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Tactical Combat Casualty Care in Operation Iraqi Freedom

CPT Michael J. Tarpey, MC, USA

Current assignment: Battalion Surgeon 1-15 IN (PROFIS) Deployed to Middle East

Permanent Assignment: Winder Clinic, Ft. Benning MEDDAC

No duty phone, May contact at


In the mid-1990s the U.S. Army Special Operations Command developed a new set of guidelines concerning the treatment of casualties on the battlefield. These guidelines, called Tactical Combat Casualty Care (TCCC), have been updated since their initial proposal and have been widely practiced with excellent results throughout the Special Operations community (1). However there has been very little spread of the use of the TCCC guidelines into conventional units. This article reviews the use of the principles of TCCC by a mechanized infantry unit in Operation Iraqi Freedom One ( OIF 1).


When Task Force 1-15 Infantry (TF 1-15 IN), part of the Third Brigade Combat Team of the Third Infantry Division, deployed to Kuwait in January 2003 in preparation for war, I was assigned from the Professional Officer Filler System (PROFIS) as their Battalion Surgeon. While the infantrymen were training over the next several months for urban combat, trench warfare, and long-range movement, our medical platoon simultaneously underwent a rigorous train-up in preparation for combat. 1LT Robert (Brian) Fox, the battalion physician assistant, SFC Christopher Parker, the medical platoon sergeant, our other medical non-commissioned officers and I concentrated on teaching our 38 enlisted medics the principles of TCCC. Briefly, TCCC breaks up battlefield medicine into three stages:

1. "Care Under Fire" is care rendered by the medic on the battlefield while under hostile fire with an aid bag as the only equipment.

2. "Tactical Field Care" is treatment provided once the casualty and his unit are no longer under hostile fire, with equipment limited to that carried into the field.

3. "Combat Casualty Evacuation Care" (CASEVAC) is treatment provided once the casualty has been picked up by aircraft, vehicle, or boat.

The training of medics by the battalion surgeon and physician assistant, together with the medical non-commissioned officers, is probably the most important job to which these professionals are assigned. However it is frequently overlooked or not done well. This is particularly true for healthcare providers who normally work in hospitals and are assigned as PROFIS healthcare providers just prior to deployment. Despite the inherent difficulties, assigned healthcare providers have to make the training of medics their first priority. Healthcare providers who normally work in hospital settings will need to make a concerted effort in their training to get out of the Advanced Trauma Life Support (ATLS) mindset and into one based around battlefield medicine, with its completely different scenarios. Intense daily training is the best way to accomplish this.

Healthcare providers assigned to to Level I positions such as a Battalion Aid Station have a particularly important role to play since up to 90% of combat deaths occur on the battlefield before a casualty ever reaches a medical treatment facility (MTF). (2) Hemorrhage from wounds remains the number one cause of mortality, accounting for 50% of all deaths. (3) In Vietnam, 50% of combat deaths were due to wounds with uncontrolled bleeding, with about 11% of these in sites accessible by first aid treatment. (3,4) Ryan et al. assert that approximately one-third of all killed in action (KIA) could potentially be salvageable and point to data from Oman in 1973 and Panama in 1989 in which the stationing of Emergency Medicine physicians at casualty collection points close to the point of wounding resulted in lower KIA rates than in previous conflicts. (5,6,7)

With this in mind, we undertook to train our medics and ourselves in the precepts of TCCC with the goal of lowering battlefield morbidity and mortality. We concentrated first and foremost on the importance of stopping hemorrhage promptly and efficiently with the use of tourniquets. We also reviewed again and again various battlefield procedures such as needle decompression of tension pneumothorax, nasopharyngeal airway insertion, and cricothyrotomy. The medics worked on starting IVs in all kinds of conditions, including in the dark with night vision goggles.

Emphasis was placed on the simple recognition and treatment of common battlefield injuries. For instance, medics were trained to recognize shock by assessing pulses and mental status, rather than with blood pressure cuffs and stethoscopes which have little use on the battlefield. The principles of hypotensive resuscitation were reviewed, as well as in what situations the judicious use of intravenous fluids was appropriate. We avoided teaching procedures like endotracheal intubation and CPR which are of little use to frontline medics in combat.

Each of the medics, alone and in teams, was run through repeated reality-based combat scenarios featuring other soldiers acting as casualties with the types of wounds likely to be encountered on the battlefield. The medics learned to quickly triage casualties before then going through the actual steps involved in their treatment. Again and again they were made to demonstrate the actual steps involved in each medical procedure. In addition, we talked through various scenarios, especially those encountered by medics in Mogadishu in 1993. Given the likelihood of impending war at that time, it was not difficult to get 100% effort from the medics in their training. By the time our unit moved north, we had reviewed these techniques and scenarios with our medics so many times that recognition and treatment involved at times simply muscle memory, which is important in the stress of combat.

Overview of the Battle

On 21 March 2003, TF 1-15 IN attacked across the Kuwaiti border into Iraq as part of the Third Infantry Division assault. Over the next 25 days of continuous combat operations, the Task Force covered over 800 kilometers of open desert and urban terrain and fought in eight major engagements for two Brigade



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