Tactical combat casualty care ( TCCC )

[Fraser.g]

While at Op Med there were several presentations covering both PHTLS, BTLS and TCCC. The big thing that was stressed was that the TCCC course was for non-medical trades. They received the TCCC, PHTLS, an orientation to lines of evac (Ambulances like the LSVW, Bison and Griffin) and a final tactical field ex. According to the presenter this took a total of 2 weeks and he was surprised that the TCCCs trainees at the end were talking like medics.

In my opinion and that of several others at the conference there is no need to teach the PHTLS course to teach the TCCC portion. What do you get out of the TCCC?

IA= Win the fire fight

A= Get your Ass down
B= Get your Butt out of the line of fire
C= Check for deadly bleeds

    -if there is a change in LOC dissarm the casualty 
    -if there is a bleed in an extremity put on a tourniquet
    -if there is a change in airway then put in a nasal trumpet (NPA)
    - if there is a chest wound with resp distress and possible tracheal shift land mark and decompress with the 14 G provided.


Why do these personnel need the anatomy and physiology of a PHTLS and/ or BTLS for this...they don't.

Why don't they get IV cannulization on this course...because fluid resuscitation with high volume cristaloid does more damage then good and by the way they can not possibly Cary enough to make a difference (3 L of crystaloid for 1 L of blood loss). and if they transfuse that amount they will destroy any chances of the casualty clotting or transporting Oxygen to the tissues any way due to dilution. One day our jump bags will carry Pentaspan but we are not there yet.

So what?

The TCCC course is great for the non medical trained, it teaches a couple of quick interventions that should be propagated within each combat arms section. The recomentation from the pilot project team is 2 TCCC per section. These two should not be jnr Pte and Cpl. It should be the Snr Cpls but not the 2IC or section commander.

It would also be an increase in skill set for the reserves. Easily and cheaply taught.

1. Reduce the course to one day of skills lab and lecture. Use the new Sim mans to teach the skills.
2. one day of orientation to the emergency veh.
3. A three day FTX where they are bombarded with casualties in different situations, and degrees of urgency.

Heck with that time line both regular and reserve combat arms pers could take the same course at the same time. Standardization, what a concept.

OK the idea is out so

comments please

GF

 

[Armymedic]

You must have fell asleep during portions of the 3 presentations of the subject...

The idea being pursued is the Combat Casualty Care will teach the cbt arms cbt medicine techniques and skills, and teach the Med tech how to think tactically while performing their skills.

So why not teach basic BTLS or PHTLS to the cbt arms? A good dose of theory and background knowledge will definitely lead to better understanding of why and when the techniques being learned are to be used. Not to mention their ability to help us when the deficat hits the ventilation and we are the only Med tech on the ground. Cbt arms are , contrary to popular belief, extremely motivated to learn the skills that will keep their buddies alive. We have taught numerous cbt arms who were applying to SAR basic BTLS, and all did well.

Nothing they talked about was new or controversial to us from the Reg force who are pushing to get this tng directed by the CF H Svc Gp.

Heck as a Bc Sn Nur you should understand you can't do anything with a whole bunch of classroom work first...

BTW, we have been carrying Pentaspan overseas for 3 yrs.

 

[Fraser.g]

Nope, I was wide awake during all three lectures as I am sure were you.

My statements about reducing the length of the course was two fold.

1. They do not need the theory and A&P to do the intereventions taught on the course.
2. By reducing the length to one week from two it will make the course more available to and possible for more combat arms to take it.

They are quite pressed for time especially when about to deploy. I can see this being treated as a nice to have rather than the need to have you and I both know it to be.
It is all about saving lives on the battle field I would like to see the day that this is a simple extention of the SFA taught on basic but that is way down the road.

As for Pentaspan, you are carrying it in your jump bag or in the amb? If it is in your bag of tricks then how much do you carry and what are your directions on indication. I am not trying to test you or sound arrogant but I have not seen it on any of my load lists and if it is there then we should have it as well.
On the same line, do you have an updated kit list for the jump bag? the ones that I have are sadly outdated and archaic.

