# New AF TCCET Teams and Mission Creep Defined.



## amlove21 (Jun 3, 2012)

So, I want to get a different view here. Maybe I am just being a little butthurt. After reading the below article, someone please explain to me why this asset is 1- needed and 2- NOT a less capable Pararescue team? 

Link



*New tactical care teams aim to save more lives*



By Markeshia Ricks - Staff writer
Posted : Saturday Jun 2, 2012 10:00:02 EDT
The U.S. military is enjoying the highest casualty survival rate in the history of modern warfare, but medical officials believe they can save even more lives by getting advanced care sooner to injured troops.
For nearly a year, a three-member team of Air Force health professionals has successfully evacuated and treated 299 severely wounded troops by taking the emergency department to the injured, and another team is set to stand up in the coming month.
Known as tactical critical care evacuation teams, or TCCET, the teams comprise an emergency medicine or critical care physician, a certified nurse anesthetist and an emergency department nurse or intensive care/critical care nurse. The teams specialize in moving and treating patients who have just been injured and risk dying if emergency treatment isn’t administered immediately.
The first team’s skills are being put to good use quickly as troops continue the fight in Afghanistan, where the improvised explosive device remains the enemy weapon of choice.
Many of the casualties of Operation Enduring Freedom suffer blast-related injuries such as burns, lung trauma, traumatic amputation, blunt force trauma and head injuries, according to Air Mobility Command surgeon Brig. Gen. (Dr.) Bart Iddins.
AMC is the lead agency for military aeromedical evacuation around the world, and missions are typically flown by air mobility aircrews and medical teams on C-17, KC-135, or C-130 aircraft. More than 186,000 patient movements have been successfully completed since the onset of operations Iraqi Freedom, New Dawn and Enduring Freedom.
Though every combat medic and many nonmedical combatants are trained to deliver tactical combat casualty care on the battlefield, Iddins said the injuries sometimes are so severe that they exceed those capabilities.
Tactical combat casualty care has saved many lives, but is in no way definitive treatment, Iddins said. “The casualty must still be evacuated to a higher level of medical care.”
*BRIDGING THE GAP*

Finding a way to provide more advanced care at the point of injury will provide a missing piece of the complex puzzle that is war-related trauma treatment. A study published last year in The Journal of Trauma found that 51.4 percent of “battle injury, died of wounds” deaths were “potentially survivable” injuries. Military medical officials believe tactical critical care evacuation teams can help turn that statistic around.
When it comes to treating and evacuating casualties with life-threatening injuries, the military has several options for treatment and evacuation, including its 119 critical care air transport teams, or CCATTs, of which 12 are deployed at any given time to support the war effort, according to Iddins.
Like the tactical teams, CCATTs comprise a three-member team of health professionals that include a critical care doctor, nurse and respiratory technician, but are mostly equipped for maintaining a stable patient during evacuation out of theater on a fixed wing aircraft, Iddins said.
The new tactical teams, which will fly most movement missions on rotary wing aircraft such as a Black Hawk helicopter, are equipped and trained to start trauma resuscitation treatment immediately after injury. And they’re able to do that work in the tight confines of a helicopter with very little equipment.
Iddins said the most common cause of preventable death on the battlefield is uncontrolled bleeding, loss of airway and tension pneumothorax in the lungs. Unlike those trained in first-responder care or combat care, TCCETs are trained and equipped specifically for dealing with such emergency scenarios, Iddins said.
The tactical team is capable of performing aggressive damage control resuscitation such as airway management, mechanical ventilation, blood administration/low-volume resuscitation, hemorrhage control, coagulopathy (bleeding) management, invasive monitoring, vasoactive (increase blood pressure) medication administration and other interventions as required throughout the course of an evacuation, according to Iddins.
That kind of aggressive treatment saves lives, Iddins said, but is beyond the scope of traditional pre-hospital tactical casualty evacuation capabilities. “TCCET is designed to bring a higher level of medical care directly to the casualty, specifically at the point of injury, in order to initiate emergency department/trauma department-level control resuscitation earlier and more aggressively than has traditionally occurred.”
*WORK AMID UNIQUE ENVIRONMENT*

