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Battlefield documentation of tactical combat casualty care in Afghanistan.


In 2006, the Joint Trauma System (JTS) established the Joint Theater Trauma System (JTTS) in Afghanistan with a hospital data collection system and a database (formerly the Joint Theater Trauma Registry, now the Department of Defense Trauma Registry), that was specifically designed to capture, consolidate, and analyze combat casualty care provided in deployed military hospitals (eg, combat support hospital). Data from this registry have subsequently produced evidence-based performance improvement recommendations that have optimized clinical practice guidelines, supported equipment and supply requirements, and ultimately advanced emergency and surgical care for severely and critically injured combat casualties. Throughout this process, there have been 44 JTS clinical practice guidelines developed to improve care for combat casualties. (1) These efforts have contributed to survival rates as high as 98% for those arriving alive at military hospitals in Afghanistan, (2) however, it has been both tactical and medical efforts that have significantly contributed to the reduction of case fatality rate to less than 10% for the entire conflict. (3)

Performance improvement initiatives and implementation of lifesaving interventions during prehospital helicopter transport have also benefitted from the availability of adequate data, particularly inflight casualty care data. Notable was the study by Mabry and colleagues (4) that demonstrated survival benefit in casualties who were transported and treated by critical care flight paramedics as compared to basic flight medics. As a result of this study, the US Army adopted the critical care flight paramedic as a standard for prehospital helicopter transport, and provided the commensurate funding, support, and training required to achieve this level of expertise. Additionally, inflight blood transfusion protocols and capability were made available for prehospital helicopter transport. (3) As each prehospital helicopter transport unit developed their own format for documenting inflight care, data points captured would subsequently vary from unit to unit. In response to this issue, the JTS developed and standardized a prehospital transport patient care record (PCR) and after action report (AAR) to improve data captured from inflight casualty care. (5) The PCR data was then entered into an evacuation care database and also scanned into the patient record on the Theater Medical Data Store (TMDS).

During the conflicts in Afghanistan and Iraq, more than 87% of US military combat casualty deaths occurred during the prehospital phase of care (6) prior to arriving at a hospital with surgical capability, and it is in this phase of care that casualty care documentation is lacking. By the year 2007, more than 30,000 casualties had already resulted from the conflicts in Iraq and Afghanistan; however, less than 10% of these casualties had adequate prehospital documentation. (7) Although inherently difficult to capture, this "gap" in documentation was a significant missing link in efforts to optimize combat casualty care. Without this requisite data, those dedicated to improving prehospital care are essentially hunting for solutions while armed with suboptimal evidence. (7) As more than 24% of prehospital deaths on the battlefield are categorized as "potentially survivable," (6,8) prehospital data capture is a must for global performance improvement of combat casualty care.

Having successfully refined its operations in Afghanistan, and having long recognized the gap in prehospital care and documentation, in 2013 the JTS developed and deployed a prehospital directorate for the JTTS in Afghanistan. In addition, novel data collection tools were developed for the capture, consolidation, and analysis of prehospital or Tactical Combat Casualty Care (TCCC). (1,9-12) These tools included the TCCC Casualty Card, the TCCC After Action Report (AAR), and the Prehospital Trauma Registry (PHTR). All of these products use the MIST (mechanism of injury, injury, signs and symptoms, and treatment) format.

During the tactical field care phase of TCCC, a TCCC Card is completed by the medical or nonmedical first responder and attached to the casualty prior to transport to the next higher role of care. This provides critical treatment information to personnel providing care during transport, and to the medical team receiving the casualty at the hospital. In order to provide documentation of care in the medical record, the TCCC Card was scanned into the patient record on TMDS.

The more comprehensive TCCC AAR was also completed by the first responder and submitted or transmitted to the JTTS within 72 hours of injury. The TCCC AAR has the same basic format and design as the TCCC Card but has more data entry points which provide for a more detailed report for analysis. The TCCC AAR affords the opportunity for senior medical providers to mentor first responders on their prehospital care and to recognize the effect of providing such care in the context of the tactical environmental. From a performance improvement perspective, it is absolutely critical to know and understand the tactical situation when interpreting prehospital care documentation. Those who are experienced in tactical care can optimize feedback and insight. The TCCC AAR was entered into the PHTR, the exclusively performance improvement section was then removed, and only the injury and treatment section was scanned into the patient record on TMDS.

