Tactical Evacuation Research Articles

Ukraine Report from the Field: TCCC in the Multidomain Battlespace

Introduction:Russia invaded Ukraine in February 2022, leading to significant preventable death across Defense forces and communities. When appropriate and adequate training has been provided, the use of point of injury (POI) care guidelines as exhibited by tactical combat casualty care (TCCC) and the implementation of damage control resuscitation (DCR) and damage control surgery (DCS) can reduce preventable morbidity and mortality in the far foreword environment. Background: Russia invaded Ukraine in 2014 exacting a heavy increase in preventable morbidity and mortality on the battlefield. Multiple global health engagement strategies by allied forces and health partners have focused on prehospital medicine. The most recent iteration of violence has seen a comprehensive invasion with the use of multi-domain battle and conventional weapons systems across nearly every state in Ukraine. These conventional weapon systems deployed by Russian forces exact a heavy lethality on all communities.Method:This report uses anecdotal data from undisclosed locations in Eastern Ukraine from the tactical evacuation care, Role 1, Role 2 to the Role 3 echelons of care as reported.Results:Appropriate application of combat application tourniquets (CATs), pressure dressings, access to tranexamic acid (TXA), antibiotics, basics of TCCC care and DCR/DCS, including access to blood as early as possible, save lives.Conclusion:Rapid access to tactical evacuation care and initiation of DCR/DCS from Role 1 to Role 2 has good effect. The Ukrainian armed forces have pushed damage control Resuscitation and Surgery as far forward as Role 1, which may require a paradigm shift within the NATO military medical standards and preparations for a peer conflict.Adequate TCCC, DCR and DCS training in the form of global health engagement have anecdotal success in the reduction of morbidity and mortality and in providing force health and medical readiness across NATO nations and partner forces such as Ukraine.

Effectiveness of Applying Tactical Combat Casualty Care Guidelines on Paramedic's Practices. An Interventional Study

Background: medical services provided by specialized paramedic played a key role in the military conflicts that occurred in Iraq during the last two decades after 2003 by first aid providing to the injured immediately in the battlefields to safe their life and transporting them to health care facilities for additional health care , as well as in the current study , which concerned with paramedics training on tactical combat casualty care standards that include three steps of care ( care under fire, tactical field care, and tactical evacuation care ) Objective(s): The aim of a present study is to determine the effectiveness of applying Tactical Combat Casualty Care (TCCC) guidelines on Paramedic's Practices. Methods: A pre-experimental design study was carried in Baghdad Operations Command in Iraq, at January 14th, to April 2nd, 2022. to find the effect of applying Tactical Combat Casualty Care guidelines on paramedics’ practices. Non-probability "purposive" sample of (40) paramedics are selected from all units in Baghdad Operations Commands. The questionnaire is composed of two main parts (demographic characteristics of the paramedics, and the second part involves four domains which was (71) items concerning paramedics' practices regarding the standards of Tactical Combat Casualty Care , the researcher used SPSS version 20 to analyze the data. Test-retest reliability of instrument was determined through the use of Pearson correlation coefficient and content validity of the instrument was determined through a panel of (fourteen) experts. Data was analyzed through the use of descriptive and inferential statistical analysis. Results: The results of paramedic's practices in overall main domains related to applying TCCC standards was inadequate in pretest , while in posttest I results showed that the paramedics' practices was improved to adequate level after application of the intervention program . Then the posttest II was done, and the results was similar to posttest I. the data show that there were highly significant differences between pre and post test , which emphasis the positive effect of program. Conclusion: The study concluded that there was improvement in paramedics' practices toward the TCCC intervention program. Recommendation: The study recommended to Continuous training for paramedics and engages them in courses, seminars, and conferences to improve their skills and information. Keywords: Tactical Combat Casualty Care, paramedics, Practices, Interventional Study.

