Tactical Combat Casualty Care (TCCC) Weaponized Medicine
BRING YOUR TACTICAL KIT AR 200 ROUNDS & PISTOL (Weapon not required / optional) AND BE READY TO LEARN AND GET DIRTY!
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The Tactical Combat Casualty Care (TCCC) course introduces evidence-based, life-saving techniques and strategies for providing the best trauma care on the battlefield. NAEMT conducts TCCC courses under the auspices of its PHTLS program, the recognized world leader in prehospital trauma education.
NAEMT’s TCCC courses use the PHTLS Military textbook and are fully compliant with the Department of Defense’s Committee on Tactical Combat Casualty Care (CoTCCC) guidelines. It is the only TCCC course endorsed by the American College of Surgeons.
The TCCC-MP (TCCC for Medical Personnel) course is designed for combat EMS/military personnel, including medics, corpsmen, and pararescue personnel deploying in support of combat operations.
NAEMT’s TCCC course is is accredited by CAPCE and recognized by NREMT.
Almost 90% of American service men and women who die from combat wounds do so before they arrive at a medical treatment facility. This figure highlights the importance of the trauma care provided on the battlefield by combat medics, corpsmen, PJs, and even the casualties themselves and their fellow combatants. With respect to the actual care provided by combat medics on the battlefield, however, J. S Maughon noted in his paper in Military Medicine in 1970 that little had changed in the preceding 100 years. In the interval between the publication of Maughon's paper and the United States’ invasion of Afghanistan in 2001, there was also little progress made. The war years, though, have seen many lifesaving advances in battlefield trauma care pioneered by the Joint Trauma System and the Committee on Tactical Combat Casualty Care. These advances have dramatically increased casualty survival. This is especially true when all members of combat units – not just medics - are trained in Tactical Combat Casualty Care (TCCC.)
We will be conducting a lung, airway, ballistic wound packing labs with many other hands on skill stations.
16 hours TCOLE Credit
16 hours Medical CEUs
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Call if you have anyquestions or to submit payment: 270-871-2953
Tactical Combat Casualty Care (TCCC) is a set of evidence-based, best practice prehospital trauma care guidelines customized for use on the battlefield.1 As of 2018, it is the standard for prehospital combat casualty care in the US Military.2 Approximately 90% of fatalities on the battlefield occur in the prehospital environment, highlighting the value and necessity of effective and ubiquitous TCCC training throughout the Department of Defense (DoD).3,4 As all DoD service members have the potential to be first responders, all first responders (medical and non-medical) are required to have initial and recurrent training and certification in TCCC commensurate to their skill level and occupation.2 The recent DoD mandate in accordance with the revised Department of Defense Instruction (DoDI), 1322.24, “Medical Readiness Training,” (March 2018), requires all uniformed service members be current in TCCC and defines TCCC as a critical wartime skill and directs that “TCCC training will replace the core trauma skills currently taught in service-specific first aid and self-aid buddy care courses.”
During recent combat operations, timely application of TCCC protocols and procedures has been demonstrated to save lives;5–11 however, TCCC training and practice have not been ubiquitous among prehospital first responders. Furthermore, TCCC training is not always taught using a high-quality, standardized curriculum, and what is taught in a particular course may not at all reflect the recommendations in the current TCCC guidelines. For example, in the Army, Brigade Combat Team Trauma Training (BCT3) is a 5-day TCCC-based course for combat medics assigned at the brigade level; medics deploying in support of combat operations are required to take this training before deployment; feedback from medics attending these courses supports variability in the curriculum. A survey conducted by the Joint Trauma System (JTS) as part of the Central Command Trauma Assessment, from January to February 2018 demonstrated that 73% of Army deployed prehospital units had >80% of their medics complete BCT3 before deployment.12 Despite the high compliance with TCCC training noted in this example, anecdotes from medics and observations by JTS personnel have also noted that medics are not always afforded the opportunity to utilize their TCCC skills to their full extent. One theory is that unit providers, physician assistants (PA), or physicians may not allow their medics to perform some of the more advanced TCCC skills in their scope of practice on the battlefield. Thus, the intent of this study was to examine the training, understanding, and utilization of TCCC among US Army physicians and PAs and to examine provider confidence in medics to perform TCCC skills. We hypothesized that decreased provider awareness of TCCC knowledge and skills was associated with decreased confidence in their medics to perform these skills on the battlefield.
