The U.S. military's Tactical Combat Casualty Care (TCCC) guidelines were first introduced in 1996 and became formalized in 2001 with the establishment of the Committee on Tactical Combat Casualty Care (CoTCCC). Since then, TCCC training programs have saved countless service members' lives after being instituted throughout the military. The CoTCCC continues to evaluate and update the guidelines based on associated research regarding combat injury and death statistics.
TCCC consists of three phases of care: Care Under Fire, Tactical Field Care and Tactical Evacuation Care. The guidelines regarding each phase of care are designed to enhance survivability of wounded personnel at the point of wounding, using basic self-aid/buddy-aid skills and proceeding through more advanced treatments as the threat diminishes and evacuation of the casualty proceeds. TCCC is fantastic for its intended purpose: providing immediate life-saving care to personnel wounded in a combat zone during ongoing operations and while facing continuing hostile threats.
Over the last several years, TCCC has increasingly found its way into law enforcement training circles. The basic TCCC guidelines are excellent for military personnel. However, they cannot and should not be applied to law enforcement officers without first being appropriately vetted and adapted to the scenarios, conditions, equipment and training requirements faced in each officer's own work environment.
Tactical Emergency Casualty Care
The Committee for Tactical Emergency Casualty Care (C-TECC) was formed in 2010 with the purpose of adapting the military's TCCC program for our nation's emergency responders. At first glance, the TECC guidelines appear very similar to the TCCC guidelines.
Like TCCC, TECC divides care into three phases:
- Direct Threat Care (DTC)
- Indirect Threat Care (ITC)
- Evacuation Care (EVAC)
However, the C-TECC recognized that combat injury and death statistics do not automatically translate into hostile environments faced by emergency responders here at home. They created a framework of guidelines that acknowledged the valuable lessons learned from military medicine but recognized that there are many operational, tactical and environmental differences regarding medical care in a third-world combat zone compared to the streets of American cities and towns.
C-TECC acknowledges that law enforcement officers, firefighters and emergency medical care providers must work within their respective scopes of practice or authorized skill sets, state laws, local protocols and the oversight of a supervising physician. Some skills detailed in the TECC guidelines may require advanced medical training that may only be performed by an EMT or paramedic, depending on your state's rules.
Despite the improved applicability that TECC provides to emergency responders over TCCC, you may need to simplify TECC guidelines and training for your own officers. Eliminating skills your officers are not trained in, equipped for or permitted to perform will make TECC more easily understood and recalled under stress. I have gotten good results for the last several years using my own simplified version of TCCC/TECC when instructing law enforcement officers who do not already possess advanced medical training.
The C-TECC is a not-for-profit organization and the TECC guidelines are available for free. TECC is not a specific training program but trainers are encouraged to incorporate TECC into their programs. The TECC guidelines are endorsed by FEMA, the U.S. Fire Administration, and the National Tactical Officers Association (NTOA). For more information, go to www.c-tecc.org.
T.H.R.E.A.T.
In April 2013, the American College of Surgeons convened a group of physicians who are recognized experts in emergency, tactical and military medicine. The group was formally known as the Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. The document that resulted from the committee's efforts is commonly referred to as "the Hartford Consensus" due to the meeting location in Hartford, Conn. The committee's mission was to improve victim survivability during and after a shooting, bombing or other hostile act targeting large numbers of people. During the course of this meeting, the participants created a simple acronym, T.H.R.E.A.T., to help all emergency responders focus on their priorities when responding to a violent mass-casualty event:
- Threat suppression
- Hemorrhage control
- Rapid Extrication to safety
- Assessment by medical providers
- Transport to definitive care
In terms of medical treatment, the Hartford Consensus concluded that a victim's best chance of survival was based on early control of external bleeding on scene combined with rapid transport to an appropriate hospital for surgical intervention to deal with internal bleeding and injuries. Training otherwise non-medically trained personnel in external bleeding control and rapid transport is simple and requires a very low budgetary expenditure. At the same time, these rudimentary skills may yield great benefits during a shooting or IED attack.
While T.H.R.E.A.T. was primarily designed for active-shooter style scenarios, it is equally beneficial when used with the concepts of self-aid/buddy-aid already taught to many officers nationwide. Law enforcement officers and other emergency responders who lack extensive medical training are prime targets for a training program based on the T.H.R.E.A.T. concept. However, anyone can save a life. In that spirit, school staff, public works crews and average citizens can all be trained in these easily understood principles and become force multipliers to aid responders in the immediate aftermath of an attack.
The T.H.R.E.A.T. concept provides common terminology and a no-frills approach that can easily be incorporated into existing training programs, particularly when paired with the issuance and pre-positioning of basic bleeding control supplies. Placing supplies of tourniquets and pressure dressings inside public AED cabinets is one such idea that has been presented.
T.H.R.E.A.T. does not work against TECC. In fact, many of the participants in the creation of the Hartford Consensus are also involved in the TECC or TCCC committees. Instead, T.H.R.E.A.T. is intended to augment TECC by providing a minimum framework of skills for those civilians or responders with the least level of medical training. You can learn more about the Hartford Consensus at http://bulletin.facs.org/2013/06/improving-survival-from-active-shooter-events/ and http://bulletin.facs.org/2013/09/hartford-consensus-ii/.
The Bottom Line
If you aren't already conducting training in T.H.R.E.A.T., TECC or other similar adaptation of TCCC in your agency, you are behind the curve. That will be a bad place to be when your community comes under attack. Training in TECC and T.H.R.E.A.T. principles is vital if you expect to be able to properly respond to a mass-casualty event involving a shooter, IED or any other intentional hostile act. Many of these skills also have at least minimal applicability to more common law enforcement scenarios that may occur in your community on a regular basis.
Many advanced skills are equipment-dependent, require more extensive initial and ongoing training, and are very rarely needed in the first few minutes after an injury is sustained. It is great if your agency has the interest, ability and authority to institute advanced medical skill training, but many law enforcement agencies and individual officers do not. Focus your limited time and equipment-carrying capacity on those simple and inexpensive skills such as bleeding control and rescue extraction tactics; these are proven life-savers that every officer should be able to initiate and successfully perform. Save the advanced skills for those personnel who are willing and legally able to perform them, such as patrol-based tactical medics or conventional EMS. Take advantage of resources such as the C-TECC, CoTCCC, the National Association of Emergency Medical Technicians and NTOA, who support and sometimes conduct these types of training. Regular refresher training is an absolute necessity if you expect to recall those skill sets under stress. Implement training that is realistic and appropriate for your training level. Like so many other law enforcement skills, your medical training must be applicable to your anticipated work environment, not the work environment of another law enforcement agency or a military unit. If those environments happen to be the same, so be it, but don't assume they are. Even the most violent attacks against our communities differ from those in an overseas combat zone if for no other reason than the quality of our local trauma systems.
Lastly, beware of those who take military combat death statistics, simply re-title them as "tactical" deaths, and automatically apply those statistics to law enforcement in the United States. There is much value in the experiences of our military forces and the development of TCCC, but those lessons require more than a cookie-cutter approach to implementation within the law enforcement community.
For information on the NTOA recommendations regarding emergency medical training for law enforcement officers, visit http://ntoa.org/site/current-news/ntoa-calls-for-increased-emergency-medical-training-for-police-officers.html.