ОСОБЛИВОСТІ РОБОТИ МЕДИЧНИХ СЕСТЕР У ЗОНІ БОЙОВИХ ДІЙ

Забезпечення кожному постраждалому належної медичної допомоги збільшує шанси на виживання та відновлення функцій протягом усього процесу надання медичної допомоги, що зумовлює актуальність аналізу складнощів у виконанні покладених на медсестер обов’язків у зоні бойових дій.
 Мета дослідження – проаналізувати особливості роботи медичних сестер у зоні ведення бойових дій та на їх основі сформулювати рекомендації щодо удосконалення освітніх навчальних програм для медсестер.
 Матеріали і методи. На базі військово-медичної служби ВМС УСБУ в Закарпатській області було про­аналізовано анкетні дані медичних сестер, які проходили військову службу в зоні антитерористичної операції упродовж 2015–2017 рр. Основним запитанням до респондентів було коротко описати складнощі у виконанні покладених на медсестер обов’язків.
 Результати. Аналізуючи отримані відповіді медичних сестер, які виконували свої професійні обов’язки в зоні бойових дій, було сформульовано основні складнощі їх роботи в умовах прямої і непрямої загрози: недостатні знання принципів Tactical Combat Casualty Care; розподіл поранених при евакуації в умовах тактичної екстреної медичної допомоги; різна популяція постраждалих, яка включала не тільки військовослужбовців, а й мирне населення, у тому числі педіатричні й геріатричні вікові групи; необхідність психологічної допомоги військово­службовцям і мирному населенню в зоні бойових дій; недостатній досвід тактичної евакуації.
 Висновки. Для оптимізації професійних знань медичних сестер у цих напрямках рекомендується включити освітні компоненти «Тактична медицина» і «Екстрена психологічна допомога» в освітні навчальні програми для медсестер.

Battlefield Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Feasibility Study During Military Exercises.

To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

“POTENTIALLY SURVIVABLE” CASUALTIES — RESERVE TO REDUCE PRE-HOSPITAL LETHAILITY IN INJURIES AND TRAUMAS

Battlefield lethality remains the most underexplored problem from the surgical point of view. 540 battle­field fatalities during the military operation in the North Caucasus region of Russia (1994–1996) were ana­lyzed. It was found that 25.4% of all “Killed In Action” refer to the group of potentially survivable. Common causes of combat death in this group were prolonged hemorrhage (78.1%), tension pneumothorax (19.0%), and hemopneumothorax (2.9%). Reducing mortality can be attained due to introduction of new means of control for life-threatening consequences of injuries, improving tactical evacuation, as well as training mili­tary personnel in providing combat lifesaver care.

Use of ketamine for prehospital pain control on the battlefield: A systematic review.

Intravenous ketamine is commonly used for pain management in the civilian prehospital setting. Several studies have evaluated its effectiveness in the military setting. To date, there has been no report reviewing the published data on the use of ketamine in this context. The objective of this systematic review was to analyze the content and quality of published data on the use of ketamine for prehospital pain management in military trauma. The MEDLINE database was searched for studies on ketamine use in combat prehospital settings, at point of injury or during evacuation, published between 2000 and 2019. The systematic review was conducted following PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42019115728). Civilian reports and case series lacking systematic data collection were excluded. Eight studies were included with 2029 casualties receiving ketamine. All but one were American reports from Afghanistan and Iraq conflicts. Studies implied retrospective cohorts or prospective observational analysis. Ketamine use rose from 3.9% during the period preceding its addition to the Tactical Combat Casualty Care guidelines in 2012 to 19.8% thereafter. It was the most common analgesic administered (up to 52% of casualties) in one of the studies. Ketamine was more likely given during tactical medical evacuation when no analgesic was provided at the point of injury. The median total intravenous dose was 50 mg. Pain intensity decreased from moderate or severe to mild or none, sometimes after only one dose. In one study, ketamine administration during tactical evacuation was associated with increased systolic blood pressure as opposed to morphine. Incoherent speech, extremity movements, and hallucinations were the main adverse events reported. Published data on ketamine use in military trauma are rare and heterogeneous. Though, all studies tend to strengthen the belief in the efficacy and safety of ketamine when given at 50-mg to 100-mg intravenous for prehospital analgesia in combat casualties. Systematic Review, Level IV.

