the airway should be anticipated at this point because of the need to move the casualty to cover as quickly as possible.4 The time, equipment, and positioning required to manage a compromised airway expose the casualty and the rescuer to increased risk. Rescuers should delay airway management until the “Tactical Field Care” phase, during which the casualty and the rescuer are safe from hostile fire.
Once the casualty and the rescuer are no longer under effective hostile fire, “Tactical Field Care” protocol can then be applied. Application of the “Tactical Field Care” phase is governed by the following8:
The risk from hostile fire has been reduced but still exists.
The medical equipment available is still limited by what has been brought into the field by mission personnel.
The time for treatment is highly variable. Time prior to evacuation can range from a few minutes to many hours.
The medical care provided during this phase is directed toward more in-depth evaluation and treatment of the casualty, focusing on those conditions not addressed during the “Care under Fire” phase of treatment. While the casualty and the rescuer are now in a less hazardous situation, evaluation and treatment are still dictated by the tactical situation, which may change quickly.
The armed with an altered mental status has to be disarmed immediately. Armed combatants with altered mental status pose significant risks to themselves and those in the unit. Main reasons for an altered mental status are traumatic brain injury (TBI), pain, shock, and analgesics.
In this phase of care, after hemorrhage control, the evaluation and management of the casualty are paramount. Intervention should proceed from the least-invasive procedure to the most-invasive:
Unconscious casualties should have their airways opened with the chin lift or jaw thrust maneuver.
In unconscious patients with spontaneous breathing and no airway obstruction, a nasopharyngeal airway (NPA) is used.
Unconscious casualties are placed in the semi-prone recovery position to minimize the risk of aspiration.
Conscious casualties with maxillofacial trauma should be allowed to assume whatever position that allows them to breathe most easily, including sitting upright if able.
If an airway obstruction develops or persists despite the use of an NPA, a more definitive airway will be required. In these cases in the tactical setting, a surgical airway is preferable to endotracheal intubation. The reasons for this recommendation are: (1) most corpsmen and medics are inexperienced in the technique of endotracheal intubation (whether on a live casualty or on a cadaver); (2) because the light source may attract hostile fire, direct-vision endotracheal intubation is not recommended10; (3) endotracheal intubation may be extremely difficult in patients with maxillofacial injury11; (4) in a combat setting, esophageal intubation may be difficult to detect.
The next aspect of casualty care in the Tactical Field Care phase is the treatment of any breathing problems, specifically the development of either an open pneumothorax (PTX) or a tension PTX:
All penetrating chest wounds should be treated as an open PTX by applying an occlusive material to cover the defect and securing it in place. There are numerous commercial chest seals available. After sealing a chest wound, the casualty must be monitored closely for any worsening of respiratory function which might indicate the conversion of an open to a tension PTX.
Consider tension PTX in a casualty with progressive respiratory distress and known or suspected torso trauma. Decompress the chest on the side of injury with a 14-gauge needle/catheter unit inserted in the second intercostal space at the midclavicular line (needle thoracostomy).