Thanks

G

 

[Armymedic]

Sure, we could teach it all in a day, but really how good would that be? Remember, unlike many who sat in on the three lectures, we have been exposed to this topic for a number of yrs. I purchased the PHTLS text and read the military chapter in it way back in 99 when it first came out. Former Airborne medics (like both my CSM and RSM who were in the sessions) quickly jumped on it (like the pun) and taught the newer medics like me the "way". Combining those "tactics" to a high BTLS skill, make for a pretty impressive package. We have never done it in a formal course, and have met stiff Resistance from "higher" anytime time it was attempted.

I do have to agree that the length is a bit much though. For the med techs a week in class and field combined would be sufficient (5 tng days). The cbt arms need longer for skills labs, and scenarios. I prefer 5 didactic/skill days and 3 field days (8 tng days). If your working on a standard Reg force tng day, add in 1 hr of pt (0700 - 0900) because after all it is physically taxing....and you might as well have a full 10 training days.

Ref Pentaspan: I carried 1x 500 ml bag plus a 500 ml bag of NS, with 2 starter sets. To properly administer it, you start the NS line then go to corn starch. I didn't leave any in the Bison because it is temperature sensitive (between 10-25 C). In Canada, we can get it but only by pulling teeth because it isn't on the UMS set of panniers. Here at home,  all my medics at the UMS are told to carry no less then 1x 500 ml of NS (dismounted role).

Any of the jump bag lists we have are those used by Amb Coy of 2 fd Amb. They will probably be as ancient. After all, budget conscious Pharmacists are the ones who decide what we are allowed to use. Hence the UMS set of panniers still carries 50 1L bags of R/L. And we heard time and again last week that R/L isn't worth the bags its in.

Personally, I change what I carry for whatever role I am in: dismounted, LSVW, Bison.

Too bad Hypertonic Saline is 10 yrs away.

Goodies I carry:
1  500 ml pentaspan,
2 Asherman seals,
2 14 gauge 3 inch long angiocaths,
1 normal sized combitube (using 100 ml syringe only)
foil blanket

to name a few...

 

[Fraser.g]

I am aware that the pentaspan is temp sensitive and it was one reason why I was enquiring. I would not want to try and start pentaspan as the primary but as a piggyback it works great. This way you will have the line after the Pentaspan is in and you don't have to mess with the ONC. I have done this on many occasions but none of them pre-hospital. Scope of practice and all that. We do use them in the Air amb quite a bit. Also if you can get a nice stable IV before they get to the Treatment facility or FSU (I wish) it makes things flow nicely. I would go for two 250 NS bags instead of one 500 and another infusion set because then you can at least get IV access and TKO for analgesic, Atropine etc. The other option is just use a saline lock. This way it is lighter and access is portable. No lines to get messed up if the patient is hemodynamicly stable.
As for the RL debate, I know many anesthesiologists that use it extensively and even order it for re hydration instead of NS. The only time they change is because of medication infusion conflict.

Now on to the time line:
You can teach the BTLS in two days but it is with a fire hose if the students are not medical providers already. I am a BTLS instructor and admit that I have not seen the PHTLS course. One decision that came out of Op med was to standardize the training for reserves from BTLS to PHTLS gradually. Once the medics have to to their re-cert they will get the PHTLS.
If the PHTLS can be taught in two days, then the skills for TCCC in one we could then do the field portion in two. This still fits into under a week. It would be a full one but once again more troops through the door.
The re cert could then be two -three days. One day class room and two days in the field.

Goodies:

I have about all the same stuff with the following extra

2x 250 cc bag NS instead of one 500 cc bag
2x Morgan lenses
3 IV start sets

 

[Armymedic]

Ack on the 250's, but we don't carry them as part of the panniers, hence not easy to get....but 100 mil NS would be the other option.

From the branch chief, BTLS WILL remain the prehosp trauma standard for Med Techs. So we'll see how the recommendations turn out on the new course.

Difference between Btls and Phtls is that the laters exam is too simple (A,B,C, D,E) and BTLS is more precise (akin a drill). The remainder medical knowledge is almost exactly the same.

