Battlefield medicine

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Combat medics attend to Irish casualties following the opening attack of the Battle of Passchendaele, 1917

Battlefield medicine, also known as field surgery and later combat casualty care, is the treatment of wounded combatants and non-combatants in or near an area of combat. Civilian medicine has been greatly advanced by procedures that were first developed to treat the wounds inflicted during combat. With the advent of advanced procedures and medical technology, even polytrauma can be survivable in modern wars. Battlefield medicine is a category of military medicine.

History

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Antiquity

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  • During Alexander the Great's military campaigns in the 4th century BC, tourniquets were used to stanch the bleeding of wounded soldiers.<ref name=nyt1401>Template:Cite news</ref> Romans used them to control bleeding, especially during amputations. These tourniquets were narrow straps made of bronze, using leather only for comfort.<ref>Template:Cite web</ref>
  • According to bamboo slips from the Han dynasty, external injury from combat and infighting comprised the plurality of injuries and illnesses from soldiers on the front line. These injuries were followed in numbers by exogenous febrile diseases and diseases of abdominal pain, namely disorders of the digestive and respiratory systems. Medical treatment was poor and comprised such treatments as acupuncture, applications of plaster, and drugs, the latter being the most common.Template:Sfn
  • During the 1st century BC, the Roman army used spider webs and honey-soaked bandages as field dressings. Wounds were packed with webs before being wrapped in honey-soaked bandages; the webs served as a natural fungicide while the honey staved off bacterial infection. Amulets were provided to wounded combatants and field doctors distributed those associated with particular gods based whichever god was most appropriate to the circumstances. This appears to have been effective for the combatant's mental health.Template:Sfn

Middle Ages

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File:BNF Français 9749, fo. 67v, c.1380.jpg
A wounded knight is carried on a medieval stretcher.

Early modern period

File:Gersdorff p21v.jpg
An illustration of the Wound Man, showing a variety of wounds from the Template:Lang ('Field Manual for the Treatment of Wounds') written by Hans von Gersdorff in 1517 and illustrated by Hans Wechtlin.
  • French military surgeon Ambroise Paré (1510–1590) pioneered modern battlefield wound treatment. His two main contributions to battlefield medicine are the use of dressing to treat wounds and the use of ligature to stop bleeding during amputation.
  • The practice of triage was pioneered by Dominique Jean Larrey, Napoleon Bonaparte's surgeon-in-chief of the Imperial Guard during the Napoleonic Wars (1803–1815). He also pioneered the use of ambulances in the midst of combat, called Template:Lang ('flying ambulances').Template:SfnTemplate:Sfn Prior to this, military ambulances had waited for combat to cease before collecting the wounded by which time many casualties had succumbed to their injuries.
  • Russian surgeon Nikolay Pirogov was one of the first surgeons to use ether as an anaesthetic in 1847, as well as the very first surgeon to use anaesthesia in a field operation during the Crimean War.
  • During the American Civil War, Jonathan Letterman modernized medical organization on the battlefield for the Union. Following his appointment as the Medical Director of the Army of the Potomac, Letterman founded an ambulance corps staffed with permanent and trained attendants which was later compounded in efficacy by the organization of hospital echelons and tent hospitals in the war's eastern theater.Template:Sfn His contributions led to his being recognized as the "father of battlefield medicine".Template:Sfn
  • The Relief Society for Wounded Soldiers, forerunner of the International Committee of the Red Cross (ICRC) was founded in 1863 in Geneva. The ICRC advocated for the establishment of national aid societies for battlefield medical relief, and stood behind the First Geneva Convention of 1864 which provided neutrality for medics, ambulances, and hospitals.<ref name="Dromi2020">Template:Cite book</ref>
  • In the late 19th century, the influence of notable medical practitioners like Friedrich von Esmarch and members of the Venerable Order of Saint John pushing for every adult man and woman to be taught the basics of first aid eventually led to institutionalized first-aid courses amongst the military and standard first-aid kits for every soldier.

