Why Tactical Combat Casualty Care (TCCC or TC3)
The NEW Way to Treat Trauma
Patrick O’Neil, PA
Trauma always evokes a lot of conversation and emotion. Part of this is due to the fact that the way we treat trauma patients has changed over the last two decades. When I first started in medicine we were taught the ABC’s of lifesaving. It was drummed into our heads, “Do this treatment sequence in this order, all the time, no exceptions.” The only problem with the ABC’s was that it may have been great for hospitals and ambulance personnel, but it wasn’t working out so well for those patients in austere places where quick access to care was unavailable. It wasn’t working out for the military, for hikers, campers, people having car accidents in semi-remote areas, etc.
In the late 80’s and early 90’s, I remember hearing about military research that was being conducted on how we treated battlefield trauma; and that there may be changes looming in the future. They were looking back at data from previous wars, doing retrospective studies, to see if our current treatment practices were sufficient. Then came Operation Gothic Serpent, or more commonly referred to as “Blackhawk Down.” During this battle, there were some really good Special Operations Medics that treated multiple casualties and returned saying that the conventional method of treating battlefield casualties didn’t work that well for them. They brought to light treatment considerations such as the use of IV’s on the battlefield, when to use the tourniquet, and a host of other issues. But, if any of you have ever served in the military, you know that change comes slowly. The military researches everything to incredible depth, at a painfully slow pace, and there is also the issue of convincing those that are resistant to change.
By the time 9/11 came around, and the world watched in disbelief as terrorists conducted a well-planned, simultaneous attack on the World Trade Centers and the Pentagon; the military was in the midst of changing how they treat wounded on the battlefield. The impending conflicts would speed up the change to what is now called Tactical Combat Casualty Care (TCCC or TC3).
What are the Differences in treatment?
First and foremost, the ABC’s were derived by civilians for the injuries they most commonly see….Blunt Force Trauma. These include vehicle accidents, falls, etc. Think of impact injuries. The ABC’s taught that Airway was the most important aspect of trauma care, that this is what would kill a patient most quickly. The next most important thing was Breathing, followed by Circulation (Hemorrhage). We then would place a C-Collar around the neck to stabilize it, and then establish two IVs into every patient. This was how we did it for every patient, every time. It didn’t matter if I came up to the side of a guy that was gushing blood from his leg, I had to check and clear his airway, secure that airway, then see if he was breathing on both sides of his chest, slap on a chest seal of some sort…..and then I could finally start to work on the bleeder that had now soaked the entire area around me.
TCCC answered the question, “In what order do I need to treat the things that can potentially save a battlefield casualty?” The military looked at all the causes of death on the battlefield. Penetrating Trauma, Blunt force trauma, burns, etc. They realized that some injuries are just not amenable to sustaining life. They are non-survivable wounds. In other words, if Joe gets shot in the head and you see brain matter coming out the hole; Joe ain’t gonna make it! If a bullet enters the left side of Joe’s chest, comes out the right side, taking out both lungs and his heart; Joe ain’t gonna make it! It doesn’t matter what you do….Joe ain’t gonna make it. Period. End of story. He may be breathing and squirming around on the ground, but he is not going to make it. He could get shot in the middle of the best trauma center in the world, and it would not change the outcome. Bag him, tag him, he is done. This is certain death. TCCC doesn’t worry about these types of injuries. The emphasis is placed on treating those injuries that can save lives.
In the research process leading up to TCCC, the military looked at tens of thousands of autopsy reports from previous wars. The vast majority of these wounds were not blunt trauma, but penetrating trauma (bullets, shrapnel…..things that fly through the air). The research also showed that there were Americans dying on the battlefield that had “survivable wounds.” That means if treated in a prompt and correct manner, those individuals should have survived their wounds. That is a hard pill to swallow. It is a tough thing to realize that Americans went home in a flag-draped coffin, and that those individuals could very possibly have been saved. Nobody even likes to think about one of America’s finest perishing needlessly. The research showed that there were several Preventable Causes of Death that were commonly found. The important word here is “Preventable.” If the preventable things are treated correctly, then the warrior should survive. They then quantified the preventable causes to see which ones were more common. The results were interesting.
Preventable Causes of Death
1. Compressible Arterial Hemorrhage (Think massive extremity bleeding)
2. Tension Pneumothorax
3. Airway Compromise
Having discovered what the Preventable Causes of Death were, the next step was to train everyone in how to prevent those deaths. It would require a new treatment sequence, as Airway was not the biggest killer it was once thought to be. New equipment would also be needed. Dedicated training was also needed to drum it into every single warrior’s head what they needed to do when confronted with a casualty. Tactical Combat Casualty Care was now created.