30 ARMY n May 2010

Servicemembers taking the combat lifesaver course in Balad, Iraq,evacuate a casualty in the mass casualty evacuation drill that is

done at the end of every training iteration.

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s noted by LTG Mark Hertling,deputy commanding general, InitialMilitary Training, U.S. Army Train-ing and Doctrine Command, inthe March issue of ARMY, the

medical community is revising the Army’stactical combat casualty care (TC3) trainingbased on extensive combat experience, adapt-ing many of the most critical tasks involvinghemorrhage and traumatic battlefield in-juries.

“TC3 is a field that originated in a lot ofunits—particularly the Rangers and SpecialForces, but also in conventional line units—where the medics and surgeons, going backas far as the conflict in Somalia, were noting‘lessons learned’ in the way that we first re-sponded to casualties, prior to when theyreached a fixed medical facility,” explainedTRADOC surgeon COL Karen O’Brien,Medical Corps. “If you think about the wayyou respond to trauma on the battlefieldcompared to the way you would do it besidean American highway, it’s quite different.There are tactical considerations that don’t

By Scott R. Gourley

Above, 1LT Eliza Wick, battalion personnel officerfor Headquarters and Headquarters Company, 82ndBrigade Support Battalion, 3rd Brigade CombatTeam, 82nd Airborne Division, puts a tourniquet onthe leg of PVT Matthew Wright during practicalcombat exercises at the tactical combat casualtycare (TC3) class at Contingency Operating BaseSpeicher, Iraq. Left, students in the combat life-saver course taught at the Tricia L. Jameson combatmedic center, Balad, Iraq, run into action during themass casualty evacuation drill in September.U

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come into play in civilian medicine: things like maintain-ing security when you are being attacked, in addition tobeing able to care for the casualty; things like teaching sol-diers that just because they are wounded doesn’t meanthat they shouldn’t keep shooting back and making surethey are neutralizing the enemy if they are able to. As a re-sult, a lot of those tactical considerations started beingtaught to medical folks and to junior leaders in the smallunits that would be helping respond to casualties.”

Noting that early activities also included reviewingdata from previous wars, she said, “What theyfound was that often after a war there would be

some lessons learned that might be forgotten. An exampleof one of those was tourniquets. If you think about it, wehave been using cravat and belt-type tourniquets eversince the Revolutionary War. Yet there was data from ear-lier wars that showed that tourniquets of that nature didn’twork very well. On top of that, there was a lot of concernabout using tourniquets because people thought that ifyou cut off circulation to an extremity for too long, youwould lose that extremity. Based on the data collected inprior conflicts, however, we were able to start putting to-gether the facts, which showed that tourniquets that workactually save lives. So a lot of development occurred in the

early 2000s to identify a good, func-tional tourniquet that could be issuedto every soldier and put into the newimproved first-aid kits.

“We think that doing that can nowbe credited with more than 1,000 livessaved,” COL O’Brien added. “Addi-tional research has also shown thatthere have been no bad outcomes onthe basis of using tourniquets. We alsoknow that there is still some hesitationin first responders to apply a tourni-quet. So they often wait longer thanthey should, and sometimes peopledie because they don’t have a tourni-quet put on in time. As a result, westill have some potential survivorswho die. The time to intervene to pre-vent these deaths is in the first 5 to 10minutes.”

That analysis of battlefield lessonshad also prompted a significant revi-sion of medical aspects of basic com-bat training, with the introduction ofcombat lifesaver training in May 2007.Among the memorable changes formany new soldiers at that time wasthe new requirement to successfullyinstall an IV [intravenous] needle with

saline bag lock.“As we started to teach all soldiers combat lifesaver

training, we started to modify that combat lifesaver cur-riculum to align it with principles of tactical combat casu-alty care,” COL O’Brien said.

Casualty analysis remains a dynamic process, however.COL O’Brien added, “One of the things they learned asthey continued to look at potentially survivable deaths andthe causes behind them: Some of those causes were‘tourniquetable’ injuries. Others involved compressible hemorrhage, which has led to the development of newspecial bandages that have material on them to preventbleeding. And there was another area that evolved, non-compressible hemorrhage—hemorrhage to the torso, likeinternal bleeding in the lungs or abdominal area. You can’treally put a tourniquet on that or compress that.”

She continued, “What they found in those situations wasthat when you get a lot of IV fluid early on, it’s actuallybad for that type of trauma. First, it raises your blood pres-sure, which can blow off a clot that is forming inside thearea that can’t be reached, and all of that data coming fromthe Joint Theater Trauma Registry has shown that we wantto keep a lower blood pressure in some of those patients.Second, all of that extra fluid can dilute your blood’s abil-ity to clot naturally.”

The concern about the noncompressible trauma wascompounded by the concern regarding remaining delaysin installing tourniquets.

32 ARMY n May 2010

Scott R. Gourley, a freelance writer, is a contributing editor toARMY.

Soldiers at FortSill, Okla., take IV

(intravenous)training. Since the

introduction ofcombat lifesaver

training two yearsago, soldiers’

medical traininghas aligned more

closely withtactical combat

casualty care.