20th and 21st centuries

File:Ww2-53.jpg
An American soldier, wounded by a Japanese sniper, undergoes surgery during the Bougainville campaign in World War II.

History of Tactical Combat Casualty Care (TCCC)

Template:One source In 1989, the Commander of the Naval Special Warfare Command (NAVSPECWARCOM) established a research program to conduct studies on medical and physiologic issues.<ref name="Butler_2017">Template:Cite journal</ref> The research concluded that extremity hemorrhage was a leading cause of preventable death in the battlefield.<ref name="Butler_2017" /> At that time, proper care and treatment was not provided immediately which often resulted in death. This insight prompted a systematic reevaluation of all aspects of battlefield trauma care that was conducted from 1993 to 1996 as a joint effort by special operations medical personnel and the Uniformed Services University of the Health Sciences.<ref name="Butler_2017" /> Through this 3-year research, the first version of the TCCC guidelines were created to train soldiers to provide effective intervention on the battlefield. The TCCC aims to combine good medicine with good small-unit tactics.<ref name="Butler_2017" /> One very important aspect that the TCCC outlined was the use of tourniquets, initially there was a belief that the use of tourniquets led to the preventable loss of an extremity due to ischemia but after careful literature search the committee arrived at the conclusion that there was not enough information out there to confirm this claim.<ref name="Butler_2017" /> The TCCC therefore outline the appropriate usage of tourniquets to provide effective first aid on the battlefield.<ref name="Butler_2017" />

After the TCCC article was published in 1996, the program undertook 4 parallel efforts during the next 5-year period. These efforts are as follows:

  1. Presenting TCCC concepts to senior Department of Defense (DoD) line and medical leaders and advocating for their use.<ref name="Butler_2017" />
  2. Identifying and developing responses to representative types of TCCC casualty scenarios.<ref name="Butler_2017" />
  3. Initiating TCCC's first strategic partnership with civilian trauma organizations—the Prehospital Trauma Life Support (PHTLS) Committee, the National Association of Emergency Medical Technicians (NAEMT), and the American College of Surgeons Committee on Trauma (ACS-COT).<ref name="Butler_2017" />
  4. Expanding TCCC training beyond medical personnel to include SEAL and 75th Ranger Regiment combat leaders and nonmedical unit members.<ref name="Butler_2017" />

Modern applications

Template:More citations needed section Over the past decade combat medicine has improved drastically. Everything has been given a complete overhaul from the training to the gear. In 2011, all enlisted military medical training for the U.S. Navy, Air Force, and Army were located under one command, the Medical Education and Training Campus (METC). After attending a basic medical course there (which is similar to a civilian EMT course), the students go on to advanced training in Tactical Combat Casualty Care.<ref>Template:Cite web</ref>

Tactical combat casualty care (TCCC)

Template:Main Tactical combat casualty care is becoming the standard of care for the tactical management of combat casualties within the Department of Defense and is the sole standard of care endorsed by both the American College of Surgeons and the National Association of EMT's for casualty management in tactical environments.<ref>Template:Cite web</ref>

Tactical combat casualty care is built around three definitive phases of casualty care:

  1. 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. This stage focuses on a quick assessment, and placing a tourniquet on any major bleed.
  2. 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. Care here may include advanced airway treatment, IV therapy, etc. The treatment rendered varies depending on the skill level of the provider as well as the supplies available. This is when a corpsman/medic will make a triage and evacuation decision.
  3. 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.<ref name="narescue.com">Template:Cite web</ref><ref>Template:Cite journal</ref>

Since "90% of combat deaths occur on the battlefield before the casualty ever reaches a medical treatment facility" (Col. Ron Bellamy) TCCC focuses training on major hemorrhaging and airway complications such as a tension-pneumothorax. This has driven the casualty fatality rate down to less than 9%.<ref>Template:Cite web</ref><ref name="narescue.com"/>

Interventions used

Listed below are interventions that a TCCC provider may be expected to perform depending on the phase of TCCC they are at and their level of training. This list is not comprehensive and may be subject to change with future revisions in TCCC guidelines.

