With more and more European partner nation Special Operation Forces (SOF) participating in ISAF operations, having medical personnel available to save the lives of wounded personnel in austere and sometimes dangerous environments is of critical importance. Medical personnel, regardless of nation, must be trained in and armed with the appropriate medical equipment and procedures corresponding to each level of care and perform to the same standards.
As a result, the U.S. Special Operations Command Europe (SOCEUR) developed and conducted a Tactical Combat Casualty Care (TCCC) Train-the-Trainer course to enhance the SOF capability and interoperability of the participating nations, but most importantly, incorporate one recognize standard for managing trauma on the battlefield.
Over a two-week period in May at Zemunik Air Base at Zadar, Croatia, 17 medics from Croatia, Germany, Hungary, Latvia, Lithuania, Romania and Ukraine received expanded medical and trauma care training from U.S. medical personnel from 1st Battalion, 10th Special Forces Group (Airborne) and 352nd Special Operations Group (SOG).
According to Lt. Col. Mark Ervin, SOCEUR Surgeon, after feedback from several multinational events and deployments that SOCEUR components participated in, it was clear that while all the participants were familiar with the principles taught as part of TCCC, there were differences in how those principles were applied.
“These differing standards led to less effective care when the injured combatant most needed rapid medical treatment,” Ervin said. “
SOCEUR’s goal in organizing the TCCC Train-the-Trainer course was to provide its partner nation SOF medics with the knowledge and skills required to instruct others in providing medical care in a combat environment following the guidelines and protocols of TCCC.
Although TCCC started as an initiative by U.S. Special Operations Command, it is now used by all services in the U.S. military, conventional as well as SOF community. It is also now used by most allied countries and has been credited as a major factor in U.S. forces having the highest casualty survival rate in our history according to United States Army Institute of Surgical Research.
“This event gave a multinational group of experienced combat trauma care instructors a common course of instruction approved by the official internationally recognized Committee on TCCC,” Ervin said. “This regularly updated and reviewed program can now be used to bring all SOF operators and medics into compliance with an internationally recognized standard.”
The initial proposal to conduct the course took place in October 2010 where members of the SOCEUR Medical Directorate briefed the Croatian Ministry of Defense on the concept of the TCCC and presented a formal request to conduct the event there. Over a five-month period, several planning conferences took place to gather input from the partner nations and to establish a common framework for the event.
“When we first starting discussing TCCC training with our partner nations, it became clear that certification from an internationally recognized body was critically important,” Ervin said. “We entered discussions with the committee on Tactical Combat Casualty Care (CoTCCC) which resulted in defined criteria for approval of international TCCC courses to be certified by the CoTCCC and the naming of two experience TCCC instructors based in Europe to serve as validating officials.”
The CoTCCC’s mission is to advise the Assistant Secretary of Defense for Health Affairs and the Service Surgeons General about battlefield trauma care for wounded warriors. The committee is responsible for making changes and updates to the TCCC program. The training objectives of the SOCEUR-sponsored event centered on the three definitive phases of TCCC:
Care under Fire: Care rendered at the scene of the injury while both the medic and the casualty are under hostile fire. Available medical equipment is limited to that carried by each operator and the medic;
Tactical Field Care: Rendered once the casualty is no longer under hostile fire. Medical equipment is still limited to that carried into the field by mission personnel. Time prior to evacuation may range from a few minutes to many hours; and
Tactical Evacuation Care (TACEVAC): Rendered while the casualty is evacuated to a higher echelon of care. Any additional personnel and medical equipment pre-staged in these assets will be available during this phase.
Training objectives included tourniquet application/hemorrhage control, needle decompression, patient movement/splinting, nasopharyngeal (NPA) airway insertion, MEDEVAC request/9-Line and rotary wing/loading procedures. Also, the participants had to be able to evaluate each other, design their own scenarios and perform other instructor skills so that they would be able to return their own units able to teach on their own.
Ervin specifically highlighted the importance of having interoperable protocols for tactical field medical care as wounded personnel may likely be treated by medical personnel from a different nation.
“With the diverse coalition contributing to ISAF, it is possible that a casualty will be seen by a combat first responder, medic, CASEVAC crew and physician that all come from different countries,” Ervin said. “A standardized protocol of field trauma care, such as TCCC, insures the injured combatant that despite the differences in language, everyone caring for him will be able to perform the most appropriate procedures and communicate using the ‘language’ of TCCC.”
As a lead instructor of the event, MSgt. Will A. Ward, noncommissioned officer in charge of Medical Operations, 352nd SOG, used his prior TCCC training to bring an air of realism to the participants, especially including “stress inoculation” during the field training exercise (FTX). The concept of "stress inoculation" is derived from a common principle in TCCC which is, care on the battlefield is almost never under good conditions.