During 2013, JTTS personnel traveled throughout Afghanistan training medical leaders and first responders on the new prehospital documentation system, starting first at main forward operating bases (FOBs) with Role 3 and Role 2 medical treatment facilities, and then to smaller FOBs and combat outposts with only Role 1 personnel. Additionally, the Commander, US Forces-Afghanistan issued Fragmentary Order 13-139 * in July 2013 which mandated the use of the TCCC Card and the TCCC AAR for all combat casualties in Afghanistan.

Assessment of adequacy of prehospital care has historically been relatively subjective. We do not know if casualties have received the standard of care in accordance with the TCCC Guidelines at the point of injury. The analysis of data captured in TCCC Cards (Figure 1) and TCCC AARs (Figure 2) permit the initiation of critical performance improvement projects. These performance improvement projects will be presented in this report and will demonstrate the value of data capture and analysis. The JTTS prehospital team evaluated compliance with documentation and use of the TCCC Card and TCCC AAR. This team also provided "near real time" performance improvement feedback and recommendations to unit commanders, medical leaders, and first responders using PHTR (Figure 3) data and analysis. This report describes those initiatives.



From July 1, 2013, to March 31, 2014, the patient records of all US military qualified casualties were reviewed on TMDS for a TCCC card. The US Central Command Commander's Daily Casualty Report was used to provide accurate casualty counts. Trauma casualties evacuated from prehospital to hospital care (from Role 1 to a Role 2 or Role 3) qualified for TCCC Cards, TCCC AARS, and entry into the PHTR.

All qualified TCCC Cards were categorized as legible if greater than 80% of the card could be read and understood. The number of data fields completed on the TCCC Card gave a percentage for completeness. Additionally, casualties evacuated out of theater were compared to their respective TCCC Card annotated evacuation precedence; "urgent," "priority," and "routine."



A total of 363 US military casualties qualified for TCCC card reporting. Only 7% (24/363) had a TCCC card, of which 96% (23/24) were legible and 88% (21/24) were complete. Of casualties with TCCC cards, 92% (22/24) were battle injuries, and 8% (8/24) were nonbattle injuries (eg, motor vehicle collision). When the 18 casualties who were evacuated out of theater were compared to their respective TCCC card annotated evacuation precedence, it was noted that 72% (13/18) were urgent, 28% (5/18) were priority, and 0% (0/18) were routine.


Ninety three percent of casualties did not get a TCCC Card. When TCCC Cards are provided, they are generally legible and complete, and first responders are triaging casualties correctly for evacuation.



Beginning in August of 2013, all qualified TCCC AARs received by the JTTS prehospital team were entered into the PHTR. For the period October 1, 2013, to April 30, 2014, the PHTR was queried for US casualty TCCC AAR compliance.


Refer to Figure 4. From October 2013 to April 2014, total TCCC AAR compliance was 50% (93/186) with the last 4 months at 84% (57/68).


Compliance with TCCC AAR submission was directly related to JTTS staff efforts and coordination with the casualty chain of command. During this study time period, the US military initiated retrograde actions for the Afghanistan campaign, and enemy fighting tapered down during the winter months. Both of these factors contributed to a decrease in US military casualties, while JTTS prehospital team efforts and commander involvement most likely accounted for increased compliance with AARs.




The TCCC guidelines recommend specific analgesia medications--fentanyl, ketamine, and IV morphine--for casualties in moderate to severe pain and do not recommend IM morphine. (13) As many casualties who incur a gunshot wound or an amputation injury experience moderate to severe pain, from July 2013 to March 2014, the PHTR was queried to assess prehospital pain management in this casualty population within US military forces. Patients who were noted to be "unresponsive" on the AVPU scale were excluded.


Refer to Figure 5. Of 49 casualties who met study criteria, 47% (23/49) did not receive analgesics in the prehospital field setting. Additionally, 14% (7/49) of casualties who received analgesics received IM morphine which is not a recommended medication.


In contrast to TCCC guidelines, medics continue to be issued and use analgesics that are not recommended. Prehospital medical directors should issue and train their medics in accordance with current guidelines and standards for prehospital care on the battlefield.