Hemorrhage control interventions include the use of extremity tourniquets, junctional tourniquets, trauma dressings, wound packing with compressed gauze and hemostatic dressings, and direct pressure.<ref name="Montgomery_2017">Template:Cite book</ref> Newer devices approved for use by the CoTCCC for hemorrhage control include the iTClamp and XStat.<ref>Template:Cite journal</ref> Pharmacological options also include tranexamic acid, and hemostatic agents such as zeolite and chitosan.<ref name="Montgomery_2017" />

In managing a casualty's airway, a TCCC provider may position the casualty in the recovery position or utilize airway adjuncts such as nasopharyngeal airways, oropharyngeal airways, and supraglottic airways.<ref name="Parsons_2012">Template:Cite bookTemplate:Dead linkTemplate:Cbignore</ref> They may also utilize the jaw thrust and head-tilt/ chin-lift maneuver to open a casualty's airway.<ref name="Parsons_2012" /> Advanced TCCC providers may also perform endotracheal intubation and cricothyroidotomy.<ref name="Parsons_2012" />

Respiratory management largely revolves around the use of chest seals, vented and unvented, and needle decompressions to manage tension pneumothoraxes.<ref name="Parsons_2012" />

In circulation management a TCCC provider may obtain intravenous/ intraosseous access for the administration of fluids such as normal saline, lactated Ringer's solution, whole blood, and colloids and plasma substitutes for fluid resuscitation.<ref>Template:Cite journal</ref><ref name="Weiser_2012">Template:Cite journal</ref> This also provides a route for the administration of other drugs in accordance with the provider's scope of practice.<ref name="Weiser_2012" />

Head injuries would indicate for cervical spine immobilization to the best of the provider's abilities if deemed appropriate in a given setting, or the use of devices such as a cervical collar.<ref>Template:Cite journal</ref>

As trauma-induced hypothermia is a leading cause of battlefield deaths, a provider may also perform hypothermia prevention can be accomplished through the use of a Hypothermia Prevention and Management Kit or emergency blanket, the placement of a casualty on an insulated surface, and the removal of wet clothing from a casualty's body.<ref>Template:Cite journal</ref>

Care under fire

Care under fire is care provided at the point of injury immediately upon wounding while the casualty and care provider remain under effective hostile fire.<ref name="Sarani_2018">Template:Cite book</ref> The casualty should be encouraged to provide self-aid and remain engaged in the firefight if possible.<ref name="USACC">Template:Cite web</ref> If unable to do so, the casualty should be encouraged to move behind cover or "play dead".<ref name="USACC" /> Due to the high risk of injury to the care-provider and limited resources at this phase, care provided to the casualty should be limited to controlling life-threatening hemorrhage with tourniquets and preventing airway obstruction by placing casualty in the recovery position.<ref name="Savage_2011">Template:Cite journal</ref> The primary focus during care under fire should be winning the firefight to prevent further casualties and further wounding of existing casualties.<ref name="Savage_2011" />

Tactical field care

Tactical field care phase begins when the casualty and care-provider are no longer under imminent threat of injury by hostile actions.<ref name="Sarani_2018" /> Though the level of danger is lessened, care-providers should exercise caution and maintain good situational awareness as the tactical situation may be fluid and subject to change. The tactical field care phase enables the provision of more comprehensive care according to care providers' levels of training, tactical considerations, and available resources.<ref name="Sarani_2018" /> Major tasks that are to be completed in the tactical field care phase include the rapid trauma survey, the triage of all casualties, and the transport decision.<ref name="Sarani_2018" />