Maj. Michael McCarthy, deputy director at the Center for the Sustainment of Trauma and Readiness Skills in Cincinnati, said that though members of the new tactical teams can conduct a CCATT mission, the teams are specifically trained to deliver high-level, critical care in the tight spaces of a helicopter with limited supplies. Unlike CCATT members, tactical care team members also are trained in combat survival.
During their 10 weeks of training, McCarthy said, future team members will spend time in a simulator that mimics conditions in Afghanistan based on experience gleaned from the first team.
“You’re space-restricted, you’re in a dark environment where you have to use low light and capability,” McCarthy said. “We pipe sound in that’s about 90 decibels … and we make them do whatever the simulation or objective is.”
McCarthy said all the training is meant to help airmen adjust to the austere environment they’ll be working in and help them identify when they’re overwhelmed.
“The [task saturation] threshold is different for every person, but what we focus on here is that you be able to recognize that you’re getting task-saturated, take a step back, call a timeout and redirect your team,” he said.
McCarthy said this mission is unique to the military and the Air Force, though civilian air care programs have provided critical transport for years.
“They don’t bring the same capability that we do, they don’t do it in same austere environment,” McCarthy said. “They don’t have the same team component, and they definitely don’t function in a combat zone.”
*READY TO EXPAND*

The success of the first TCCET operating downrange has service officials champing at the bit to get the second team into action.
AMC plans to stand up the next team by the end of May or early June, Iddins said. The command also is expanding the number of personnel for sustaining current and future mission requirements.
Whether there will be more than two teams remains to be seen, but signs are good. Tactical teams are currently sourced from active-duty and Air National Guard components, but there are plans to put Air Force Reserve members in the mix as full teams or as individual augmentees, Iddins said. Team deployments are 179-day rotations.
“The TCCET casualty movements have been enormously successful — there have been no reported deaths, nor complications associated with TCCET movements thus far,” Iddins said.


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## 0699 (Jun 3, 2012)

Everything is better if you use the word tactical.  I'm surprised they didn't use the word operator too (tactical care operator), as that would have improved their efficiency and capabilities 100%.  Give them their own beret and they could be the newest Tier 1 guys...


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## CDG (Jun 3, 2012)

So what happens when a helo goes down and these "Tactical" teams have to fight their way out?


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## AWP (Jun 3, 2012)

> Maj. Michael McCarthy, deputy director at the Center for the Sustainment of Trauma and Readiness Skills in Cincinnati, said that though members of the new tactical teams can conduct a CCATT mission, the teams are * specifically trained to deliver high-level, critical care in the tight spaces of a helicopter with limited supplies*. Unlike CCATT members, tactical care team members also are trained in combat survival.
> During their *10 weeks of training*, McCarthy said, future team members will spend time in a simulator that mimics conditions in Afghanistan based on experience gleaned from the first team.
> “You’re * space-restricted, you’re in a dark environment where you have to use low light and capability,*” McCarthy said. “*We pipe sound in that’s about 90 decibels* … and we make them do whatever the simulation or objective is.”


 
HOLY SHITBALLS!!!!!!!!!!!!!!!!!!! Trained to operate in the tight spaces of a helicopter? 10 whole weeks of school to do this in sounds up to 90 decibels? And in the dark where the boogeyman lives?

Drain the pool at Lackland, kill the 1T2X1 AFSC, and just add 10 weeks of school on top of a military nurse or doc's pipeline and you're all set.







PS: Send a case of Tuck's pads to all of the IDMTs that just had their mission stolen from them....the mission they tried to steal from Pararescue a few years ago, and tell them the circle is complete.


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## 0699 (Jun 3, 2012)

Also,

Great.  One more thing to feed a doctor's ego...