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“Often first responders were focused on starting the IV,thinking that the IV was the lifesaving intervention,” COLO’Brien said. “In fact, there is really no data to show thatgetting an IV in the first 5 to 10 minutes is going to saveanybody’s life. It’s not that IVs are bad in the long run. It’sthat the priority of what should happen in the first fewminutes should be geared toward stopping bleeding.”

Based on the analysis of all the data, the Committee onTactical Combat Casualty Care hadrecommended that the Army stop in-serting IVs during the “care underfire” phase of medical treatment—pri-marily the first few minutes after be-ing wounded.

A s a result, GEN Martin E. Demp-sey, TRADOC commandinggeneral, made the decision to

suspend IV training in basic combattraining in September 2009. Followingadditional analysis, a new medicaltraining support package was re-leased in January 2010.

“We have changed the training toplace more emphasis on mastery ofbleeding control,” COL O’Brien said,adding that another area of emphasisin the new program involves familiar-izing soldiers with the importance ofbeing evaluated after exposure to blasteffects. “If you’ve been in a vehicle ex-posed to a blast, within 50 meters of ablast, in a structure hit by a blast, orhave any kind of direct blow to yourhead or loss of consciousness, youneed to be evaluated by a medical pro-fessional, whether by a 68W [Armycombat medic] or at an aid station,”she explained. “But you do need to be

evaluated, and possibly allowed to rest for 24 hours, be-cause if you get that rest early on, it allows your ‘harddrive’ to reset. But if you don’t get that rest and you driveon, then you could have lingering problems for months.”

Another example of coordination across the Army med-ical and training communities during this same period isthe release of the new Army field medical card, alsoknown as the TC3 card, in individual first-aid kits.

SPC ChaseCarman, a medicand TC3 instructor,shows soldiers howto load a casualtyat the 82ndAirborne Divisiontroop medical clinicon ContingencyOperating BaseSpeicher.

SGT PatrickMalone, C Troop,2nd Squadron, 14thCavalry Regiment,2nd BrigadeCombat Team, 25thInfantry Division,demonstrates howto apply the combat applicationtourniquet during abilateral exercise atCamp Bundela,India.

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“The field medical card is the card identifying you whenyou are a casualty,” COL O’Brien said. “Under our old sys-tem, that card was initiated once you entered the medicalsystem. So we really weren’t capturing a lot of data aboutwhat was actually happening at the level of the first re-sponder, before someone entered the evacuation system:things like what time your tourniquet was applied or whatother lifesaving measures were carried out by the first re-sponder. We had a great joint theater trauma registry thatwas capturing care after someone was further along in themedical system, but we didn’t have that early-on data. Thenew card is aligned with TC3, allowing the data to be cap-tured very early, and also to assist us in analyzing data andimmediately responding to lessons learned as we continueto refine the field of TC3—as we work to whittle away theapproximately 20 percent of combat fatalities that we be-lieve to have been potentially survivable.”

The removal of the IVs from the combat lifesaver bags—fielded per AR350-1 at a level of one per squad—has alsoallowed the fielding and related training of new hypother-mia-prevention/warming blankets.

“When you lose a lot of blood, even if it is 100 de-grees outside, you get cold,” COL O’Briensaid. “If you get cold, your blood stops clot-

ting. You also have a higher likelihood of dying from othercomplications. So these new blankets will help keep peoplewarm during the evacuation process, again bolstering theirsurvivability.”

Other changes in the new medical training supportpackage include training in tactical movement of casualtiesand expanded tactical scenario training.

Another recent adjustment in Initial Military Training in-volves hearing protection and starting to train soldiers touse the new combat arms earplugs.

“We are using an innovative approach developed bysome of our audiologists, bringing the training out to therange, so that when soldiers have their first basic riflemarksmanship, they will also be issued the earplugs andtrain with them at that range,” COL O’Brien said. “Nowthey will be using them right after they train with them. Wehave also worked with our safety colleagues to incorporatehearing protection into the safety briefings at the ranges, ty-ing those things together. Since hearing loss is the top rea-son for VA [Department of Veterans Affairs] claims fromsoldiers, we think this will have a huge benefit.”

In parallel with the new medical training efforts, theTRADOC surgeon is also involved with issues surround-ing sleep deprivation. “I have been reviewing a lot of thematerial currently available, and we are looking at betterways to educate the force about the importance of sleep.We are looking at how to make our Army more resilient,and sleep is an important component of that,” COLO’Brien said. Acknowledging that the sleep-deprivationawareness and education campaign has to overcome a tra-ditional service approach of digging deep and driving on,she added, “The old doctrine for sleep was that you shouldget a minimum of three hours a night. Last year we re-leased a new field manual, FM 6-22.5 Combat and Opera-tional Stress Control Manual for Leaders and Soldiers, whichsays that there is not a minimum number of hours, that weneed to strive for 7 to 8 hours of sleep, and any time youfall below that for any significant number of days, yourfunctions will start to be compromised.” M

34 ARMY n May 2010

Soldiers from the82nd Airborne

Division practiceloading a casualtyinto a paratrooper

medical platformvehicle during

practical combatexercises at the

TC3 class at themedical clinic at

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