Mosby Got TCCC?

Medicine is a funny thing. It claims to be—and SHOULD be—very empirical, very reason and science based. The reality however, tends to be less concrete. From doctors and research scientists who refuse to look at new evidence that refutes the same education they received in med school, even if med school was thirty years ago, to the belief that no one who has not been through four years of med school, plus internships, etc, to earn the privilege of adding a couple of letters behind their name.

One of the ironic things about the belief, in the medical community, of their own reliance on empiricism, is the idea that 20 years of research and experience in military medicine should have no bearing on emergency care, since it doesn’t have “adequate” research behind it.

My experiences teaching TC3 for over 15 years, as both a soldier and a civilian instructor notwithstanding, my medical training includes: holding a first-aid and CPR certification since I was 16 years old, once upon time being on the National Registry as an EMT-Intermediate, ongoing membership in the Special Operations Medical Association (SOMA) and a National Outdoor Leadership School (NOLS) Wilderness First Responder (WFR) certification. Those certifications are not intended to illustrate the depth or breadth of my expertise. By any measure, there are a whole lot of people out there with far more impressive credentials for medical care. This is not even a complete look at the Tactical Combat Casualty Care (TCCC or TC3) protocols.

The point of this article is to demonstrate the absolute importance for preppers—whether they are “gun people” or not, in taking a solid TC3 medical class, as soon as possible. Why? Because there is nothing in modern medicine that offers a more rational, empirically-supported set of protocols for emergency and field medical care available today. Period.

Let’s look at some of the issues I have with the differences between TC3 and my personal experiences with civilian pre-hospital trauma life-saving (PHTLS) methods.

The ABCs

I actually almost failed out of my NOLS WFR course, because of my unwillingness to accept that they were still teaching—even in a remote wilderness setting—the absolute primacy of the ABC method of patient assessment. Even during practical exercises during the class, I unfailingly reverted back to my TC3 training and the MARCH protocols. The MARCH protocols stand for Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia/Hypovolemic shock. The only difference, obviously, is the emphasis on Massive Hemorrhage in the tactical model.

The ABC method is predicated on the idea that an airway obstruction will lead to death in a matter of minutes. Thus, ensuring a patent Airway is the first priority (after scene size-up, etc, of course). This makes a lot of sense…if your kid is fucking choking on a chicken McNugget…

A major hemorrhage, such as from a severed artery, can lead to unconsciousness and death in less than one minute. When I pointed this out during a recent TC3 course in Idaho, both of the local paramedics in the course, as well as a nurse with three decades of experience, all acknowledged befuddlement that no one had ever considered this in their educational experience.

The first objection most people in the medical field have is that “most of our patients haven’t been shot or stabbed, so massive hemorrhage can be treated during our blood sweep, during ‘circulation.’” The ironic thing about this is, BECAUSE most of their patients aren’t victims of gunshot or stab wounds, it’s all the more important that they start thinking differently, especially within the context of remote/austere medical care. For preppers, the potential for massive trauma wounds, from mechanisms of injury other than gunshot wounds and stabbing, should be obvious. Cutting wood, with a chainsaw or ax, motor vehicle accidents, tripping and falling and impaling yourself; there are a number of potential injuries that make it entirely possible for the amateur or part-time medical care provider to lose a patient to blood loss, even as they try to initiate a chin-lift/jaw thrust to “save the patient” from choking….

Moral #1: Let’s stop worrying about our ABCs, and focus on MARCH.

Airway Issues

The chin-lift/jaw-thrust is the standard method of ensuring a patent airway for PHTLS, for anyone with less than an EMT-I certification (I know EMT-B who are taught, and allowed, by the ambulance services they work for to use, intubation, but—in my experience—they are the exception that proves the rule). For a patient that you are going to have lots of help with, and not have to move, this is sensible. What about when it’s you, or you and one other person, trying to move a patient, who is unconscious with an existing or impending airway obstruction, even as simple as their tongue rolling back into their airway and causing a blockage?

The method I’ve been taught, and the method I teach, is pretty simple: if I have a casualty that has lost, or that I believe will lose, consciousness, they get a nose hose (obviously, absent contraindications). A nasopharyngeal airway device (NPA), often referred to as “nose hose,” “nasal trumpet,” etc, is a simple, soft rubber hose designed to be placed into the nose of the casualty, and running through the nasal passages into the back of the airway, past the mouth. This allows the airway to remain in place and patent, even if the patient loses consciousness.

The funny thing about NPA is, despite the fact that we teach 18 year old privates to emplace them, I’ve yet to see a first-aid course that even discussed them. During my NOLS WFR certification, both of the instructors claimed to have no idea what they were when I pulled them out of my aid bag. A NPA as a method for maintaining a patent airway is a simple, intelligent approach, especially when we have to consider that we may be moving a casualty, quickly, in the dark, in tactical situations that preclude having a third care-giver standing around to hold the chin-lift/jaw-thrust.

The NPA is contraindicated in cases of maxillo-facial trauma, such as gunshot wounds, or kissing a steering wheel or windshield, during a motor vehicle accident. In the TC3 protocols, if a patent airway cannot be maintained, and a NPA is contraindicated, the next step is a surgical crichothyroidotomy, also known as a “cric” (pronounced KRIKE). Since this is definitely an invasive, surgical procedure, there are obviously legal liability reasons that they are not taught in PHTLS courses….