Tactical evacuation care

Tactical evacuation care refers to care provided when a casualty is being evacuated and en-route to higher levels of medical care.<ref name="Sarani_2018" /> Care providers at this phase are at even less risk of imminent harm as result of hostile actions.<ref name="Sarani_2018" /> Due to improved access to resources and the tactical situation, more advanced interventions can be provided to casualties such as endotracheal intubation.<ref name="Sarani_2018" /> Patient re-assessments and the addressing of issues that were not or were inadequately addressed previously are also major components of this phase.<ref name="Sarani_2018" />

In tactical evacuation (TACEVAC), casualties are moved from a hostile environment to a safer and more secure location to receive advanced medical care. Tactical evacuation techniques use a combination of air, ground and water units to conduct the mission depending on the location of the incident and medical centres. Ground vehicle evacuations are more prevalent in urban locations that are in close proximity to medical facilities.<ref name="TEC">Template:Cite web</ref> Requests for evacuation of casualties and pertinent information are typically communicated through 9-Line MEDEVAC and MIST reports.<ref>Template:Cite journal</ref>

Tactical evaluation is an umbrella term that encompasses both medical evacuation (MEDEVAC) and casualty evacuation (CASEVAC). Medical evacuation platforms are typically not engaged in combat except in self-defence and defence of patients.<ref>Template:Citation</ref> MEDEVAC takes place using special dedicated medical assets marked with a red cross. Casualty evacuation is through non-medical platforms and may include a Quick-Reaction force aided by air support.<ref name="TEC" />

For aircraft involved TACEVAC situations there are many considerations that need to be accounted for. Firstly, the flying rules vary widely depending on the aircraft and units in play.<ref name="TEC" /> The list of determinants to create the TACEVAC strategy include the distances and altitudes involved, time of day, passenger capacity, hostile threat, availability of medical equipment/personnel, and icing conditions.<ref name="TEC" /> As mentioned TACEVAC is more advanced than TCCC, it also includes training to/for:<ref name="TEC" />

  • improve breathing <ref name="TEC" />
  • provide supplemental oxygen <ref name="TEC" />
  • administer Tranexamic acid (TXA) <ref name="TEC" />
  • deal with traumatic brain injuries <ref name="TEC" />
  • fluid resuscitation<ref name="TEC" />
  • blood product administration<ref name="TEC" />
  • blood transfusion<ref name="TEC" />
  • preventing and treating hypothermia<ref name="TEC" />

Canadian armed forces

Template:One source There are three levels of tactical combat casualty care providers in the Canadian Armed Forces.

Combat first aid

Every soldier receives a two-day combat first aid training course. The course focuses on treating hemorrhages, using tourniquets and applying dressings, and basic training for casualty management.<ref name="Savage_2011"/>

Tactical combat casualty care

A select number of soldiers are chosen to participate in an intense 2-week tactical combat casualty care course where soldiers are provided with additional training.<ref name="Savage_2011" /> Overall, they are trained to work as medic extenders since they work under the direction of medics.

Tactical medicine

The tactical medicine (TACMED) course is offered exclusively to medics. The tactical medicine program provides training for advanced tactical combat casualty care and is the highest level of care provided by the Canadian Armed Forces in a battlefield setting.<ref name="Savage_2011" /> Medics are trained to treat and manage patients using the MARCHE protocol.<ref name="Savage_2011" /> The MARCHE protocol prioritizes potential preventable causes of death in warfare as follows:

  1. Massive hemorrhage control<ref name="Savage_2011" />
  2. Airway management<ref name="Savage_2011" />
  3. Respiratory management<ref name="Savage_2011" />
  4. Circulation<ref name="Savage_2011" />
    1. Bleeding control<ref name="Savage_2011" />
    2. Intravenous (IV)/ intraosseous (IO) access<ref name="Savage_2011" />
    3. Fluid resuscitation<ref name="Savage_2011" />
    4. Tourniquet reassessment<ref name="Savage_2011" />
  5. Hypothermia prevention<ref name="Savage_2011" />
  6. Head injuries<ref name="Savage_2011" />
  7. Eye injuries<ref name="Savage_2011" />
  8. Everything else<ref name="Savage_2011" />
    1. Monitor patient<ref name="Savage_2011" />
    2. Pain management<ref name="Savage_2011" />
    3. Head-to-toe assessment<ref name="Savage_2011" />
    4. Address all wounds found<ref name="Savage_2011" />
    5. Antibiotics<ref name="Savage_2011" />
    6. Tactical evacuation preparation<ref name="Savage_2011" />
    7. Documentation of care and findings<ref name="Savage_2011" />

United States

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Care under fire

Care under fire happens at the point of injury. According to tactical combat casualty care guidelines, the most effective way to reduce further morbidity and mortality is to return fire at enemy combatants by all personnel.<ref name="Butler_TCCC">Template:Cite web</ref> The priority is to continue the combat mission, gain fire superiority, and then treat casualties.<ref name="Butler_TCCC" /> The only medical treatment rendered in care under fire is the application of direct pressure on massive bleeding.<ref name="Butler_TCCC" /> Tactical combat casualty care recommends a tourniquet as the single most important treatment at the point of injury.<ref name="Butler_TCCC" /> It is recommended during care under fire to quickly place tourniquets over clothing, high, and tight; the tourniquet should be reassessed when out of danger in the tactical field care phase.<ref name="Butler_TCCC" />

Tactical field care

Tactical field care is considered to be the backbone of Tactical Combat Casualty Care and consists of care rendered by first responders or prehospital medical personnel while still in the tactical environment.<ref>Template:Cite book</ref><ref>Template:Cite journal</ref> The acronyms MARCH and PAWS help personnel remember crucial treatment steps while under duress.

MARCH

The MARCH acronym is used by personnel to remember the proper order of treatment for casualties.

Massive hemorrhage. The most potentially survivable cause of death is hemorrhage from extremity bleeds, however more than 90% of 4596 combat mortalities post September 11, 2001 died of hemorrhage associated injuries.<ref name="Butler_TCCC" /> It is recommended to apply a Committee on Tactical Combat Casualty Care (CoTCCC) approved tourniquet for any life-threatening extremity hemorrhages.<ref name="Butler_TCCC" /> Tourniquets during tactical field care should be placed under clothing 2 to 3 inches above the wound, with application time written on the tourniquet.<ref name="Butler_TCCC" />

Airway. Non-patent or closed airway is another survivable cause of death. Airway injuries typically occur due to inhalation burns or maxillofacial trauma.<ref name="Butler_TCCC" /> If a person is conscious and speaking they have a patent open airway, while nasopharyngeal airway could benefit those who are unconscious and breathing.<ref name="Butler_TCCC" /> However, unconscious casualties who are not breathing could require surgical cricothyroidotomy, as endotracheal intubation is highly difficult in tactical settings.<ref name="Butler_TCCC" />

Respirations. Tension pneumothorax (PTX) develops when air trapped in the chest cavity displaces functional lung tissue and puts pressure on the heart causing cardiac arrest.<ref name="Butler_TCCC" /> Thus, open chest wounds must be sealed using a vented chest seal.<ref name="Butler_TCCC" /> Tension pneumothorax should be decompressed using a needle chest decompression (NCD) with a 14 gauge, 3.25 inch needle with a catheter.<ref name="Butler_TCCC" /> Ventilation and/or oxygenation should be supported as required.<ref name="Butler_TCCC" />

Circulation. It is more important to stem the flow of bleeding than to infuse fluids, and only casualties in shock or those who need intravenous (IV) medications should have IV access.<ref name="Butler_TCCC" /> Signs of shock include unconsciousness or altered mental status, and/or abnormal radial pulse.<ref name="Butler_TCCC" /> IV should be applied using an 18 gauge catheter and saline lock in tactical field care, secured by transparent would-dressing film.<ref name="Butler_TCCC" /> Tranexamic acid (TXA) should be given as soon as possible to casualties in or at risk of hemorrhagic shock.<ref name="Butler_TCCC" /> An intraosseous (IO) device could also be used for administering fluids if IV access is not feasible.<ref name="Butler_TCCC" />