Its late, more tomorrow...

 

[JANES]

And what is 500ml of NS going to do for anybody?

 

[Armymedic]

It gets the IV started and give you the greatest versitility to switch that particular line to any other IV solution currently used by the CF, i.e. Pentaspan, blood products, etc.

 

[Fraser.g]

At Op Med we saw video evidence of it used on a Pig Femoral Artery successfully. That being said I still do not like the idea of cooking the flesh around the wound to a depth of 5 mm. This would require a large vein graft at the least to correct the damage caused by the product.

 

[JANES]

But wait, wouldn't a saline lock do the same thing, and lighten the medics load????

 

[Armymedic]

No. because what good is sticking a hole in someone without anything to put in it?

Second to trauma, heat illness/dehydration is the next likely use for a solution, and 500 ml is a real good start in solving those problems

 

[JANES]

Its a shame what the JI is teaching our medics!

 

[Armymedic]

Couldn't really comment on that due to the fact I have yet to have the "privilege" of their tutelage.

But its still a medical course, and no matter the type, its still what we do. Nobody is really in a position to judge the merits of a particular technique or procedure. It is always good to have 2 or 3 different ways to deal with any situation, and then its up to the particular person in that situation to judge which would be the most effective/appropriate at the time. End result should be in every case a favourable outcome of our patients.

 

[Donut]

Uhmmm, JANES, could you be a little more specific?

Neither of the other posters in this thread have anything to do with the JIBC, so if this is about the saline lock/500 ml NS issue, please leave them out, they have their own problems.

I'm not a card-carrying member of the JIBC fan club, but I've been a student in their Paramedic Academy and taught for their Professional Health Programs, as well as knowing many of the Chilliwack staff professionaly, and some personally, too. They try to give students three or four ways to deal with a situation, and try to teach some decision making, and then it's up to the MedTechs.

I will say that the PCP scope of practice, with some intelligent interpretation of the situation and a little experience, is effective for the vast majority of EMS calls.  I look around and see two other JI grads, and a current student, I don't think we've killed anyone in weeks  . 

So maybe you think there's something wrong with the scope of practice, or treatments, or the appropriateness of teaching civilian EMS to med techs,

Its a shame what the JI is teaching our medics!

is a great third post.

Welcome to the board.

 

[JANES]

So what is this tactical combat casualty care?  Whats wrong with the what we have?

 

[Fraser.g]

So what is this tactical combat casualty care? Whats wrong with the what we have?

OK,

Let me get this strait, you wade into a discussion with out reading the previous postings, make disparaging comments and then when you get scolded by one of the members you then ask for clarification? Not a great way to start off in this forum son.

By the way the other members in this thread I would trust with my life. Some of which are trained by the JI and some by other military and civi schools across this country. Each has the ability to think around a situation, size up what is required and then act in the most favorable way for the patint. What you have so far revealed is linear thinking. You see one line of action and then go ahead with out getting all the facts. Scary!

Many of the other posters have years of experience with pre hospital and Emergent training and experience, it would serve you well to listen, read and then ask questions not only on this forum but in your civi and military life as well.

 

[JANES]

Easy there cowboy, I was just asking a couple questions.  Lets watch our hippocriticism.

 

[R22eRKodiak]

I am very excited by what I am reading in this thread.

Being a proud infantryman, I cannot stress enough the importance of what Armymedic stated:

'' Cbt arms are , contrary to popular belief, extremely motivated to learn the skills that will keep their buddies alive. We have taught numerous cbt arms who were applying to SAR basic BTLS, and all did well. '' (I'm afraid I haven't figured out how to quote yet! :)

We all need to know how to keep our soldiers alive in a state that they can be helped when the professional caretakers arrive.   Unfortunately, the little section first aid kits and the St Johns first aid course, although nice for dealing with minor scrapes and sprains of daily life, are insufficient for the type of trauma that are usually caused by weaponry whose sole purpose is to maim and kill.   Although it is nice to believe that one of our fine and dedicated medical personnel will be immediately on hand to treat critically injured personnel, it is simply not a realistic assessment of the actual threat that we face.  