Chest Seals

It amazes me that a first-aid course, whether first-aid or WFR, still teaches the “expedient chest seal” with a piece of plastic wrap and duct tape, as the prime choice to treat penetrating chest wounds. Whether a HALO chest seal, Bohlin, or Asherman device (or the host of other pre-packaged chest seal devices available), the superiority of these to the expedient version is exponential.

During my WFR certification, one of our practical exercises included what turned out to be a “gunshot wound” to the upper chest (in the hippy-leftist flavor of NOLS, of course, it was a random gunshot from a hunter in the mountains, striking your backpacking companion….). While my class peers were still tearing open bandages and digging for duct tape, I had ripped open a HALO seal, plastered it over the entry and exit wounds, and gotten on with my patient assessment. The instructors of course, were livid, because I was “missing” the opportunity to practice making the expedient dressing. The fact that I had done so hundreds of times in the past was irrelevant. The fact that I carry multiple chest seal devices in my IFAK/BOK and medic’s bag, was irrelevant. Since their protocols didn’t recognize the chest seal devices, “they didn’t work.”

Needle Decompression

The same issues arose during WFR when the topic of pneumo- and hemo-thorax arose. The NOLS standard was to “evacuate immediately. There’s nothing you can do to help them. If it turns into a tension pneumo, there’s certainly nothing that can be done for them in the field.”

This is, as any recent infantry veteran of Iraq or Afghanistan can tell you—probably from personal experience—is absolute, utter, and complete bullshit.

There are a number of ways to deal with penetrating chest wounds that develop into pneumo- or hemo-thorax. The needle decompression involves using a 3.25” 14-gauge needle catheter to allow the trapped air or blood to escape, reducing the pressure on the lungs and heart that lead to death.

An alternative that is uncommon in the US, apparently, but well-regarded in the rest of the world, is “digital decompression,” using the finger to manually open the path through the chest between the trapped air or blood and the external surface, serving the same purpose as the needle decompression, albeit in a more rapid fashion.

In a remote situation, pneumo- and/or hemo-thorax MUST be treated. “Evacuate immediately” is a grand strategy, as long as evacuation can happen rapidly, and as long as there is somewhere to evacuate the casualty to, that will provide a more definitive level of care. That doesn’t mean however, that in a grid-down situation, you’re not going to have to deal with it, to keep the casualty alive long enough to get them evacuated.
Tourniquets

Of course, the most obvious shortfall of the relationship between PHTLS and TC3 is the still present (although, fortunately, admittedly closing) gap regarding the use of tourniquets for massive hemorrhage from the extremities.

From a video I saw on FB recently that had a deputy sheriff pulling an appropriately applied tourniquet off a casualty, to the number of medical personnel I still meet who insist that “tourniquets cause limb loss,” there is still a large amount of ignorance, even in the medical field, about the experiences of the military medicine field regarding tourniquet use over the last decade and a half.

Here’s the rub: tourniquets save lives. I know of exactly one otherwise avoidable loss of limb from appropriate tourniquet application. Yet, during refresher first-aid courses and WFR certification, the standard PHTLS mantra regarding tourniquets is still “last resort, because they’ll cause loss of limb.”

The old-age tourniquet alternatives such as a bootlace and stick are not desirable, but using a tourniquet recommended and authorized by the CoTCCC (Committee on TCCC), will not “automatically result in loss of limb.” It WILL save lives.

Conclusions

I see a lot of people on various Internet forums and blogs and articles that insist on how important it is to take a EMT-B course, a WFR course, or even just a basic first-aid course. I’m not about to argue with them, because I agree. There’s a lot of benefit to having a) a legal certification right now, and b) the opportunity to learn to treat with some of the more common civilian issues that don’t arise in the military/tactical environment (My WFR course, for example, opened my eyes to some of the issues that arise with treating lifestyle illnesses and diseases that I had not spent much time considering in the past. This actually led to a pretty drastic changes in my TC3 POI when I teach the class, in order to help address some of those that preppers are likely to see, that are really non-issues in military TC3 classes).

Unfortunately, none—or very few—of the available PHTLS courses of instruction deal with gunshot wounds, stabbings, and burn/blast injuries that we can expect to become more prevalent in our daily lives as things become more apocalyptic. You NEED to take a TC3 course.

Obviously, it goes without saying, I recommend my own TC3 class. Others I can recommend, either from personal experience, or from the word of people I trust implicitly, include those taught by Greg Ellifritz of Active Response Training in Ohio, and Caleb Causey of Lone Star Medics. In fact, I know Lone Star Medics has their annual Tactical Medicine Conference coming up, that should be on the short list for training for anyone in the South, West, or Southwest.

http://lonestarmedics.com/tactical-medicine-conf/







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TC3 in a nutshell:

• Stop the bleeding (tourniquet)
• Start the breathing (NAS airway)
• Seal the front (Chest seal - entry or exit wound)
• Check the back (Chest seal - entry or exit wound)

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