MethodsA cross-sectional survey of TCCC training, knowledge, and utilization was developed by members of the JTS and Committee on TCCC. The survey had four parts: (1) general demographics, (2) deployment history and deployment health care skills experience, (3) TCCC training and pain management, and (4) TCCC knowledge test. Using a list of email addresses provided by the consultants to the Army Surgeon General, a link to the survey website was distributed to US Army physicians and PAs. The surveys were conducted anonymously online through a secure website. Data were collected between June and October 2017, with two reminder emails sent to encourage maximum participation. The survey was exempted from review by the US Army Research Institute for the Behavioral and Social Sciences (Exemption Number: DAPE-ARI-AO-17-01) and approved by the US Army Institute of Surgical Research.
Dichotomous measures of TCCC knowledge test score of 80% or higher, confidence with medic utilization of TCCC, and medic utilization of ketamine were used as the main independent variables for each analysis, respectively.
A TCCC knowledge test score was calculated using questions from the TCCC knowledge section of the survey; respondents with a grade of 80% or higher were the comparison group while respondents with a grade below 80% were the reference group. A threshold of 80% was used to delineate passing vs. failing the TCCC knowledge test as this is the same cutoff point used for end of course exams given in TCCC courses.
A dichotomous measure of confidence with medic utilization of TCCC was generated using seven questions from the deployment history and deployment health care skills experience portion of the survey. Respondents who supervised medics during their previous deployments were asked about their confidence in their medics to perform a variety of skills. Providers were coded as being “not confident” if they indicated they were “not at all confident” in their medic’s ability to perform a surgical airway, needle chest decompression, insert a chest tube, place an intraosseous device, give tranexamic acid, administer ketamine, or place a junctional tourniquet. Participants who were “not confident” were coded as the reference group. All other providers were coded as “Confident.” In the initial model, the following variables were included: having supported Special Operations Forces (SOF), Advanced Trauma Life Support (ATLS) certified, unit mandate of TCCC, type of deployment when they supervised medics (combat, non-combat, humanitarian), percent of medics the provider believed had completed a TCCC course, how long ago providers believed their medics had completed their TCCC course, age, years of licensed independent practice, provider type (physician vs PA), last role of care where they were deployed to, active duty status, and last deployment type (non-combat/humanitarian vs. combat).
The measure for medic utilization of ketamine was based on a single question, which asked if participants allowed their medics to use ketamine while in the field, using providers who did not allow ketamine use by medics as the reference group. This question was used as a surrogate for other measures of providers’ confidence in their medics given that it is a medication that many providers do not have experience with and because it is clearly delineated in the TCCC guidelines as the first line agent for prehospital pain management. Demographic, health care skills experience, and deployment history variables were used as covariates in all three analyses. Respondents who had supervised medics during their previous deployments were asked if they allowed their medics to administer pain medications at the point of injury. Participants who responded positively were asked what pain medications they allowed their medics to administer, respondents who indicated any of the following were categorized as allowing ketamine use by medics: intra-muscular, intra-nasal, and intra-osseous/intra-venous. In the initial model, the following variables were included: having supported a SOF, previous experience as a medic, ATLS certification, unit mandate of TCCC course, completion of TCCC course, place where respondent last supervised medics, percent of medics the respondent believed had completed TCCC, allowing medics access to naloxone, years of licensed independent practice, provider experience with administering ketamine to patients, provider confidence in their medics, last year respondent supervised medics, officer level, active duty status, and experience administering ketamine in a simulation.