Critical Care Skill Triad for Tactical Evacuations

ObjectiveProviding medical support to French soldiers deployed on war theater everywhere around the world is the first mission of the French Military Medical Service (FMMS). En-route critical care is critical to maintain the continuum of care and safety during forward and tactical medical evacuation (MEDEVAC). The FMMS has developed specific training programs to ensure optimal en-route critical care air transport. These courses need to be continuously adjusted to the returns of experience and to the operational changes. The aim of our survey was to characterize the critical care skills required for tactical MEDEVAC on fixed wing aircraft. MethodsA 10-items survey was sent to 22 flight surgeons previously deployed in the Sahel-Saharan Strip. Eight questions focused on basic critical care skills. The 2 last items assessed the flight surgeons' willingness to follow a pre deployment course in a critical care unit and in a transfusion center. ResultsFourteen of the 22 flight surgeons responded to the survey. All but one responder had to deal with at least one critical care skill. The most frequent critical care skills required were the management of mechanical ventilation, catecholamine infusion and blood product transfusion. Five of the 14 responders reported on-board blood product transfusion, including red blood cells, lyophilized plasma and fresh whole blood. ConclusionOur survey highlights the need for the MEDEVAC teams to be skilled in critical care medicine. We defined a triad of critical care skills required for the management of severe casualties, including the management of mechanical ventilation, catecholamine infusion and blood product transfusion.

Evaluating the Military Medical Evacuation Chain: Need for Expeditious Evacuation Out of Theater?

An important factor within the military medical logistical chain is the capability of expeditious evacuation from point of injury, through a Medical Treatment Facility, to the country of residence where highest level of care can be provided. Although many factors can relate to patient outcome, the evaluation of the medical evacuation chain related to long-term patient outcome can be important for investigating possibilities for performance improvement in this domain. This article aims to provide a means to evaluate the quality of care of the medical evacuation chain. Repatriated service members from the Afghan theater between 2004 and 2014 were invited to participate in a survey concerning functional outcome and quality of life using Lower Extremity Functional Scale, Short Form health survey 36, and EuroQol-6D questionnaires. Possible associations between these outcomes were analyzed in respect to duration of medical evacuation from point of injury to arrival in the Dutch military hospital. The duration was dichotomized into within and after 72 hours. Ordinal regression was used to analyze a possible association with duration as a continuous variable. Sixty percent (28/47) of battle casualties arrived in The Netherlands within 72 hours. For the nonbattle injury cohort this was 30% (7/23). Of those who became ill, 18% (5/28) was evacuated in 72 hours. No significant independent associations between interval duration and measured outcomes were found. Repatriated battle casualties had lower outcome scores compared to the disease nonbattle injured service members. Significant differences in functional outcome and quality of life with respect to evacuation duration were not found. Specialized tactical evacuation and en route care capability during strategic evacuation contributed to relative high standards of care. Combined with our results, this could implicate that delivery of the right care to the right patient at the right time is a justifiable paradigm. The main focus of the medical support organization is to offer the highest level of care per echelon as soon as possible in conjunction with facilitating maximum social support through expeditious evacuation out of theater. Further research using semistructured interviews among the direct circle around battle casualties, including caregivers, is needed to provide insight into these complex matters.

Efficacy of the Mnemonic Device "MARCH PAWS" as a Checklist for Pararescuemen During Tactical Field Care and Tactical Evacuation

The application of Tactical Combat Casualty Care (TCCC) represents evidence-based medicine to improve survival in combat. Over the past several years, US Air Force Pararescuemen (PJs) have expanded the mnemonic device "MARCH" to "MARCH PAWS" for use during tactical field care and tactical evacuation (TACEVAC). The mnemonic stands for massive bleeding, airway, respiration, circulation, head and hypothermia, pain, antibiotics, wounds, and splinting. We undertook this performance improvement project to determine the efficacy of this device as a treatment checklist.The mission reports of a 16-PJ combat rescue deployment to Operation Enduring Freedom (OEF) from January through June 2012 were reviewed. The triage category, mechanism of injury, injury, and treatments were noted. The treatments were then categorized to determine if they were included in MARCH PAWS.The recorded data for missions involving 465 patients show that 45%, 48%, and 7%, were in category A, B, and C, respectively (urgent, priority, routine); 55% were battle injuries (BIs) and 45% were nonbattle injuries (NBIs). All treatments for BI were accounted for in MARCH PAWS. Only 9 patients' treatments with NBI were not in MARCH PAWS.This simple mnemonic device is a reliable checklist for PJs, corpsmen, and medics to perform TACEVAC during combat Operations, as well as care for noncombat trauma patients.