For hypothermia prevention, the TCCC guidelines recommend the use of the Ready Heat blanket with the heat reflective shell (HRS). To assess compliance with this device, the PHTR was queried from July 2013 to March 2014 identifying US military casualties who were treated with a hypothermia prevention device.


Refer to Figure 6. Of 253 casualties who met study criteria, 51% (129/253) were treated with the Hypothermia Prevention and Management Kit, which contains the Ready Heat blanket with the HRS, and 4% (11/253) were treated using the Ready Heat blanket with the Blizzard blanket. The remaining 45% (113/253) of casualties were treated through improvised measures and did not receive the heat producing Ready Heat blanket.



Hypothermia in combination with coagulopathy and acidosis is designated the "lethal triad." Blood loss can significantly affect a patient's ability to generate body heat, especially in the stressful combat environment. The TCCC guidelines recommend the use of the Ready Heat blanket with the HRS for combat casualties, and it should be made accessible during combat operations when possible.



Eastridge and colleagues (6) identified 19% of potentially survivable prehospital deaths were due to junctional hemorrhage. Between January 1, 2013, and March 22, 2014, 541 casualties were entered into the PHTR. The PHTR provided insight into the use of junctional tourniquets in the field.


The data from the PHTR query showed that 178 casualties had either been injured in the junctional region or did not have adequate control of extremity hemorrhage after application of a tourniquet. Nineteen of these 178 casualties required a massive transfusion. To ensure other sources of hemorrhage were not the source of blood loss, casualties with injuries to other body regions (6 patients) were excluded. This left a cohort of 13 patients who demonstrated the potential need for a junctional tourniquet. In this group of 13 patients, only one (7%) was managed with a junctional tourniquet. (14)


Although the investigators could not quantitate the specific number, several of the casualties received care at locations that did not have junctional tourniquets available. Subsequently, the Army added a junctional tourniquet to medical sets.


A survey conducted by Sauer and colleagues (2) in Afghanistan in 2013 showed that deployed US military personnel confirmed that they had received pre-deployment training, including TCCC card training: 88% of nonmedics had attended the Combat Lifesaver (CLS) course; 88% of medics had completed Brigade Combat Team Trauma Training, and 69% of medical officers had completed the Tactical Combat Medical Course or Combat Casualty Care Course. Additionally, 92% of US military personnel carried an Individual First Aid Kit containing a TCCC card which is usually prefilled with the service member's name, unit, and battle roster number as per unit standard operating procedure. The Commander, US Forces-Afghanistan issued an order in July 2013 directing the documentation of prehospital casualty care using the TCCC card and the TCCC AAR. However, even with trained end-users, TCCC card availability, and an order issued by the senior commander in Afghanistan, after 9 months the JTTS prehospital team still reported only 7% of prehospital casualty care had been documented to the patient record on a TCCC card. The missing element was leadership enforcement of the mandate.

McGarry and colleagues (15) conducted a study on whether there was a training deficiency on using the TCCC Card by military medical providers at the Tactical Combat Medical Course (TCMC) course. Their study, conducted between January and April of 2013, demonstrated the contrary as their results showed prehospital medical documentation compliance of 99% (130 cards for 131 manikins) and accuracy of information of 83% (1300 of 1560 fields completed correctly).

Over a 2-year period, 60 midlevel and senior US Army Medical Department and Department of Defense medical trainers, many of whom were senior noncommissioned officers (NCO) with prior combat deployments as a front-line medic, were approached and asked why TCCC cards were not being used for prehospital documentation. * These medical trainers reported that the tactical situation--multiple casualties, rapid helicopter transport times, the need to complete the mission--was the main reason for the lack of documentation. The TCCC card was otherwise not considered a treatment priority as it does not directly contribute to saving a casualty's life. Many of those interviewed also acknowledged that TCCC card completion is not an enforced or reportable event. As there are no consequences if the card is not completed, many also admitted to not even attempting to fill out the card during prehospital care.