Logistic regression analyses were conducted on the three main outcomes of TCCC knowledge test score, confidence with medic utilization of TCCC, and medic utilization of ketamine. Odds ratios were used as the primary measure of association between each of the three main outcomes and selected covariates. Associations were estimated by crude and adjusted OR (AOR) and 95% confidence interval (95% CI) were calculated using logistic regression. Bivariate associations between each covariate and each outcome were assessed. In order to fully capture potential predictors for the multivariate model, the bivariate analyses considered all covariate combinations. In the initial model to determine predictors for test success, the following 11 variables were included: has supported SOF, fellowship completion, ATLS certification, unit mandate of TCCC completion, completion of TCCC course, provider type (Doctor of Medicine/Doctor of Osteopathy) vs. PA, officer level (Junior or Senior officer), active duty status, simulation experience with 16 specific skills, patient experience with 16 specific skills, and having ever been deployed.
Independent variables with a value of P < 0.20 in the bivariate analysis were introduced into the full multivariate model. Multicollinearity was then assessed using pairwise correlation coefficients between these variables. Step-wise selection methods were used to build the final models. A likelihood ratio test was conducted to compare each reduced model with the unadjusted full model. Covariates with a significant likelihood ratio test (P < 0.05) were included in the final model. Diagnostic statistics such as the Hosmer–Lemeshow goodness of fit, area under the receiver operator characteristic (ROC) curve analyses and other measures of fit statistics were computed on the final models. All analyses were performed using Stata 15 (College Station, TX).
The survey message and website link were distributed to a total of 7,210 email addresses. The total denominator of actual surveys distributed to active email accounts was unknown, as the number of duplicate and inactive email addresses was unknown. There were 823 (11.4%) surveys initiated, of which 613 (74.5%) were fully completed. Twelve surveys were dropped because of inconsistent responses (eg, originally stated they had deployed, but then subsequently reported zero deployments). Thus, a total of 601 fully completed surveys were ultimately included in these analyses (Fig. 1).
Open in new tabDownload slideSurveys included for analyses.
Demographics and training reported by the study population can be found in Table I. Excluding the response of “Other,” respondents primarily identified their area of practice as family medicine/community-based clinic (24.2%), emergency medicine (13.3%), or surgery/surgical subspecialties (13%). Among respondents was a mean (range) of 2.6 (0–43) total deployments, which included 1.8 (0–36) combat deployments, 0.6 (0–25) non-combat deployments, and 0.23 (0–20) humanitarian deployments. Ninety percent of respondents reported that they had heard of TCCC; however, only 60% knew where to find current TCCC guidelines. Nearly 60% of respondents reported having ever completed a TCCC training course, with only 28% reporting their unit mandated TCCC training. However, 58% of respondents reported that TCCC training was required before deployment. Among respondents was a mean (range) for completed TCCC training of 2.3 (1–10+), with 20% and 16% having completed their most recent course in either 2016 or 2017, respectively. The average TCCC knowledge test was 89% (range 30–100%).
Demographics and Training Reported by Study Population (N = 601)
Male 497 (82.7%)
Age (mean) [range] 42.7 years [28–66]
Active Duty 446 (74.2%)
Reserve 98 (16.3%)
National Guard 57 (9.4%)
Service time (mean) [range] 15 years [<1–43]
Officer level (Grade)
Junior (O3 and below) 354 (58.9%)
Senior (O4 and above) 247 (41.1%)
Physician (MD/DO) 468 (77.9%)
Physician Assistant 133 (22%)
Not fellowship trained 381 (63.3%)
Previous service as medic 102 (17%)
ATLS certified 304 (50.6%)
Unit mandated TCCC training
Yes 166 (28%)
No 275 (46%)
Do not know 160 (27%)
Completed TCCC training
Yes 354 (59%)
No 247 (41%)
Most recent TCCC course provider
Unit 89 (25%)
TCMC 162 (46%)
DMRTI 28 (8%)
Time between course and deployment
<30 days 47 (15%)
31–119 days 128 (42%)
120–364 days 35 (11%)
1–3 years 28 (9%)
4–5 years 4 (2%)
More than 5 years 6 (2%)
While deployed 6 (2%)
Have not deployed since training 50 (16%)
TCCC required for deployment 146 (39%) ATLS, advanced trauma life support; TCCC, tactical combat casualty care; TCMC, tactical combat medical care; DMRTI, Defense Medical Readiness Training Institute.
