Is Tactical Combat Casualty Care (TCCC) worth the investment?

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.