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## DA SWO (Jun 4, 2012)

My take is non- 1st responder.
i.e PJ/Dustoff does the pickup initial transport, and the CCAT/TCCAT does the next move.
What isn't said is the helo they are using?  CH-47?
This could actually be fun to watch as the CSAR-X could end up being a HH-47.
Why is AMC doing tactical anything besides airlift?


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## policemedic (Jun 4, 2012)

This may hurt some people's feelings, so I'll be unusually kind and preface my opinion by saying that I am absolutely a strong advocate of improving care at the point of wounding and throughout the entire continuum of hospital/rehab treatment.  

With that said, BG Iddins is at best simply disingenuous and at worst colossally ignorant of the capabilities of conventional and SOF medics.  MAJ McCarthy is likewise suffering from craniorectal inversion.  



amlove21 said:


> .
> The tactical team is capable of performing aggressive damage control resuscitation such as airway management, mechanical ventilation, blood administration/low-volume resuscitation, hemorrhage control, coagulopathy (bleeding) management, invasive monitoring, vasoactive (increase blood pressure) medication administration and other interventions as required throughout the course of an evacuation, according to Iddins.




There is a name for this kind of care provider; in fact, there are several.  Paramedic, PJ, SF Medical Sergeant, Independent Duty Corpsman...All of whom are equipped with the skills to perform everything above.  They are notably different from the TCCET team in their more highly developed gunfighting and tactical skill sets.


I am not making an argument that a medic can manage a trauma resuscitation as well as a physician.  I do believe that it is abundantly clear that in the combat setting, at the point of wounding and in transportation to a CSH, there is no difference in functional capability between a well-trained paramedic, 18D, PJ, etc., and a physician.  The limitations of working in an austere, resource constrained environment mitigate the physician's superior knowledge base and procedural skill.



amlove21 said:


> That kind of aggressive treatment saves lives, Iddins said, but is beyond the scope of traditional pre-hospital tactical casualty evacuation capabilities. “TCCET is designed to bring a higher level of medical care directly to the casualty, specifically at the point of injury, in order to initiate emergency department/trauma department-level control resuscitation earlier and more aggressively than has traditionally occurred.”




Bullshit.  Even our basic, fresh from the schoolhouse medics do a fine job at rapidly treating the three main causes of preventable death on the battlefield.  To argue otherwise is to highlight one's own bias and demonstrate stellar idiocy.  



amlove21 said:


> there have been no reported deaths, nor complications associated with TCCET movements thus far,” Iddins said.


 
This just means they haven't seen enough very sick patients.  The fact that Iddins made that statement is prima facie proof that he's too dumb to draw breath.


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## DA SWO (Jun 4, 2012)

They should let them do the next pickup during the firefight.


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## Ranger Psych (Jun 4, 2012)

Maybe I'm not reading into it the same as you guys, but this is basically what one joint unit already does within our community.


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## Salt USMC (Jun 4, 2012)

This sounds a lot like the British MEDEVAC team they've got out here in country these days.  Supposed to be a flying hospital in the back of a 47.  For the life of me I cant remember the name of it, though.


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## JustAnotherJ (Jun 4, 2012)

My POV:  do it!  Let them have it.  For once in the air forces big blue gay life, let the PJs go where they need to go (ie farming out to other SOF teams as imbedded CSAR.  That's just me.


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## amlove21 (Jun 4, 2012)

JustAnotherJ said:


> My POV: do it! Let them have it. For once in the air forces big blue gay life, let the PJs go where they need to go (ie farming out to other SOF teams as imbedded CSAR. That's just me.


Quote of the thread. This article pisses me off in so many ways, it's unreal. However, if they did take the FOB-FOB transfer mission (which is why they claim 290 missions and no deaths, fucking liars), and left us with only hot LZ POI pickups- then shit, we'd actually have the manning to support the missions that need us. What a novel concept.


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## Ranger Psych (Jun 4, 2012)

Going further, this sounds like Medevac on steroids.... which is something I've heard that PJ's don't do, you don't do casevac or medevac, you do personnel and equipment recovery.  So, if anything, this would "hopefully" be what would be showing up when you have conducted said recovery and now it's time for extraction of said injured and recovered personnel.