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Pass/Fail of TCCC Knowledge Test
Of the 601 survey respondents, 499 (83%) passed and 102 (17%) failed the TCCC knowledge test. Respondents who had been previously deployed, regardless of deployment type (combat, non-combat, or humanitarian), had increased odds (AOR = 2.31, 95%CI = 1.31–4.09) of passing the TCCC knowledge test compared to those who had never been deployed (Table II). Having supported SOF and having a unit mandate to complete a TCCC course were also associated with increased odds of passing the test. Completing a TCCC course and having any non-training patient experience with 16 common combat medical skills (eg, managing mass casualty situation, administering blood products, applying combat gauze, applying a tourniquet, etc.) were also characteristics associated with increased odds of passing the test. Conversely, senior officers (grade O4+) were less likely to pass compared to junior officers (grade O3 and below). The likelihood ratio test p-value of < 0.001, area under the ROC curve of 0.7457, and goodness of fit test p-value of 0.1468 indicated a good fit for the final model.
Survey Variables and AORs Associated With Passing the TCCC Knowledge Test
Survey VariableAOR95% CIP-valueSpecial operations forces support
Yes 1.99 1.13–3.5 0.017
Unit TCCC mandate
No 1.0 —
Yes 1.89 0.9–3.97 0.094
Do not know 0.64 0.39–1.05 0.08
Completion of TCCC course
No 1.0 —
Yes 1.82 1.08–3.05 0.024
Officer level (Grade)
Junior (O3 and below) 1.0 —
Senior (O4 and above) 0.59 0.35–0.99 0.048
Patient experience with 16 common combat casualty skills
No 1.0 —
Yes 1.93 1.09–3.42 0.024
No 1.0 —
Yes 2.32 1.31–4.09 0.004
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Of the 601 survey respondents, 419 had supervised medics during their previous deployments. Of these respondents, 171 (41%) were “Not Confident” and 248 (59%) were “Confident” that their medics could perform all TCCC skills. Respondents who believed that 80 to 100% of their medics had completed TCCC training had increased odds (AOR = 2.34, 95%CI = 1.33–4.1) of having confidence in their medics, compared to providers who did not know how many of their medics completed TCCC training (Table III). Conversely, providers who believed that none of their medics completed TCCC training were at decreased odds (AOR = 0.28, 95%CI = 0.08–0.93) of having confidence in their medics. Respondents whose last deployment was with SOF (compared to those last deployed to a Role 1) and reservists/National Guard members had increased odds of having confidence in their medics. The likelihood ratio test p-value of < 0.001, area under the ROC curve 0.7246, and goodness of fit test p-value of 0.2 all indicated that the final model was a good fit.
Survey Variables and AORs Associated With Provider Confidence in Their Medics to Perform TCCC Skills
Survey VariableAOR95% CIP-valueUnit mandate of TCCC
Yes 1.63 0.95–2.78 0.076
Do not know 1.08 0.61–1.91 0.793
Percent of their medics the respondent believed had completed TCCC training
Do not know 1.0
0–39% 1.89 0.75–4.77 0.179
40–79% 1.78 0.78–4.07 0.172
80–100% 2.34 1.33–4.1 0.003
None 0.28 0.08–0.93 0.038
40–49 1.29 0.8–2.11 0.298
50–69 1.55 0.82–2.93 0.178
Last role of care respondent was deployed to
Role 1 (Battalion Aid Station or equivalent) 1.0
Role 2 without surgical capability 0.65 0.3–1.4 0.273
Role 2 with surgical capability 1.1 0.58–2.1 0.768
Role 3 (Combat Support Hospital or equivalent) 0.7 0.36–1.36 0.289
SOF Medical/Surgical Team 4.52 1.78–11.51 0.002
Other 1.68 0.73–3.89 0.222
Active Duty 1.0
Reserve/National Guard 1.86 1.04–3.34 0.036
Physician (MD/DO) 1.0
Physician Assistant 0.58 0.33–1.02 0.058
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Use by MedicsOf the 601 survey respondents, 419 had supervised medics during their previous deployments. Of those who supervised medics, 341 (81.4%) responded positively for allowing their medics to administer pain medications at the point of injury. Those who supervised medics after 2015 had increased odds of allowing their medics to administer ketamine (AOR = 3.67, 95%CI = 2.1–6.43), compared to providers who last supervised medics from 2000 to 2014 (Table IV). Provider confidence in their medics, provider experience with administering ketamine to patients, ATLS certification, and having supported SOF were all characteristics associated with increased odds of allowing medics to administer ketamine. Conversely, most recent deployment where the provider was supervising medics in a non-combat zone (compared to combat zone) and having 10 to 19 years of licensed independent practice (compared to < 1 year) were at decreased odds of allowing their medics to administer ketamine. Finally, allowing medics to have access to naloxone (used as a surrogate for medic expanded scope of practice) was also associated with increased odds (AOR = 2.37, 95%CI = 1.23–4.57) of allowing medics to administer ketamine, compared to providers who did not allow medics access to naloxone and therefore presumably narcotics. The likelihood ratio test p-value of < 0.001 and the area under the ROC curve of 0.81 both indicated that the final model was a good fit.
