TRAINING FOR ARMED CONFLICTS

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TRAINING FOR ARMED CONFLICTS Hreckovski
Boris Department of surgery General hospital
Dr. Josip Bencevic Slavonski Brod Croatia
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Historical evidence make it all clear, and
besides that, in a knowledge which is based on
experience, have excellent evidence power. More
than anywhere else, this is thrue in war
practice.
Clausewitz
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The more things change, the more they seem to
remain the same. - remarkable changes in
surgical diagnostic and
therapeuthics in the last two decades
- wound ballistics, injuries are the same
- DOW in Word War II 3.5, Vietnam 3.4
- penetrating wounds of the head and chest
are as lethal today as they where
in biblical times
Dave Ed. Lounsbury, MD

Colonel, Medical Corps
Emergency War
Surgery, 2004.
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Aim of combat medicine is to achieve the return
of the greatest number of injured to combat and
the preservation of life, limb,
eyesight.Victory is the best medicine
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How to achieve improvement in combat medicine?-
body armours in combat operations- move surgeons
towards front line, FSU- training medical
personality for armed conflicts- BLS education
for all professional soldiers, BTLS for special
forces units- new concept - tactical combat
casualty care TCCC- damage control surgery-
combat trauma life support course
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Differences in civilian and military prehospital
environments1. Scene safety2. Number of
causalties3. Time on scene4. Type of
causalties5. Transport time6. Limitation of
medical resources
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Prehospital care in the tactial environment
(TCCC) 1. Care under fire 2. Tactical field
care 3. Combat Casualty Evacuation Care (CASEVAC)
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Tactical Combat Casualty Care has been approved
by the American College of Surgeons and National
Association of EMTs and is included in the
Pre-hospital Trauma Life Support manual 5th
edition. Three goals of TCCC 1. Treat the
casualty save preventable death 2. Prevent
additional casualties 3. Complete the mission
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Factors influencing tactical combat casualty care
- Enemy Fire - Medical Equipment Limitations -
Widely Variable Evacuation Time - Tactical
Considerations - Casualty Transportation
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Tactical Combat Casualty Care
This approach recognizes a particularly important
principle Performing the correct intervention
at the correct time in the continuum of combat
care. A medically correct intervention performed
at the wrong time in combat may lead to further
casualties.
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Care under fireHot ZoneSECURITY!!Limited to
what is carried by medic and soldiersCare based
on MARCH acronymM Massive BleedingA
AirwayR RespirationsC CirculationH -
HeadThe best treatment for a patient under
fire is to gain Fire Superiority!!
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Care under fire- move from hot zone, hemorrhage
control- suppressing the enemys fire-return
fire- decision maker is tactical commander-
medical focus is on hemorrhage control- best
method - tourniqets
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Combat Tourniquet
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Medical personnels firepower may be essential in
obtaining tactical fire superiority. Attention to
suppression of hostile fire may minimize the risk
of injury to personnel and minimize additional
injury to previously injured soldiers. Personnel
may need to assist in returning fire instead of
stopping to care for casualties Wounded soldiers
who are unable to fight should lay flat and
motionless if no cover is available or move as
quickly as possible to any nearby cover
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PREVENTABLE Mortality armed conflicts
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Mortality curve penetrating trauma
Instantaneous Death
100
Breathing complications
80 70 60 50
PPE and good tactics
Shock
Hemorrhage Airway obstruction
Infections
ALS level skills
Self aid Buddy aid EMT-B
Surgery interventions And Antibiotics
6min 1hr 6hr 24hr
72hr
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Tactical field careWarm zone- move to warm
zone, out of direct line of enemy fire, threat
still exist.- ABC procedures starts- tension
pneumothorax was the second leading cause of
preventable combat mortality in Vietnam War-
causalties with uncontrolled hemorrhage (internal
or external) require a hypotensive
resuscitation protocol- analgesia, antibiotics-
hypothermia (first sign of lethal triad) 80 of
nonsurviving patients have had body temperature
lt34- prevention of hypothermia is much easier
than threatment of hypothermia
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Combat Causalty Evacuation Care- care of the
causalty during evacuation via ground, air,
wather- additional equipment and personell
assist in causalty care, opportunity to
increase medical support- continuing evaluation,
monitoring, preventing hypothermia,
establishing IVs, splinting, endotracheal
intubation, drainage of thorax- 1/3 of
helicopter evacuation missions might be aborted
because of weather, inability to locate scene,
etc.
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Tactical Combat Causalty Care- provide medical
support at right place, at right time without
interrupting or interfering with tactical
procedures- two competing thruths exist
a) proper prior planning prevents poor
performance b) best planes always fall
appart when bullets start flying-
formulate appropriate medical plan understand
proposed tactical plan- medical providers must
understand principles of TCCC
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Tactical Combat Causalty Care- tactical
environment is difficult, sometimes exotic place
to give medical care- ATLS if often non
feasible or applicable to the tactical medical
environment- BLS is able to prevent further
injury. When resources are constrained move
from BLS to ALS procedures- military decision
making process key questions what medical
support is required, where and when is needed,
what type of causality is anticipated- good
medicine can sometimes be bad tactics and bad
tactics can lead to mission failure
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TCCC- armed tactical medical personell are able
to protect themself, defend patient, move
independently within combat zone, build trust
and confidence of the team- 70 hours per year
tactical physician should be training with
tactical team- tactical team will establish a
safe perimeter where medical personell can
work- medical personell preffered qualifications
- BLS, ALS, BTLS, IPLS- ability to perform
medical duties under adverse conditions-
skills to be learned must be trained in a tough,
realistic environment
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Damage control capacity of a ship to absorb
damage and maintain mission integrity. USA Navy
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Lesson from War in Croatia 1991-1995- good
integrated health system of civilian and
military medical care- 20-30 mobilised
medical personell is not suitable for work in
tactical enviroment- motivation - tehnical
skills and knowledge- equipmentDifference in
work with professional and reserve soldiers units.
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Conclusion- mission success is the ultimate
objective in military- civilian surgeon v.s.
army surgeon- develop new courses (combat trauma
life support)- bring medicine to non medical
personell (Tactical Combat Casualty Care)-
disaster medicine- victory- DOW in Homeland war
1991-1995- soldiers 1,8- civilians - 3,6
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Thank you for your attention!