During the FTX the participants were exposed to stressful factors that could influence battlefield casualty care such as enemy fire (the number one factor that determines when and how much care can be provided), darkness, terrain, environmental factors, limited medical equipment, evacuation times and platforms (aerial) based primarily on the tactical situation at the time of the evacuation. They underwent several training lanes in which they were evaluated for their ability to make timely life care decisions under duress.
“Exposing students to a ‘stressful’ environment while making them follow the guidelines and theories of TCCC is the only real way to see if they can follow those guidelines while dealing with what could be a very difficult tactical situation,” Ward said.
During the FTX, Ward’s lane focused on rapid patient stabilization while breaking contact, hot landing zone selection, nine-line procedures, and loading and unloading patients from a helicopter. Ward highlighted that most battlefield casualty scenarios involve making both medical and tactical decisions very rapidly, so placing the medics in situations where their decisions would be the difference between life and death added to their stress level.
“I really wanted to focus on giving the partner nations the same quality and level of training that we get for our initial training,” Ward said. “This includes the same intensity in the exercises. I remember the first time that I had to perform TCCC guidelines in the dark, in a room simulating aircraft sound, temperature controlled at 105 degrees, and with an instructor who was more than happy to ‘hurry me along’ if I was going too slow. Those lessons helped when I had to perform in theater, so I want to embark that on them.”
As the host of the TCCC course, Maj. Mladen Gavrich, Chief of Medical Department, Croatian Special Operations Forces Battalion, was very impressed with the degree of training the medics underwent. Recognizing that regardless of the subject matter expertise and experience of his own nation’s medics had prior to attending the course, Gavrich mentioned the TCCC brought a new dimension to causalty care training that the Croatians had never experienced.
“We’ve never trained like this before, especially placing our medics in stressful conditions,” Gavrich said. “The training gave our medics a realistic picture of what could go right or wrong when treating a casualty on the battlefield – especially when taking fire with someone’s life is depending on them to keep them alive.”
He added that with future deployments of the Croatian SOF in support of ISAF, the TCCC course provides a valuable resource and important skills for medics to be successful while conducting this type of medical care to wounded troops on the ground when needed.
But most importantly, Gavrich stressed the course lays a foundation for future medical training as the Croatians will implement their own TCCC course later this year, “taught with common standards and guidelines of the NATO community.”
“The knowledge of what they gained here will allow us to develop better and quality training for our soldiers,” Gavrich said. “I look forward to see how our instructors will train our medics with the skills that they take back from this training and I can say that the TCCC brings our combat medical care to a higher level.”
Ervin agreed with Gavrich’s conclusion on the importance of the TCCC in developing more qualified medics and added linking the event to the CoTCCC provides a continuity of updated training requirements that all the nations can maintain.
“This committee (CoTCCC) regularly updates the curriculum based on battlefield evidence from trauma casualties,” Ervin said. “The NATO SOF Headquarters (NSHQ) Medical Advisors Office, who coordinated CoTCCC support for this event, is the link between these newly minted NATO TCCC trainers and the CoTCCC.”
For one of the training participants, the TCCC course proved very beneficial. A Lithuanian Special Forces (SF) medic, with three combat tours in Afghanistan, mentioned that although his medical standards were similar to the Americans, it was very important to have one standard for all NATO countries serving together in a coalition capacity.
“If we start to train repetitiously according to the TCCC model, we will be able to better save lives,” the Lithuanian SF medic said. “This course brings legitimacy to the direction we (Lithuania) want to go when developing our Special Forces operators and medics to perform the TCCC protocols to the international standard. We will also take those same standards to better develop our conventional forces.”
He specifically stressed the importance of knowing what actions to take when taking fire.
“This course allowed me to think what my actions are when in combat and treating a casualty,” the Lithuanian SF medic said. “All of my medics understand first aid, but they must be able to think quickly on when to engage the enemy on the battlefield and also be able to provide care while under fire. The TCCC qualification is something that we are going to look at for ensuring medics who deploy in the future have as part of their skill set.”
Having met SOCEUR’s short-term goal of providing an internal mechanism for partner nation SOF to train their own forces in the life saving battlefield skills to the level of the international standard, Ervin mentioned the way ahead for SOCEUR to maintain the momentum of the TCCC event.
“Long term, this is the first step in the development of an international cadre of TCCC instructors that will provide NATO SOF greater interoperablity in field trauma care,” Ervin said. “Ultimately, we expect that the employment of the TCCC standard within NATO (and NATO partner countries) will drive the introduction of the best European combat trauma scientific research into the proceedings of the CoTCCC.”