There is no standard location or recommendation for TCCC Card attachment to the combat casualty. TCCC Card placement is left to the discretion of the individual units and thus will vary from unit to unit. The CLS Course Student Self Study Manual trains Soldiers to "attach the TCCC Card to the casualty or place the card in the upper left sleeve or the left trouser pocket of the casualty clothing." (16) In 2012, the Combat Casualty Care Course (C4) and TCMC courses trained Soldiers to tape the TCCC Card to the outside of the casualty's hypothermia blanket. ([dagger]) The TCCC handbook does not indicate where the completed TCCC Card should be attached but does provide the alternative of using 3-inch white tape on the casualty's chest and an indelible pen as an alternative to TCCC Card documentation. (17) Additionally, in Afghanistan in 2014, it was noted that some units chose to annotate care information directly onto the casualty's chest instead of using a TCCC Card.

By incorporating a standard location for attaching the TCCC Card to the casualty in the field, those who transport casualties or receive them at a treatment facility can anticipate and expect the TCCC Card. Thus, ensuring the card does not get discarded with clothing, blankets, and dressings. Based on C4 course training observations and discussions

with members of the Committee on Tactical Combat Casualty Care and the Department of Combat Medic Training, the TCCC Card should be attached to the casualty's wrist or the ankle.


In respect to DOTMLPF (Doctrine, Organization, Training, Material, Leadership, Personnel, Facilities), and in contrast to those who believe that money and technology are the ultimate solutions to this problem, prehospital documentation and data capture is a Doctrine and Leadership issue. A mandate and policy for prehospital documentation and data capture, and the enforcement of this mandate through leadership, is required. Throughout most of the conflict in Afghanistan, the US military has collected minimal prehospital data. Updated prehospital documentation tools and a prehospital trauma registry is now in place; however, command ownership and leadership enforcement of this process is a requisite for achieving success. Leaders are accountable for the tactical combat casualty care given to their wounded Soldiers; consistent documentation of this care will permit performance improvement to thrive.



(1.) US Army Institute of Surgical Research. Joint Trauma System [internet]. Available at: http:// Updated March 16, 2015. Accessed September 8, 2015.

(2.) Sauer SW, Robinson JB, Smith MP, et al. Saving lives on the battlefield (part II)-one year later a Joint Theater Trauma System and Joint Trauma System review of prehospital trauma care in Combined Joint Operations Area-Afghanistan (CJOAA) Final Report, 30 May 2014. J Spec Oper Med. 2015;15(2):25-41.

(3.) Kotwal RS, Howard JT, Orman JA, et al. The effect of a golden hour policy on morbidity and mortality of combat casualties. JAMA Surg; 2016;151(1):15-24.

(4.) Mabry RL, Apodaca A, Penrod J, Orman JA, Gerhardt RT, Dorlac WC. Impact of critical care-trained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan. J Trauma Acute Care Surg. 2012;73(2 suppl 1):S32-S37.

(5.) Nohrenberg JL, Tarpey BW, Kotwal RS. Data informs operational decisions: the tactical evacuation project. United States Army Aviation Digest. October-December 2014:17-19. Available at: http:// Accessed January 29, 2016.

(6.) Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012; 73(6 suppl 5):S431-S437.

(7.) Eastridge BJ, Mabry RL, Blackbourne LH, Butler FK. We don't know what we don't know: pre-hospital data in combat casualty care. US Army Med Dep J. April-June 2011:11-14.

(8.) Kotwal RS, Butler FK, Edgar EP, Shackelford SA, Bennett DR, Bailey JA. Saving lives on the battlefield: a Joint Trauma System review of pre-hospital trauma care in Combined Joint Operating Area-Afghanistan (CJOA-A) executive summary. J Spec Oper Med. 2013;13(1):77-85.

(9.) Kotwal RS, Montgomery HR, Mechler KK. A pre-hospital trauma registry for tactical combat casualty care. US Army Med Dep J. April-June 2011:15-17.

(10.) Kotwal RS, Montgomery HR, Kotwal BM, et al. Eliminating preventable death on the battlefield. Arch Surg. 2011;146(2):1350-1358.

(11.) Kotwal RS, Butler FK, Montgomery HR, et al. The Tactical Combat Casualty Care Casualty Card: TCCC Guidelines Proposed - Change 1301. J Spec Oper Med. 2013;13(2):82-87.