Let's think about this for a minute. Policemedic cited a bunch of duty positions that are capable of a large majority of the tasks due to extensive training. Let's face it, we pass off patients to higher level care.  Being completely honest, PJ's, Ranger medics, SF medics shouldn't be passing their patients off to (as an example) your run-of-the-mill medevac.  Unless things have changed drastically from when my wife was working on enlisting, Paramedic qualification is a SSG/E-6+ thing that happens for leg medics. 

I know that when I did some training with the Medivac units on Benning many moons ago, as an EMT-B with additional instructor credentials and classes under my belt... AS INFANTRY, I was effectively higher qualified than they were.  Toss on what additional stuff I got OJT'ed on and what I would have on my medsov or load onto a casevac platform? I was rolling better trained and better equipped than your standard medivac platform and crew.   Couple that with the expanded scope that all SOF medics have to varying degrees depending on duty, and you can run into passing off a patient to a crew that honestly isn't qualified, trained, or has a fucking clue as to how to handle.

We've all seen the flying er's. Now they're just flying on rotary wing instead and the ER comes to you.  I think it's a good thing and it doesn't encroach on anyone's jobs, if anything it pushes the more tactically trained medical personnel that would be flying forward to where they could do more good, being a rifle on the ground until it's necessary to intervene immediately following the point of injury

And if their bird gets lit up? Honestly, you aren't in any worse of a position than you would be otherwise. Best case, you've got surviving medical personnel on the ground to try to keep who's left alive longer, worst case you've got about the same number of bags you have to deal with and extract.  They obviously aren't going to have the same amount of tactical training nor recurring tactical training as "insert SOF medic type here" but that can be said for any medivac platform unless it's a SOF platform.


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## AWP (Jun 4, 2012)

Considering the AF's history with Pararescue this just sounds like an attempt for Big Blue to say "Our caregivers can do the PJ's mission, so why do we have so many J's?" The way the article is written it reads like AMC is trying to get a slice of the pie enjoyed by ACC. AMC's role is to take the patient from places like Bagram to Landsthul....now AMC is in the "tactical" business as well?

As an outsider it sounds like Big Blue is chipping away at Pararescue's mssion. In general I'm leery of any organization that does something on their own like this because mission creep is inevitable and 5-10 years down the road it becomes a case of "Why do we have two units doing the same mission?". I've personally witnessed it in Afghanistan, with the Air Force, but on communication systems and the infighting was brutal...now they are adding a MAJCOM to the mix with a high-profile mission?

I read it as a land grab.


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## JustAnotherJ (Jun 4, 2012)

I'll add my enlisted scum outlook again. If they want that mission so that PJs can perform the mission that we were intended to do, then I'm all for it. It could be a land-grab move, but the war is slowing down and hopefully transitioning to a SOF-led war, so the land that their grabbing is like a oil field on the verge of drying up. I don't mean to bash this new concept by any means because it's akin to shitting in our own house. I have faith that the PJ CFM and top level CRO's will get us into the right(ful) mission set and doing what we were truly bred to do. Though the casevac mission has created some real rock star PJs in medicine, I feel that it's time to evolve yet again, to meet the needs of the war to come. If it is taken over, the upper echelon will soon realize that PJs doing casevac have made uncommon valor, common. I think that will be the biggest shock to the system will occur when they no longer have teams hoisting into active fire fights or mine fields and assaulting their way to survivors.

Lastly and most importantly, 10 weeks of training will not mimic the capabilities of PJs...I say that not based upon ego, whatsoever, but more as a warning. Our pipeline is 1.5 years plus ~6 months of upgrade training just to produce a "combat ready" PJ, and even after that, a lot falls upon the Team Leader's shoulders to ensure true combat effectiveness. Placing highly trained medical professionals into a combat situation, IMO, is like utilizing Labrador's as IED/Hit dogs...the shock of combat is far greater upon them, versus a Malinois/German Sheppard; Two different animals that, though they are highly trained and good at what they do, do not necessarily place them into the same realm or level the playing field.