Survey Variables and AORs Associated With Providers Allowing Medics to Administer Ketamine
Survey VariableOdds Ratio95% Conf.P-valueSupport SOF
Yes 2.42 1.42–4.13 0.001
Yes 1.84 1.07–3.16 0.028
Deployment type of most recent medic supervision
Combat Zone 1.0
Non-Combat Zone 0.26 0.12–0.53 <0.001
Humanitarian/Other 0.31 0.1–1 0.05
Medics access to naloxone
Yes 2.37 1.23–4.57 0.01
Years licensed to independently practice
<1–9 years 1.0
10–19 years 0.36 0.19–0.66 0.001
20+ years 0.5 0.23–1.09 0.083
Provider experience administering ketamine to patients
Yes 1.88 1.06–3.33 0.03
Provider confidence in their medics
Yes 2.03 1.17–3.53 0.012
Most recent year respondent supervised medics
2015–2017 3.67 2.1–6.43 <0.001
Active Duty 1.0
Reserve/National Guard 0.49 0.24–1.02 0.055
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This study examined the training, understanding, and utilization of TCCC among US Army providers (physicians and PAs), provider confidence in medics to perform TCCC skills. The hypothesis was that provider knowledge of TCCC, or lack thereof, had a direct effect on their confidence in medics to perform TCCC skills. It has been observed in the current deployed theaters of operations that medics have not performed all of the TCCC skill sets, and factors that influence this observation were intended to be investigated by this survey. If providers were not TCCC-trained, or did not have confidence in their own capabilities to perform TCCC skills, it could potentially influence the skills that they would both teach and allow their medics perform. The administration of ketamine was used as a surrogate; if providers allowed their medics to administer ketamine, then they were presumed to be more likely to allow their medics to practice to their full potential in terms of the TCCC skill set.
Providers that passed the TCCC knowledge test were more likely to: have supported SOF during their career, have completed a TCCC course, have had direct patient experience with common combat casualty care skills, and have deployed in support of combat operations. Senior officers had lower odds of passing the exam compared to junior officers. Provider confidence in medics was associated with the percent of medics the respondent believed had completed TCCC training (both high and low categories were significant), having the respondents last deployment with a SOF Medical/Surgical Team and being in the Reserve/National Guard.
We chose to look at providers allowing medics to administer ketamine as a representative proxy for providers to allow medics to practice the full spectrum of pain management skills outlined by TCCC. Factors associated with the provision of ketamine usage were having supported SOF, most recent deployment type when the respondent supervised medics, medics having access to naloxone, provider experience with Ketamine, provider confidence in their medics, and having supervised medics between 2015 and 2017. Providers licensed to practice medicine independently for 10 to 19 years were associated with lower odds of allowing medics to use ketamine.
Patient experience was an important factor in passing the TCCC knowledge test. Other factors predictive of passing the TCCC knowledge test were if providers supported SOF, completed a TCCC course, having at least one deployment, and having direct patient experience (not training) with 16 common combat skills. Interestingly, senior officers who were less likely to pass the TCCC test when compared to junior officers appeared to be in conflict with the other variables; presumably, senior officers will have more experience with combat skills, more deployments, and experience in other clinical and operational areas which should help inform their TCCC knowledge. However, 51% of senior officers stated they had completed TCCC training, compared to 66% of junior officers. More senior officers who participated in the survey reported that their unit/medical treatment facility did not mandate TCCC training (49%), and 28% of senior officers were not sure if their unit mandated TCCC training.