Extraglottic Airways in Tactical Combat Casualty Care: TCCC Guidelines Change 17-01 28 August 2017.

Extraglottic airway (EGA) devices have been used by both physicians and prehospital providers for several decades. The original TCCC Guidelines published in 1996 included a recommendation to use the laryngeal mask airway (LMA) as an option to assist in securing the airway in Tactical Evacuation (TACEVAC) phase of care. Since then, a variety of EGAs have been used in both combat casualty care and civilian trauma care. In 2012, the Committee on TCCC (CoTCCC) and the Defense Health Board (DHB) reaffirmed support for the use of supraglottic airway (SGA) devices in the TACEVAC phase of TCCC, but did not recommend a specific SGA based on the evidence available at that point in time. This paper will use the more inclusive term "extraglottic airway" instead of the term "supragottic airway" used in the DHB memo. Current evidence suggests that the i-gel® (Intersurgical Complete Respiratory Systems; http://www.intersurgical.com/info/igel) EGA performs as well or better than the other EGAs available and has other advantages in ease of training, size and weight, cost, safety, and simplicity of use. The gel-filled cuff in the i-gel both eliminates the need for cuff pressure monitoring during flight and reduces the risk of pressure-induced neuropraxia to cranial nerves in the oropharynx and hypopharynx as a complication of EGA use. The i-gel thus makes the medic's tasks simpler and frees him or her from the requirement to carry a cuff manometer as part of the medical kit. This latest change to the TCCC Guidelines as described below does the following things: (1) adds extraglottic airways (EGAs) as an option for airway management in Tactical Field Care; (2) recommends the i-gel as the preferred EGA in TCCC because its gel-filled cuff makes it simpler to use than EGAs with air-filled cuffs and also eliminates the need for monitoring of cuff pressure; (3) notes that should an EGA with an air-filled cuff be used, the pressure in the cuff must be monitored, especially during and after changes in altitude during casualty transport; (4) emphasizes COL Bob Mabry's often-made point that extraglottic airways will not be tolerated by a casualty unless he or she is deeply unconscious and notes that an NPA is a better option if there is doubt about whether or not the casualty will tolerate an EGA; (5) adds the use of suction as an adjunct to airway management when available and appropriate (i.e., when needed to remove blood and vomitus); (6) clarifies the wording regarding cervical spine stabilization to emphasize that it is not needed for casualties who have sustained only penetrating trauma (without blunt force trauma); (7) reinforces that surgical cricothyroidotomies should not be performed simply because a casualty is unconscious; (8) provides a reminder that, for casualties with facial trauma or facial burns with suspected inhalation injury, neither NPAs nor EGAs may be adequate for airway management, and a surgical cricothyroidotomy may be required; (9) adds that pulse oximetry monitoring is a useful adjunct to assess airway patency and that capnography should also be used in the TACEVAC phase of care; and (10) reinforces that a casualty's airway status may change over time and that he or she should be frequently reassessed.

Prehospital pain medication use by U.S. Forces in Afghanistan.

We report the results of a process improvement initiative to examine the current use and safety of prehospital pain medications by U.S. Forces in Afghanistan. Prehospital pain medication data were prospectively collected on 309 casualties evacuated from point of injury (POI) to surgical hospitals from October 2012 to March 2013. Vital signs obtained from POI and flight medics and on arrival to surgical hospitals were compared using one-way analysis of variance test. 119 casualties (39%) received pain medication during POI care and 283 (92%) received pain medication during tactical evacuation (TACEVAC). Morphine and oral transmucosal fentanyl citrate were the most commonly used pain medications during POI care, whereas ketamine and fentanyl predominated during TACEVAC. Ketamine was associated with increase in systolic blood pressure compared to morphine (+7 ± 17 versus -3 ± 14 mm Hg, p = 0.04). There was no difference in vital signs on arrival to the hospital between casualties who received no pain medication, morphine, fentanyl, or ketamine during TACEVAC. In this convenience sample, fentanyl and ketamine were as safe as morphine for prehospital use within the dose ranges administered. Future efforts to improve battlefield pain control should focus on improved delivery of pain control at POI and the role of combination therapies.

Evolution of Pararescue medicine during operation Enduring Freedom.

