Sunday, November 22, 2009


Pre Hospital Trauma Life Support (PHTLS) found its origins in Vietnam. The speed at which U.S forces extracted wounded soldiers from the field was actually quite good. The skill and valor that our pilots showed while attempting to evacuate our wounded was quite phenomenal. Those actions alone were responsible for saving many lives.

The media reports from Vietnam showing our dead and wounded soldiers being 'Med Evaced' made our medical personnel back in the U.S sit up and take note. It was assessed that the ability of the combat medic and the speed at which casualties were delivered to field surgical hospitals was directly attributable to a successful outcome in the OR.

On highways back in the U.S delivery times of casualties sustaining life threatening injuries from motor vehicle accidents to primary surgical facilities were well over an hour due to distance and method of transport. Learning from their military counterparts in Vietnam the National Registry of EMTs made a decision that would change the face of civilian field medicine. The decision was to introduce EMS Paramedics, with a capability of Aero Medical Evacuation using Department of Defense helicopters in-conjunction with civilian authorities.

TCCC first popped up on the radar in 1996 and by 2002 a committee was established by the U.S Special Operations Command who endeavored to continually update the TCCC guidelines and there use.

Delineating the difference between civilian and military Pre Hospital Trauma Life Support (PHTLS) is really quite simple. Are hostilities involved?
In nontactical settings, standard PHTLS principles must be followed. However in combat settings there are very unique factors that are considered.
  • Hostile fire
  • Darkness
  • Environmental conditions - extreme heat or cold, dust or snow storms and mountainous terrain.
  • Resource limitations - Medical blowout kits and Medic Aid bags
  • Prolonged evacuation times
  • Transportation issues
  • Experience of personnel
TCCC is designed to be used on the battlefield in a tactical pre hospital setting. Again, when setting is nontactical, standard PHTLS principles should be followed.

When tending to a casualty on the battlefield it's important to understand the phases of TCCC. By knowing the phases of TCCC, soldiers can make better tactical decisions on the medical treatment and interventions of the casualty and take appropriate precautions to ensure that 'they' don't become a casualty!
This refers to care rendered while under effective hostile enemy fire. At this time the risk is extremely high for the casualty and the provider.
Care under fire is broken into three areas.
  1. Self aid - This is where injured personnel have the opportunity to tend to there own wounds. Soldiers must attempt to reposition themselves behind cover and conduct a self assessment of their injuries.
  2. Buddy aid - If the casualty has sustained injuries inhibiting his ability to move himself or cannot understand verbal commands, 'buddies' should attempt to move casualties to a position of cover and quickly assess the casualties injuries.
  3. Medic aid - If the medic has the opportunity to assess and treat a casualty he will. Remember that the mission has priority and the medic may be busy regaining the initiative by returning effective fire. Gone are the days of calling "MEDIC!" and a medic arrives.
It is in this phase of TCCC that our scenario plays out. The soldier on the ground with wounds to his chest and leg being dragged behind cover by a team mate.
So what should you do?
If your not actively being targeted by the enemy, quickly assess the casualty in order to identify any life threatening hemorrhage.
In our scenario, our casualty had been shot in the lower extremity, above the knee. He has what looks to be arterial bleeding coming from a wound in his thigh, the blood beginning to pool on the ground.

Our buddy in this scenario a graduate of a previous Combat Life Saver course, quickly identifies the casualties CAT tourniquet that is located in an obvious exposed place on the front of his body armor and places it over the casualties leg. He places it all the way up the leg to the groin and cinches it down and uses the windlass to tighten down on the muscle. He wound the CAT down until the bleeding stopped.

(Our casualty was switched on enough to have prepared his tourniquet so it easily fits over his boot and leg.)

Thats a good time to get a bit of focus back on the gun fight. A quick all round scan to stay in touch with the team and maybe to return some fire on enemy targets of opportunity.

In our scenario it appears that the enemy has broken contact and withdrawn.

Our casualty who is conscious, tells our buddy that he has been shot in the chest. Our buddy opens the casualties armor and places it over his helmet. He unbuttons the casualties field shirt and uses his trauma sheers to cut away the t-shirt. Our buddy immediately spots an entrance wound in the upper thorax and dives into the casualties blow out kit looking for his Asherman's chest seal which he places directly over the wound. Our buddy then checks for down sign or exit wounds on the casualties back. His bloodied hand reveals an obvious exit wound.

Note - This is the hardest wound to dress for a CLS provider as blow out kits tend to be small and little attention is payed to large injuries and dedicated occlusive dressings.

Our buddy opens his Isreali dressing and uses the plastic wrapper as an occlusive and tapes it in place. He then lays the casualty back down and places his armor back to provide him some protection ensuring the one way valve of the Asherman seal is clear. He then places the pad of the Isreali dressing on the exit wound on the casualties leg and wraps the bandage around the leg to create a pressure dressing.

Our buddy assess' the situation again and drags the casualty a bound to cover and signals to the team commander that he has one casualty.

The ambush was brief but violent and resulted in one friendly casualty. Thanks to the quick response of the Combat Life Saver our casualty lived and was 'Cas Evaced' to a Field Surgical Hospital via a dedicated rotary wing platform.


For more information on TCCC or if you would like to attend a CLS COURSE please email.

Remember, the right intervention at the wrong time could be the difference between life and death!

Stay safe.

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