This sort of instruction would be invaluable to us because:

A.   I am afraid that there simply aren't enough of you around to ship out with every patrol that goes out (particularly the longer duration ones)

B.   A critical incident (artillery, mine, IED strike, ambush, etc,) may cause more critical casualties than a single medic can handle.   That's the whole reason the bad guys are trying to do this, after all.

C.   What happens if the medic is one of the casualties?   Do we simply condemn everyone because of this, or do we increase our chances of making it through by giving ourselves the best chances possible and most redundancy possible.

I am not advocating making cbt arms pers medics by any means, but we must give them the training that is sufficient to actually make a difference.   I am glad to hear that there is support for such initiatives as the TCCC program.   I will be deploying soon, and as such have run many medical/trauma scenarios integrated into our standard operations, using troopers that we have managed to train on TCCC or other qualifications (e.g. those that are interested in becoming SARTECHs; I have a few of those, and they can't get onto enough medical courses!!)   Unfortunately, operational schedule has prevented us from having the experts out with us as counsel, as they are scattered to   the four winds to cope with tasking demands (reminiscent of point A above).

We have come to the conclusion that the current training and kit available to cbt arms sections(TCCC notwithstanding -- I'll get to that in a bit), is insufficient to the real demands of a critical incident.   I am particularly concerned, as my troops may be operating quite some time away from medevac due to terrain and distance factors and in some occasions, medical personnel may not be able to be attached to them (again, A above).

We tried to get a TCCC setup for the troops.   After much deliberation, the course was allowed, but because of the time constraints, it was limited to a one day course (20 candidates for the bde), and there appears to be no occasion to run it again until we get in theatre.   As I understand, the main issue was one of liability.   On this level, I believe it may be more one of interpretation of the code of law, as you all appear to be very supportive of training cbt arms pers in this critical skillset.

I understand that there are limitations governing the employment of such skills in Canada, but what concerns can we have overseas?   Is it better to have someone that is trained trying to save someone's life in an incident (and possibly facing legal ramifications) rather than someone who has no idea what to do other than putting a shell dressing and cepacol on a traumatic amputation of a lower extremity (which is just about what any infanteer would try to do with the knowledge and kit they have right now at their disposal   ;D)

We've been relatively lucky so far with casualties.  We have been unconsciously counting on our luck up to now to get us through.  However, all it would take is one event for us to come to the same painful conclusions that the US currently are.  Luck shouldn't be a doctrine (even an unwritten one).  Commanders have the responsibility of minimizing risk by taking the steps they can to control as many factors of the battle/operation that they can all while accomplishing the mission.  This is one that we can control.  Let's keep as many of our troops alive as possible so that we can keep on giving the bad guys a hard time and keep on doing the good job we have been.  More Canadians alive after ambush = more Canadians around to make life hard on the bad guys. 

My kind of math.


In conclusion:

1.  Keep up the good GREAT work
2.  Help us by giving us the means to keep our buddies alive until you can get to them
3.  Glad to hear that the mindset is evolving
4.  Sure love for someone to clarify liability issues so that I can continue to develop things on my side in a more informed fashion

Thanks!

 

[Armymedic]

Thank guy...we serve so you survive

 

[Fraser.g]

  As I understand, the main issue was one of liability.   On this level, I believe it may be more one of interpretation of the code of law, as you all appear to be very supportive of training cbt arms pers in this critical skillset.

I understand that there are limitations governing the employment of such skills in Canada, but what concerns can we have overseas?  

The Liability issue was brought up at a medical conference in September. The way that the pilot course navigaed it by keeping the TCCC kits in theater and only issue them on arrival. With keeping the equiptment concontrolled and stressing that this was for battle field use only the MO for the course seemed confident that he was not releasing a bunch of infanteers with the overwhelming desire to drive 14g cathlons into every civi they met at West Edmonton Mall  .

If you BN was to to the same they might have a more favorable outlook on the training.

Good luck and keep us posted as to your progression with this fight.

GF