Head injury/hypothermia. Secondary brain injury is worsened by hypotension (systolic blood pressure under 90 mmHg), hypoxia (peripheral capillary oxygen saturation under 90%), and hypothermia (whole body temperature below 95 Fahrenheit or 35 Celsius).<ref name="Butler_TCCC" /> Medical personnel can use the Military Acute Concussion Evaluation (MACE), while non-medical personnel can use the alert, verbal, pain, unresponsive (AVPU) scale to identify traumatic brain injury.<ref name="Butler_TCCC" /> The "lethal triad" is a combination of hypothermia, acidosis, and coagulopathy in trauma patients.<ref name="Butler_TCCC" /> Since hypothermia can occur regardless of ambient temperature due to blood loss, the Hypothermia Prevention and Management Kit (HPMK) is recommended for all casualties.<ref name="Butler_TCCC" />

PAWS

The PAWS acronym is used by personnel to remember additional casualty care items that should be addressed.

Pain. Proper management of pain reduces stress on a casualty's mind and body, and have reduced incidents of post-traumatic stress disorder (PTSD).<ref name="Butler_TCCC" /> Pain management is shown to reduce harmful patient movement, improves compliance and cooperation, and allows for easier transport as well as improved health outcomes.<ref name="Butler_TCCC" />

Antibiotics. All battlefield wounds are considered contaminated, and thus any penetrating injury should receive antibiotics at the point of injury as well as in tactical field care.<ref name="Butler_TCCC" /> The recommended parenteral antibiotics are 1g ertapenem or 2g cefotetan, which can treat multi drug-resistant bacteria.<ref name="Butler_TCCC" /> if the casualty can tolerate oral fluids, 400mg moxifloxacin can be administered orally instead of ertapenem or cefotetan.<ref name="Butler_TCCC" />

Wounds. Assessing the casualty for additional wounds improves morbidity and mortality. First responders must address burns, open fractures, facial trauma, amputation dressings, and security of tourniquets.<ref name="Butler_TCCC" /> Prior to movement, reassessment of wounds and interventions is very important. Casualties with penetrating trauma to the chest or abdomen should receive priority evacuation due to the possibility of internal hemorrhage.<ref name="Butler_TCCC" />

Splinting. Explosions (such as from improvised explosive device or land mines) that cause lower extremity traumatic amputation cause forces to move upward through the body, which may cause further bone disruption, hollow organ collapse, or internal bleeding.<ref name="Butler_TCCC" /> Thus, first responders should use the Combat Ready Clamp (CRoC), the Junctional Emergency Treatment Tool (JETT), or the SAM Junctional Tourniquet to control junctional hemorrhage and stabilize the pelvis.<ref name="Butler_TCCC" /> In cases of penetrative eye trauma, responders should first perform a rapid field test of visual acuity, then tape a rigid shield over the eye to prevent further damage, and also give 400mg oral moxifloxacin as soon as possible.<ref name="Butler_TCCC" /> Pressure must never by applied to an eye suspected of penetrative injury.<ref name="Butler_TCCC" />

