Are the practices of Tactical
Combat Casualty Care (“TCCC”) training a good
investment for civilian emergency medical services (“EMS”)? The year 2014
brings a continuation in declining training budgets for first responders. Currently,
civilian EMS systems lack the comprehensive death and injury data
base that have been developed by the military and little to no national
research has been done on the results of Tactical Emergency Medicine Support
(“TEMS”) teams in the United States. In a budget conscious environment, is
it a lack of conclusive data to support the cost or lack of unified standards
to make TCCC an integral part of Emergency Medical Services training?
The 20th
anniversary of the introduction of TCCC will occur in 2016
marking its first adoption by the US Navy SEALS and US Army 75th
Rangers. By 2014, all US forces and the US Coast Guard have incorporated
TCCC into their standard combat training. Multiple combat allies have also
accepted the validity of TCCC and integrated it into its own training
standards. Despite this, the question arises if TCCC is meaningful
training in the civilian EMS environment.
The US Army and Canadian
military forces have recently published its death and injury data from
2001-2011 combining both Iraq and Afghanistan theaters. Unsurprisingly,
traumatic hemorrhage remains the leading cause of preventable death on the battlefield.
The predominate mechanism of injury for both military forces was
explosive. Tension pneumothorax and loss of airway continue to follow hemorrhage
as the leading causes of preventable death but only a distant second
and third respectively.
The US military command and
its allies have committed millions of dollars to train their troops in TCCC. Evidence
based review demonstrates this was money well directed. The armed
forces trauma information system is used to track injury, patho-physiology
of death, battlefield circumstances, pre-hospital treatment and hospital
management. The military tracking system also includes detailed autopsy
reports. Currently, the US civilian emergency medical system has yet to
achieve a comprehensive data base capturing the continuum data from point
of injury to hospital based care. Despite the lack of a broad
based civilian trauma tracking system, the increasing incidents of
public mass shootings and bombings, similar to the Boston Marathon, have brought
awareness to some important deficits in civilian EMS capabilities.
Education and training for mass traumatic hemorrhage is paramount and its
recognition has unequivocally saved thousands of lives in terrorist
type situations worldwide.
Yet still it is
said that combat casualties and civilian injuries are not mirror images of one
another. The development of Tactical Emergency Casualty Care (“TECC”) has been
an attempt to create a "civilian" version of TCCC that better
addresses the civilian needs given the uptick in traumatic attacks on the
public. Critics of TECC argue that it too closely resembles TCCC training and
does not address the top causes of death in the civilian world. This
argument exists because the top
causes of traumatic civilian death have not been well
demonstrated. TECC, like TCCC, is centered on teaching the “MARCHE”
algorithm. Massive bleeding, Airway, Respirations, Circulation, Hypothermia and
Evacuation make up the MARCHE methodology. The core skills taught are
tourniquet placement, chest needle decompression and recovery airway
position in both TCCC and TECC.
Detractors of TECC
suggest that management of mass bleeding is the only addition needed to the
traditional "ABC"s of standard U.S. EMS training. However, tension pneumothorax leading to death in
the civilian population is extremely rare making the chest
decompression skill a nice addition, but far from necessary. The
Canadian military data from Afghanistan support this argument against
teaching chest decompression. The Canadian findings indicate the
majority of soldiers who attempted a needle decompression on the battlefield
performed it incorrectly. Teaching the recovery airway position may also be a
poor utilization of resources. Following "ABC" training, U.S.
EMS's goal is a definitive airway. The recovery airway position taught in TCCC
and TECC is not an acceptable management of an unconscious
person in the U.S. system. It is not difficult to
appreciate the argument against acceptance of an entirely new training system
when the current nationwide U.S. EMS protocols can be modified to
meet the evolving needs.
The need for tactical
training is strongly supported across the United States by local, state
and federal law enforcement, fire and EMS. Multiple national organizations
and government agencies representing these entities have publicly supported and
are actively developing programs to prepare EMS and firefighters to work in more austere
or violent environments. Unfortunately, unlike the military, there is
no nationally unified tactical emergency medical training. Laws, policies, and
organizational development vary extensively from state to state.
California is one of a few states that has a
centralized governing body for all law enforcement standards and
education which includes tactical training. This allows for the
development of a statewide tactical training program that fit the
needs of the state’s centralized EMS system. The other 49 states may have
institutional differences and their tactical programs vary by each state’s or
region’s standards of training. This creates the need for a national
standardized training program, but the implementation, is understandably,
difficult due the wide ranging variation in institutional structure, training
and working environment.
A recent national study
on the strategic planning and training for American law enforcement indicates
that 2-year plans are being created to be more flexible with the dynamics of
the external traumatic environment. Currently data regarding crime rates is
available in the U.S. Partnering with
the National Board of Critical Care Transport Paramedic Certification and
further analysis of crime data may pinpoint training in regions with and above
a certain crime rate index to begin
nationalizing mandates and require a TEMS program with locally tailored TECC
training or newly modified “ABC-H” training
Training supervisors are
expected to carefully scrutinize training expenditures. Hemorrhage control and
tactics training for a violent environment are two components of TCCC
that have repeatedly proven valuable training in the more recent civilian
terrorist events. To accomplish the incorporation of this
new training into the current standards and protocols, it may
require an unprecedented partnership between federal, regional, state and
municipal law enforcement, fire, and EMS to make meaningful progress. Basic
unified standards that are adaptable for localized training programs and
additional funding will prepare present
emergency medical services in times of crises derived from our increasingly
global and violent society.
