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CASE PRESENTATION

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A unit of a 14-person, six-vehicle military convoy is moving through a village in northern Afghanistan. As the convoy pulls out on open road at the end of that village, an improvised explosive device (IED) discharges under the second vehicle manned with two soldiers. Intensive sniper fire follows and the rest of the convoy is busily engaged in suppressing it. The non-armored disabled vehicle is right side up and not on fire. You are the medic of the unit and you are in an armored vehicle, next to the demolished vehicle with the two victims. As you arrive at the vehicle, you find two casualties: Casualty #1 is the driver of the vehicle. He sustained bilateral mid-thigh traumatic amputations, as well as a penetrating injury of the pelvis and the abdomen. Furthermore, there is a large open head wound in which mangled gray matter is clearly visible. There are no vital signs—he is obviously dead. Casualty #2 is the front-seat passenger. He sustained a below-knee amputation of his left leg with heavy arterial bleeding from the stump, as well as multiple injuries to the left side of his face. He has significant soft-tissue trauma, and has sustained a visible comminuted fracture of the mandible. You note moderate bleeding from the left facial injury. The soldier is conscious and has a good radial pulse but the airway appears compromised due to disrupted airway anatomy (maxillofacial trauma) and bleeding into the airway.

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INTRODUCTION

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Immediate trauma care on the battlefield varies in many respects from pre-hospital trauma care as practiced in the civilian setting. First, the causes, types, and severity of injury differ; second, in combat settings, the incidence of hostile fire, dark environments, limited medical equipment, and prolonged evacuation times is greater. Therefore, treatment guidelines developed for the civilian setting do not necessarily work well in the military setting. The need for reconsideration of trauma care guidelines in the tactical setting has long been recognized.1-3 The Tactical Combat Casualty Care (TCCC) project was initiated by the US Naval Special Warfare Command in 1993, and later continued by the US Special Operations Command (USSOCOM). Within the framework of this project a bundle of tactically appropriate battlefield trauma care guidelines were developed.4 These TCCC guidelines combine “good medicine” with “small-unit tactics.”

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TCCC has three goals for trauma care in the tactical setting: (1) treat the casualty; (2) prevent additional casualties; and (3) complete mission. TCCC is divided into three phases:

  • Care under Fire

  • Tactical Field Care

  • Tactical Evacuation Care

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TCCC is performing the correct intervention at the correct time in the continuum of field care (Figure 58–1). In the Care under Fire phase, medical personnel and casualties are under effective hostile fire and tactical considerations predominate. The medical care is limited to extremity hemorrhage control with tourniquets. In the Tactical Field Care phase, more extensive medical ...

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