TCCC / TC3 : Saving Lives on the Battlefield A Joint Trauma System Review of Pre-Hospital Trauma Care in Combined Joint Operating Area - Afghanistan (CJOA-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 command-directed 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.