On the morning of the Boston Marathon, I would have never imagined that the tragic events of that day would result in the best argument to date for the advancement of the Tactical Emergency Casualty Care (“TECC”) doctrine. Born from the military Combat Casualty Care (“CCC”) philosophy, TECC is the civilian modification of CCC. The emphasis of both is based on the recognition and treatment of the top causes of death after a survivable injury before evacuation to an acute care medical facility. Combined with the importance of maintaining the highest level of tactics and operational security, TECC provides first responders with the training and equipment needed to fulfill any mission as well as successfully treat many injuries that can result in death in as quickly at three minutes. CCC was first introduced in 1996 after a retrospective review of military combat deaths. Bleeding, inability to breathe, and chest trauma that occurred before a soldier could be transported to a medical facility were identified as the top causes of battlefield death. These causes of death were associated with a 14% mortality rate during the Vietnam War. The battlefield mortality rate decreased to approximately 9% during the first Gulf War and was attributed to the roll-out of CCC training for all combat soldiers. These statistics further improved with the later conflicts in Iraq and Afghanistan. By 2006, all combat soldiers in the US military were being issued combat tourniquets as part of standard first aid equipment. The training dictated that operational tactics and safety were always top priority. Regardless of the injured, CCC, however, emphasizes that when under an attack the priority is to fight and overwhelm the enemy with superior firepower. If a rescue was possible during the fight an attempt would be made, but a suicide rescue was never an option. Once the injured and rescue team were in a place of protection, only then would treatment to manage bleeding, loss of airway and chest injury commence.

The two bombs that exploded in Boston were each built inside a self securing metal pressure cooker and were detonated minutes apart among the spectators. Each device had explosives, nails and bbs packed inside the containers. The three people who died most likely died from the effect of the blast pressure of the explosion. This type of injury is classified as a primary blast injury. The 300 surviving victims had a combination of the 4 classes of blast injuries (Primary, Secondary, Tertiary, and Quaternary). Secondary injuries are caused by shrapnel or fragmentation of the bomb container. Tertiary injuries result when the victim is thrown against an object or off their feet. Quaternary is any injury not associated with the other 3 classes. The most common non-lethal primary injury is the loss of hearing due to the pressure disruption of the ear drum. Severe injury or death is due from the effect the pressure wave has on the internal organs. Almost every Boston victim had some loss of hearing along with multiple other injuries. The predominant injury encountered was the secondary class. Shrapnel and fragmentation resulted in penetrating trauma with all forms of amputation, life threatening bleeding, loss of breathing, and chest injuries. The fact that so few died after two explosions initially was thought to be a miracle. The fact, however, is that training provided by CCC and TECC to soldiers and emergency first responders is what made the difference. Present as support staff for the Boston marathon were 400 Massachusetts National Guardsmen who all had received CCC training and had battle tourniquets as part of their personal equipment. The quick recognition of the injuries and critical bleeding led to battle tourniquets being placed on many of the victims. This also provided the example for many of the Good Samaritans helping other victims to model. Belts, torn clothing and shoe laces were all used as tourniquets to slow life threatening bleeding. According to one Boston physician, they had never seen so many tourniquets. The number of deaths that could have occurred had it not been for the heroic actions of the first responders could have been in the hundreds.

Interest in Tactical Emergency Casualty Care is growing, but it is not standard or part of mainstream first responder training. Despite this, there are hundreds of examples where TECC training was used to save a civilian or first responder's life. With the significant increase of deaths of law enforcements officers caused by gunfire in the last decade, it is difficult to understand why TECC training has not been incorporated into the training of every law enforcement officer in the United States. Progress is being made in educating our government officials on the benefits of TECC training. The recent formation of the Committee for Tactical Emergency Casualty Care has brought physicians, law enforcement, rescue and emergency medical service together to lead the future of TECC programs. The Los Angeles County Sheriff SWAT team and the US Border Patrol Borstar division fully recognized the benefits of TECC training and have implemented it in their respective departments. Orange County, California has become the gold standard for TECC training for all its law enforcement officers. Through a Homeland Security Urban Area Security Initiative Grant, the Santa Ana and Anaheim Police Departments have combined to train over 800 officers in TECC with courses occurring monthly open to all county law enforcement. Local and national awareness of TECC is on the rise. It has become the passion of Huntington Beach, CA Firefighter Ray Casillas. A highly decorated firefighter/paramedic, Casillas has drawn from his long career as a SWAT medic and firefighter to seek the assistance from two of the biggest names in the development of the military CCC doctrine, Drs. Frank Butler and U.S. Surgeon General Frank Carmona to support TECC training.

No miracle occurred in saving the lives of many of the Boston bombing victims. The fast action and training of the first responders is what made the difference. Those in the terrorist intelligence community are probably a little surprised it took as long as it did to have a successful bombing on U.S. soil. When we look at our own landscape just in California, the list of potential terrorist sites is probably too long to count. Our success thus far in preventing terrorist attacks has been good and perhaps occasionally lucky. Boston clearly indicates that our post attack response can still use improvement furthering the need for mandatory advanced training. Sadly, it has taken 300 hundred injured and three dead to really draw attention to our violent society and the critical responsibilities of our first responders. In the last 12 months, eight mass shootings have occurred in the United States. We probably cannot determine exactly, but now know for sure there were large numbers of lives saved because of TECC training at each of these incidents.  Hopefully in the future, Orange County, the Los Angeles County Sheriff and the U.S. Border Patrol current training procedures will be considered standard mainstream training and not cutting edge training and deployment programs.