Evaluating effectiveness

In order to evaluate the effectiveness of Tactical Combat Casualty Care, a study was conducted which analyzed US military casualties who died from an injury that occurred while they were deployed to Afghanistan or Iraq from October 2001 to June 2011.<ref name="Eastridge_2012">Template:Cite journal</ref> Of the 4,596 casualties, 87% died in the pre-medical treatment facility, prior to receiving surgical care.<ref name="Eastridge_2012" /> Of the casualties in the pre-medical treatment facility, 75.7% of the prehospital deaths were non-survivable, while 24.3% of deaths were potentially survivable.<ref name="Eastridge_2012" /> Instantaneous non-survivable mortalities included physical dismemberment, catastrophic brain injury, and destructive cardiovascular injury.<ref name="Eastridge_2012" /> Non-instantaneous non-survivable mortalities included severe traumatic brain injury, thoracic vascular injury, high spinal cord injury, and destructive abdominal pelvic injury.<ref name="Eastridge_2012" /> These injuries are very difficult to treat given currently fielded medical therapies such as Tactical Combat Casualty Care.<ref name="Eastridge_2012" />

In terms of potentially survivable mortalities, 8.0% of mortalities were associated with airway obstruction.<ref name="Eastridge_2012" /> Majority of mortalities (90.9%) which were classified as potentially survivable mortalities were attributed to hemorrhage, with 67.3% of the hemorrhage being truncal, 19.2% junctional, and 13.5% extremity.<ref name="Eastridge_2012" /> During the study period, there were no effective protocols put in place to control junctional or truncal sources of hemorrhage in the battlefield, which suggests a gap in medical treatment capability.<ref name="Eastridge_2012" />

This study shows the majority of battlefield casualties which occur prior to receiving surgical care are non-survivable. However, of the casualties which are survivable, the majority of deaths can be attributed to hemorrhages.<ref name="Eastridge_2012" /> Developing protocol which can control and temporize hemorrhage in the battlefield would improve the effectiveness of Tactical Combat Casualty Care, and decreases the number of casualties in the battlefield.<ref name="Eastridge_2012" />

Another study analyzed the effectiveness of tourniquets for hemorrhage control, which are used in Tactical Combat Casualty Care.<ref name="Lakstein_2003">Template:Cite journal</ref> A four-year retrospective analysis showed that out of 91 soldiers who were treated with tourniquets, 78% of tourniquets were applied effectively.<ref name="Lakstein_2003" /> The success rate for tourniquets applied to upper limbs was 94% while the success rate for tourniquets applied to lower limbs was 71%.<ref name="Lakstein_2003" /> The difference between the success rates can be attributed to the tourniquets themselves, as in another study, tourniquets applied on healthy volunteers resulted in a much lower success rate for lower limbs in comparison to upper limbs.<ref name="Lakstein_2003" /> Therefore, the tourniquets themselves can be redesigned to increase its effectiveness and improve Tactical Combat Casualty Care.<ref name="Lakstein_2003" />

A prospective study of all trauma patients treated at the Canadian-led Role 3 multinational medical unit (Role 3 MMU) established at Kandahar Airfield Base between February 7, 2006, to May 20, 2006, was conducted to examine how Tactical Combat Casualty Care interventions are delivered.<ref name="Tien_2008">Template:Cite journal</ref> The study concluded that tourniquets are effective, but must be used appropriately.<ref name="Tien_2008" /> The distinction between venous and arterial tourniquets must be reinforced in Tactical Combat Casualty Care training.<ref name="Tien_2008" /> Tactical Combat Casualty Care courses must also train soldiers to remove tourniquets for the purposes of reassessing trauma after the patient and caregiver is no longer under enemy fire.<ref name="Tien_2008" /> This is because the risks of iatrogenic ischemic injury of prolonged use of tourniquets outweigh the risks of increased blood loss.<ref name="Tien_2008" />

The study also identified technical errors in performing needle decompressions.<ref name="Tien_2008" /> All needle decompressions were performed at least Template:Cvt medial to the mid-clavicular line and well within the cardiac box. This may result in injury to the heart and surrounding vasculature.<ref name="Tien_2008" /> Tactical Combat Casualty Care training must reinforce using landmarks when performing needle decompressions.<ref name="Tien_2008" /> This is especially useful since soldiers may have to perform this procedure in poor lighting conditions.<ref name="Tien_2008" />

See also

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