A Special Forces sergeant in Afghanistan was wounded in the right arm and the right leg by an explosion from a rocket-propelled grenade. There was significant external hemorrhage from the injury to his leg. The year was 2003 and the US military had not yet begun to field modern, commercially manufactured tourniquets. The unit’s medic was killed early in the attack. Three improvised tourniquets applied by his other teammates failed to stop the hemorrhage, and the wounded Special Forces warrior exsanguinated from his leg wound. A well-designed commercial tourniquet would have saved his life, but neither he nor anyone in his unit had one.

Multiple studies have shown that the very large majority of those killed in combat die in the prehospital phase of care (killed in action, or KIA, just as the casualty described above did). Most of these KIA deaths result from overwhelming injuries and could not have been prevented by improvements in medical care – so-called “non-preventable” deaths . Some deaths, however, result from injuries that were potentially survivable had optimal care been rendered and the casualty transported rapidly to a medical treatment facility with a surgical capability. It is the prehospital phase of care that offers the greatest opportunity to reduce combat fatalities, since the overwhelming majority (97%) of casualties who arrive at a medical treatment facility alive go on to survive their injuries.

In contrast to the medicine practiced in hospitals, which is overseen by hospital commanders, it is the combat line commanders who are responsible for all aspects of what their units do on the battlefield, including the care of wounded unit members. Training and equipping for Tactical Combat Casualty Care and executing these concepts on the battlefield may not be well executed if medical personnel have not emphasized the importance of this critical aspect of combat operations to their commander. If the commanders, in turn, have not made Tactical Combat Casualty Care training and equipment a point of command emphasis, unit members with potentially survivable injuries may be needlessly lost.

Tactical Combat Casualty Care (TCCC) has transformed battlefield trauma care in the US military over the 20-year period from 1996 to 2016. TCCC is a set of evidence-based, best-practice prehospital trauma care guidelines that are customized for use on the battlefield. Its concepts are built around the absolute necessity to combine good medicine with good small unit tactics when caring for casualties at the point of injury. In that setting, there is not just one but rather three goals to consider while rendering care: (1) save the casualty, (2) prevent additional casualties, and (3) complete the mission.

Tactical Combat Casualty Care is the prehospital component of the Joint Trauma System (JTS) . The JTS was created by the US military during the Afghanistan and Iraq conflicts to oversee the care provided to our casualties, to document that care, to look for opportunities to improve the delivery of trauma care, and to advise the US Central Command surgeon about how to optimize the delivery of combat casualty care from a systems level.

At the end of the Vietnam War, Navy Captain J. S. Maughon observed that very little had changed in the prehospital phase of combat casualty care in the last 100 years. Twenty-two years later, in 1992, that statement was still true. Advances in battlefield trauma care are challenging to accomplish because there is very little high-level evidence regarding the interventions used on the battlefield and the benefits associated with their use. Also, combat medics are typically not experts in the academic aspects of trauma medicine; trauma surgeons and emergency medicine physicians, in contrast, are typically not expert in providing trauma care in the midst of the lethal chaos of the battlefield. The line commanders who are the ultimate authority for battlefield medicine are experts at neither. This set of circumstances provides an optimal setting for clinical stagnation , which was exactly where the US military (as well as other militaries) were in 1992.

Since there was no single group in the US military with a mission to develop evidence-based, best practice trauma care guidelines for prehospital combat casualty care, training in this area was based largely on civilian trauma courses. Examples of the principles of battlefield trauma care as practiced in the military in 1992 included the following:

The initial impetus for TCCC was the observation that the recommendation to avoid tourniquet use, as taught in the Advanced Trauma Life Support (ATLS) course and virtually all other course and other trauma courses at the time, was not well supported by the available evidence. Tourniquet use was strongly discouraged in both military and civilian prehospital trauma care despite the following: (1) exsanguination from extremity hemorrhage had been well described as a leading cause of preventable death in combat casualties; (2) tourniquets can definitively stop extremity hemorrhage; and (3) tourniquets were – and are – routinely used for short periods of time in orthopedic surgery procedures without causing loss of limb from tourniquet ischemia. So, if it is appropriate to use a tourniquet in the operating room to help do extremity surgery in a bloodless field, why was it not appropriate for combat medics, corpsmen, and PJs to use them to save lives on the battlefield?

This realization caused the Naval Special Warfare Biomedical Research Program to launch a complete review of battlefield trauma recommendations in the US military in 1992. This project was a collaborative effort between Special Operations medical personnel and the Uniformed Services University of the Health Sciences as well as and a large group of volunteer civilian consultants. For 3 years, every aspect of prehospital combat casualty care was reviewed in light of current evidence, battlefield conditions, and the unique prism of the combat medic. Combat medics, corpsmen, and PJs played a major role in developing these guidelines through a series of workshops dedicated to obtaining their input for this project.

Also, the interventions proposed by TCCC were sharply focused on the causes of preventable death on the battlefield as described by COL Ron Bellamy, CAPT Maughon, and other military authors from the Vietnam era: hemorrhage, airway obstruction, and tension pneumothorax. Additionally, the rule of evidence was applied to all existing recommendations in prehospital trauma care – as opposed to requiring definitive evidence for only proposed new interventions. Many aspects of prehospital care at the time, not just tourniquets, were not well supported by the available evidence.

This project resulted in the original TCCC paper, which was published as a special supplement in the journal Military Medicine in 1996. It included a number of recommendations that were novel and controversial at the time, including the aggressive use of tourniquets for initial control of life-threatening extremity hemorrhage, the use of a hetastarch solution rather than crystalloids for resuscitation of casualties in shock from controlled hemorrhage, no prehospital fluids for casualties in shock as a result of non-compressible hemorrhage, and the use of IV rather than IM morphine for battlefield analgesia, to list a few.

TCCC was well publicized within the Department of Defense but was not widely used in the US military during the interval from the publication of the original TCCC paper in 1996 to the start of the war in Afghanistan in 2001. The novel recommendations in TCCC gave military medical decision makers a pause. Briefings to senior military medical and line leaders did not produce any widespread changes in battlefield trauma care concepts in the DoD.