Provider confidence in their medics only had four significant predictors, of which two were based on the proportion of medics the respondent believed had completed TCCC. The two significant categories were “80 to 100%” and “None;” when providers believed that the majority of their medics were TCCC trained, they had greater odds of being confident in their abilities (AOR = 2.34), but if they believed none of their medics received TCCC training, they were less likely to be confident in their medics (AOR = 0.28). The majority of providers either believed that 80 to 100% of their medics received TCCC training (35%) or they did not know how many of their medics might be TCCC-trained (45%). Since provider confidence is associated with their belief in how many of their medics are TCCC trained, they must have access to the service designated training tracking systems that will inform them which medics is trained in TCCC and which medics still need to be trained, while deployed. Given that the recently published DoDI mandates that all service members must take TCCC, this should be mitigated by this DoD-wide directive. However, leadership buy-in at all levels will be necessary to implement and enforce this across the force. Operational units will likely have a higher compliance with this DoDI, and the concern is that providers who practice in Military Medical Centers (MEDCENs) will not get the exposure to this training. Leaders at MEDCENs, especially those with residency training programs, should help enforce this requirement so providers who deploy from MEDCENs will not only have situational awareness of the importance of TCCC but help facilitate medic training and education in terms of the TCCC skill set. Additionally, the core of combat medic competence is based on the skills taught in TCCC; therefore, knowing that TCCC training is up to date would not only increase provider confidence in their medics, but also help providers identify which medics need additional training.
Allowing association with allowing medics to administer ketamine related strongly with provider confidence in permitting medics to perform the full TCCC skill set. Other associations with provider confidence in their medic’s skills were the recent supervision of medics and medics having access to naloxone (which is a surrogate for access to pharmaceuticals in the scope of practice). Interestingly, providers who had been licensed to independently practice for 10 to 19 years were less likely to allow their medics to use ketamine when compared to those who practiced 1 to 9 years. The survey did not delineate if these were providers who practice more in the MEDCEN/beneficiary care mission. Although this group of providers may not work regularly with medics, there is a good chance (if they are at a MEDCEN) that they are part of residency training programs and therefore can directly impact providers who may soon be working with medics on deployments. This is another area where provider experience, or potentially providers who have not received the updated TCCC guidelines, might not be allowing their medics to use TCCC skills to their full extent. Both non-combat and humanitarian deployments have resulted in lower odds of allowing medics to administer ketamine, when compared to combat deployments, but having supported SOF was associated with higher odds of medics administering ketamine. The question we must now answer is this: what is different about combat zone vs. non-combat zone and humanitarian supervision of medics that causes providers to allow medics work in their full scope of practice and administer ketamine? Having a better understanding of the demographics of provider types that deploy in support of humanitarian missions, as opposed to combat missions, could help delineate this group of providers and allow targeted TCCC educational initiatives.
Throughout all three fitted models, there is one commonality: experience with SOF. In the models on passing the TCCC knowledge test and allowing medics to administer ketamine, the respondents experience with ever having provided support to SOF increased the odds of passing the TCCC test and allowing medics to administer ketamine. In the provider confidence in medics model, if the last role of care the provider was deployed to was a SOF Medical/Surgical Team, then the respondent had greater odds of having confidence in their medics. The current study did not allow for us to collect more data that might possibly explain why SOF support experience tends to be associated with positive outcomes in providers, but there are a number of theories that can be hypothesized: the highly trained nature of SOF and the higher risk missions not only allow providers to be more confident in their medics, but require it since there is a higher rate of dependency on the team as a whole than compared to more traditional units, or providers were able to see SOF team medics in action and were able to witness their medical skills first hand.