This article highlights recent advances made in U.S. Air Force Pararescue Medical Operations in relation to tactical evacuation procedures. Most of these changes have been adopted and adapted from civilian medicine practice, and some have come from shared experiences with partner nations. Patient assessment includes a more comprehensive evaluation for hemorrhage and indications for hemorrhagic control. Ketamine has replaced morphine and fentanyl as the primary sedative used during rapid sequence intubation and procedural sedation. There has been an increasing use of the bougie to clear an airway or nasal cavity that becomes packed with debris. Video laryngoscopy provides advantages over direct laryngoscopy, especially in situations where there are environmental constraints such as the back of a Pave Hawk helicopter. Intraosseous access has become popular to treat and control hemorrhagic shock when peripheral intravenous access is impractical or impossible. Revisions to patient treatment cards have improved the efficacy and compliance of documentation and have made patient handoff more efficient. These improvements have only been possible because of the concerted efforts of U.S. Air Force and partner platforms operating in Afghanistan.

Review of new topical hemostatic dressings for combat casualty care.

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third-generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

Military trauma system in Afghanistan

This review focuses on development and maturation of the tactical evacuation and en route care capabilities of the military trauma system in Afghanistan and discusses hard-learned lessons that may have enduring relevance to civilian trauma systems. Implementation of an evidence-based, data-driven performance improvement programme in the tactical evacuation and en route care elements of the military trauma system in Afghanistan has delivered measured improvements in casualty care outcomes. Transfer of the lessons learned in the military trauma system operating in Afghanistan to civilian trauma systems with a comparable burden of prolonged evacuation times may be realized in improved patient outcomes in these systems.

Tactical Evacuation of Casualties by Military Helicopters: Present and Future Aspects

ABSTRACTInjury is a surgical disease, and survival is inversely proportionate to elapsed time to treatment. As the routine use of helicopters started during the Vietnam War, it has been well-established that rapid transport was associated with unprecedented survival of critically injured patients. Currently, helicopters are used for tactical and medical evacuation purposes both in the Turkish Military and civilian health care system. Despite the rapid transport advantages, these flying ambulances are austere environments in terms of limited space and medical resources. Accordingly, a study group consisting of experienced military trauma surgeons has analyzed the data related with the present and future aspects of casualty evacuation missions with military helicopters.The main focus of this study was to increase the Turkish Trauma Society awareness, improve en route care quality, identify new research topics and increase military medical readiness for the ensuing conflicts and disaster situations.How to cite this articleÜnlü A, Can MF, Yagci G, Ozerhan I, Asensio JA, Petrone P. Tactical Evacuation of Casualties by Military Helicopters: Present and Future Aspects. Panam J Trauma Critical Care Emerg Surg 2013;2(2):83-88.

Abdominal Aortic Tourniquet™ Use in Afghanistan

The Abdominal Aortic Tourniquet? was used recently used in Afghanistan to control severe hemorrhage in a casualty who had traumatic bilateral amputations of the lower extremities. Excerpts from the medical provider?s account of the tactical evacuation phase of care are provided.

Tactical Combat Casualty Care in the Canadian Forces: lessons learned from the Afghan war

Tactical Combat Casualty Care (TCCC) is intended to treat potentially preventable causes of death on the battlefield, but acknowledges that application of these treatments may place the provider and even the mission in jeopardy if performed at the wrong time. Therefore, TCCC classifies the tactical situation with respect to health care provision into 3 phases (care under fire, tactical field care and tactical evacuation) and only permits certain interventions to be performed in specific phases based on the danger to the provider and casualty. In the 6 years that the Canadian Forces (CF) have been involved in sustained combat operations in Kandahar, Afghanistan, more than 1000 CF members have been injured and more than 150 have been killed. As a result, the CF gained substantial experience delivering TCCC to wounded soldiers on the battlefield. The purpose of this paper is to review the principles of TCCC and some of the lessons learned about battlefield trauma care during this conflict.

Continuous Improvement in Healthcare Support to Operations

This paper discusses the emerging concept of Continuous Improvement in Healthcare Support to Operations (CIHSO) recently introduced within NATO. It starts by summarising the developments in NATO policy regarding clinical...

Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities

Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities

Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities

Tactical Evacuation: Extending Critical Care on Rotary Wing Platforms to Forward Surgical Facilities