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New Strategy Trains All Soldiers in Trauma Care
Date:8/16/2011

By Jenifer Goodwin
HealthDay Reporter

MONDAY, Aug. 15 (HealthDay News) -- During a firefight in Afghanistan, Sgt. 1st Class Leroy Petry, an Army Ranger, picked up a live grenade and threw it away to save the lives of his fellow soldiers. As he did, the grenade exploded, blowing off his right hand. A bleeding Petry, who'd also been shot in both legs, stopped the bleeding by tying his own tourniquet.

"He probably saved his own life by doing it," said Dr. Russ Kotwal, deputy surgeon and medical training officer with the U.S. Army Special Operations Command.

Petry -- who was awarded the Medal of Honor by President Obama last month -- learned how to tie a tourniquet as part of a new strategy for preventing battlefield deaths. Called Tactical Combat Casualty Care (TCCC), the strategy includes training all military personnel -- not just medics -- on the basics of emergency trauma care and giving each soldier a kit that contains lifesaving supplies such as pressure dressings and tourniquets.

"If you have 50 guys going out on a mission, you want all 50 of those guys trained to use their weapons, even medics," Kotwal said. "So wouldn't you want everybody trained on the basics of medical care as well? You are trying to kill the enemy and you are also trying to save lives."

According to a new study, TCCC is working. Petry was a member of the Army's 75th Ranger Regiment, among the first in the U.S. military to implement TCCC, said Kotwal, a former battalion and regiment medical officer who has been deployed 12 times to Iraq and Afghanistan.

Between October 2001 and March 2010, 419 of the 3,500-strong regiment were injured during battles in Afghanistan and Iraq.

Of those, 10.7 percent of those injured were killed in action, meaning they died before they were able to get to a hospital. That's significantly better than the 16.4 percent of the casualties who were killed in action from the rest of the military.

Another 1.7 percent of injured Rangers died of their wounds at the hospital -- again, lower than the 5.8 percent of other injured military personnel who died at the hospital.

The difference in survival can't be explained by less severe injuries. Injured Rangers actually had a lower return-to-duty rate (back on the job within 72 hours) than the wider military population, suggesting that Ranger injuries may have actually been more severe, according to the study.

"This kind of information is exactly the kind of evidence we wanted to see," said Dr. Peter Rhee, chief of trauma at University Medical Center in Tucson who is on the Defense Health Board, an advisory committee that oversees the TCCC.

The study is published in the Aug. 15 online issue of the Archives of Surgery.

TCCC has three objectives: treat the patient, prevent additional casualties, and complete the mission. The guidelines focus on preventing the three major causes of battlefield deaths: severe bleeding due to a loss of limb or other injury; tension pneumothorax (lack of oxygen and low blood pressure from a collapsed lung); and airway obstruction.

TCCC emerged from studies of casualties in previous wars, during which combat casualty care followed the civilian strategy -- physicians and medics were responsible for delivering care on the battlefield, Kotwal said. But conflicts in Iraq and Somalia in the early 1990s showed that there were "profound medical differences between civilians and military environments," according to the article.

Among them: care often had to be delivered in the dark of night, in extremes of temperature, while being fired at, and with only a handful of physicians or physician assistants attached to any regiments, sometimes not enough to get to everyone who needed treatment quickly enough, Kotwal said.

TCCC called for dramatic changes, said Rhee, who had a 24-year military career and who treated the victims of the January shooting rampage in Tucson, Ariz., that included Congresswoman Gabrielle Giffords.

Among them: in civilian trauma, it's common to give victims of trauma IV fluids, but research has indicated that giving fluids may cause harm by triggering an inflammatory process, raising blood pressure and making bleeding worse, not to mention it's nearly impossible to do in the dead of night during a firefight, Rhee said.

Instead, during combat, the focus is on stopping the bleeding using tourniquets and pressure dressing, which are coated in drugs that help in clotting.

"From head to toe, with every aspect of trauma care, we made subtle but substantial changes in the way people are treated," Rhee said.

Today, all Rangers carry kits with pressure dressings, tourniquets and other medical supplies needed for emergency care. All Rangers are taught the basics of emergency care. Others -- from cooks to infantrymen -- go through additional training and become emergency medical technicians.

Of the 419 injuries, about 42 percent of tourniquets were applied by non-medical personnel; 26 percent of all attempts to stop bleeding were done by non-medical personnel, according to the report.

Other aspects of TCCC included having a "line commander" who takes responsibility for casualty care, and a registry in which incidents and outcomes are recorded, allowing for analysis and quality improvement, Kotwal said.

Among the advances: Kotwal and his colleagues showed that using fentanyl lozenges could help ease pain when it wasn't possible to start an IV with painkillers.

Gradually, the rest of the military is adopting the TCCC guidelines, Rhee said.

More information

The Wounded Warrior Project has more on wounded U.S. servicemen and women, and how to help.

SOURCES: Russ S. Kotwal, M.D., M.P.H., deputy surgeon and medical training officer, U.S. Army Special Operations Command, Fort Bragg, N.C.; Peter Rhee, M.D., M.P.H., chief of trauma, University Medical Center, Tucson, Ariz.; Aug. 15, 2011, Archives of Surgery, online


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