Overall, not enough soldiers are completing TCCC training; 41% of respondents stated they have not completed TCCC training, with 37% of those who have been deployed stating they have never received TCCC training. At the time of the survey, 46% of respondents stated that their unit does not mandate TCCC training, and 27% had no idea if their unit had a TCCC training mandate. Although mandating training does not result in 100% compliance, it does increase the number of service members trained (of those who stated that training was mandated for their unit, only 7% had not completed TCCC training). This not only underscores the importance of policy, but the paramount importance of leadership-driven compliance with prehospital education and training. The survey also revealed that not enough soldiers are getting TCCC training before deployment, with only 42% stating that TCCC was required before deployment. Given that SOF support was found in each of the final models, perhaps other units should take notice and at least model their TCCC training requirements after SOF. Given that at the time of the survey, DoDI 1322.24 had not been published, the new mandate for TCCC training should mitigate this gap. It will be important to repeat this survey tool a couple of years after the DoDI publication to assess interval compliance with TCCC training.
Units should also look beyond the training that occurs in the classroom. Confidence in medics increased when providers believed that their medics were TCCC-trained, and decreased when they believed they were not trained. A unit level program that not only requires all medics to receive TCCC training, but also allows providers to understand what skills medics are taught in the course, and also an easy way for providers to know who has completed TCCC training and who has not, would go a long way in improving provider confidence. An example unit level program such as this in the US military has previously been shown to instill provider and leader confidence and ownership of the program, as well as medical and non-medical first responder competence, which ultimately saved lives.7,13 In the civilian sector, self-efficacy scores equating to user confidence and the decision to intervene have also been shown to increase from pre- to post-training of first responders on TCCC skills.14 Regardless, many of the deficiencies identified by this study should improve following the recent mandate that requires all personnel throughout the DoD to conduct TCCC training.2 However, enforcement of this mandate by medical and combatant leaders will be key to the program’s success and to saving lives.
This study is not without its limitations. Our survey was sent out to all Army physicians using a listserv provided by leadership; however, we cannot be sure that the listserv was complete or contained old email addresses, thus our population is as complete as we can make it, but we may have missed some Army providers. Surveys are based off of self-reported data, and as a result, our data may be biased because of selective memory attribution, telescoping, or exaggeration. One concern about self-reporting is that those providers who have an interest in prehospital care delivery would be more likely to have taken the survey while those who have no interest in TCCC training may have ignored the survey request. Should this be the case, then these data may actually underrepresent those who have not taken TCCC training or those who would not support medic utilization of the full TCCC skill set. The aforementioned biases are present in any survey-based study; however, given the large amounts of data that were collected for this study, these biases are likely limited. Our study finds its strength in contacting as many Army providers as possible by using the official listserv and sending the survey out through leadership to gain more credibility and visibility. This survey also collected data from Active Duty as well as Reservists ensuring capturing data from a wide breadth of experiences and predeployment training experiences. Future studies should be conducted to follow up on training experiences and skills after implementation of the DoDI that requires TCCC training for all deploying medical personnel in order to track the increase of training and skill use.
Our analysis shows that provider knowledge and understanding of TCCC is the foundation which enables medics to utilize their skills fully within the prehospital scope of practice. These results indicate that providers who have personal experience with TCCC skills and have knowledge of their medics training increase the skills providers allow medics to utilize. TCCC was developed to reduce prehospital deaths on the battlefield. Although the application of TCCC has transitioned from the battlefield to all military operations; therefore all providers, and especially those who supervise medics, must lead by example and ensure that all unit personnel are welltrained in TCCC and prepared to save lives while also successfully completing the tactical mission. Like all things in the military, or any large organization, leadership-driven initiatives and enforcement of training are necessary for short-term and enduring success, which in the case of TCCC gives the added benefits of practitioners who are willing to allow their medics to perform all the skills they have been trained in addition to ensuring that all providers receive their TCCC training as well. Given that TCCC has recently become a requirement for all DoD service members, the divergence in TCCC utilization should decrease; future assessments will inform whether these requirements were effectively implemented throughout the military.
The authors would like to thank the military men and women whose hard work and personal sacrifice are evidenced in this data set.
Presented as a poster at the 2018 Military Health System Research Symposium, August 201878, Kissimmee, FL: abstract# MHSRS-18-0547.
The views expressed in this article are those of the authors and do not necessarily represent the official position or policy of the U.S. Government, the Department of Defense, Department of the Army, Department of the Navy, or the Department of the Air Force.