(12.) Geracci JJ, Kotwal RS, Day CD, Bailey JA, Costello CN. Implementation of a Joint Trauma System Pre-hospital Trauma Registry in Afghanistan: Cracking the Code on Data Capture for Tactical Combat Casualty Care. Oral presentation at the Special Operations Medical Association Scientific Assembly; Tampa, Florida; December 2013; and the Military Health System Research Symposium; Fort Lauderdale, Florida; August 2014.

(13.) Butler FK, Kotwal RS, Buckenmaier CC 3rd, et al. A triple-option analgesia plan for tactical combat casualty care: TCCC guidelines change 13-04. J Spec Oper Med.2014;14:13-25.

(14.) Marcozzi D, Smith MP, Witte SM, Burrell E, Curtis RA, Gross KR. A 2013-2014 comparison of the potential benefit versus actual use of junctional tourniquets in a theater of operations. Poster presented at : The Special Operations Medical Association Scientific Assembly; Tampa, Florida; December 2014.

(15.) McGarry AB, Mott JC, Kotwal RS. A study of prehospital medical documentation by military medical providers during precombat training. J Spec Oper Med. 2015;15:79-84.

(16.) US Army. Combat Lifesaver Course: Student Self Study Manual, Subcourse ISo0871. ed C. Ft Sam Houston, TX: US Army Medical Department Center & School; September 2013:7-18.

(17.) US Army. Tactical Combat Casualty Care Handbook. Ft Leavenworth, KS: Center for Army Lessons Learned; March 2012 No. 10-44:18. Available at: report/call/call_12-10.pdf. Accessed January 29, 2016.

([dagger]) Combat Casualty Care Course, March 2012, Camp Bullis, TX; Tactical Combat Medicine Course, July 2012, JBSA Ft Sam Houston TX.


MAJ Robinson is with the Mission Command Training program, Fort Leavenworth, Kansas.

Mr Smith is with Southern Illinois University Edwardsville, Edwardsville, Illinois.

COL Gross and COL (Ret) Kotwal are with the Joint Trauma System, US Army Institute of Surgical Research, Joint Base San Antonio Fort Sam Houston, Texas.

COL Sauer is Director, Joint Trauma System Strategic Programs, Naval Air Station, Pensacola, Florida.

COL Geracci is with the Office of the Corps Surgeon, III Corps, Fort Hood, Texas.

MAJ Day is the Interservice Physician Assistant Program Coordinator, Irwin Army Community Hospital, Fort Riley, Kansas.

* Author J. B. Robinson: conversations with NCO Instructors at the AMEDD Advance Leaders Course, Ft Sam Houston, TX, June 2014; Combat Casualty Care Course Instructor Course, Camp Bullis, TX, August 2014; 32D Medical Brigade Training Support Company Best Medic competition rehearsals at Camp Bullis, TX, October 2014; Brigade Combat Team Trauma Training at Camp Bullis TX, March 2015; Soldier Medic Training Site, Camp Bullis, TX, May to September 2014.
Figure 4. Tactical Combat Casualty Care After Action Report
compliance; October 2013-April 2014.

        Casualties Reported   TCCC AARs Submitted

Oct     49                    4

Nov     38                    17

Dec     31                    15

Jan     24                    20

Feb     22                    21

Mar     9                     7

Apr     13                    9

Note: Table made from bar.

Figure 5. Analgesia administered to amputation or gunshot
would casualties not unconscious; July 2013-March 2014.

             Amp/GSW & AVPU>U   No Meds   TCCC Meds   Not Recommended

Casualties   49

No Meds                         23

Fentanyl                                  11

Morph IV                                  3

Ketamine                                  10

Morph IM                                               7

Note: Table made from bar graph.

Figure 6. Hypothermia prevention using Tactical Combat Casualty
Care recommended Ready Heat Blanket; July 2013-March

             Treated for Hypothermia   No Ready       TCCC
             Prevention                Heat Blanket   Recommended

Casualties   253

51% Primary                            129

4% Alternate:                          20

45%                                                   113

Note: Table made from bar graph.
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Article Details
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Title Annotation:Programmatic Implementations to Improve Health
Author:Robinson, John B.; Smith, Michael P.; Gross, Kirby R.; Sauer, Samual W.; Geracci, James J.; Day, Cha
Publication:U.S. Army Medical Department Journal
Article Type:Report
Geographic Code:9AFGH
Date:Apr 1, 2016
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