My fingers are crossed that this goes as I hope it does because if it doesn't, it's going to be really rough.


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## JustAnotherJ (Jun 4, 2012)

Deathy McDeath said:


> This sounds a lot like the British MEDEVAC team they've got out here in country these days. Supposed to be a flying hospital in the back of a 47. For the life of me I cant remember the name of it, though.


 MERT - Medical Emergency Response Team

They're composed very similar to that of this proposed TCCET.


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## Salt USMC (Jun 4, 2012)

JustAnotherJ said:


> MERT - Medical Emergency Response Team
> 
> They're composed very similar to that of this proposed TCCET.


 
Thanks JAJ.  I've not heard much about that particular element, but people say they're good for what they do, although they take a bit longer to spool up versus Dustoff/Pedro.


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## policemedic (Jun 4, 2012)

The comment about invasive monitoring goes further up my ass the more I think about it.  Some AF doc is going to insert a Swan-Ganz as the bird lifts off the battlefield so he can look at a PCWP waveform?  Good luck analyzing that inflight.  Not to mention that this would be the worst possible time to try to insert any sort of invasive hemodynamic monitoring catheter.

The CCATTs do good work.  In an inter-facility setting, critical care docs, anesthesiologists, nurses and medics can function as a highly capable multidisciplinary team.  

This TCCET?  I'm not sold.


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## JohnnyBoyUSMC (Jun 4, 2012)

So a question for those PJ's on here: what would be your preference were you to be suddenly promoted to the top of the AFSOC chain? How would you want the allocation of PJ's and their mission focus/training to go in light of units like this being stood up, the winding down of theaters of the GWOT, etc? I've seen a few things on here as to a general idea of what you'd like but wanted to hear some specific stuff you guys had in mind.


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## HealwithSteel1 (Jun 4, 2012)

Ranger Psych said:


> Going further, this sounds like Medevac on steroids.... which is something I've heard that PJ's don't do, you don't do casevac or medevac, you do personnel and equipment recovery. So, if anything, this would "hopefully" be what would be showing up when you have conducted said recovery and now it's time for extraction of said injured and recovered personnel.
> 
> Healwith Steel1 States:
> This has been an interesting discussion on this topic. SOWT’s take is right that TCCET is a Non-1st Responder. Having some knowledge of the training of these TCCETs, I would point out the following facts:
> ...


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## DA SWO (Jun 5, 2012)

Let me add.
I like if it reduces the PJ load; my question is why is this AMC and not ACC/AFSOC (manning?)
Will they embed with the ERQS? and a manning decision gets made at launch (medevac=TCCAT) PR/Under fire=PJ)?
It would be interesting to see if this added requirement suddenly became part of the CSAR-X RFP.  The HH-47 could suddenly reappear.


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## amlove21 (Jun 5, 2012)

Im going to respond by the numbers, not aggressively, just- pointedly. :-"

1- If they aren t trained to treat casualties under fire, they why are they being marketed as "point of injury tactical medical teams"? Thats disingenuous at best. 

2- Why in the world would I deliver a patient to another helo borne asset when I could just take them to the hospital? I am not going to transload when I can just deliver to an actual definitive care facility. And please, save the extremely specific, non-theater scenarios (soooo, youre out in the middle of nowhere, and there is a mascas, and you have to quick turn, like 100 patients, and you cant fly all the way....). It't not the war we are fighting now, and it's most likely not the next one either. I can "what if" scenarios that lead down all sorts of roads- but that doesnt mean that crap is going to happen. 

3- So, again, I am not transloading. I dont care if some 68W bird has an anesthesiologist on it. Cause you know what else that bird has? Zero power thanks to their 600lbs worth of dude and 1000lbs worth of equipment. They wont be able to take my 5 patients anyway. And since they have docs and nurses, why they hell would they keep the emt-b/68w? And now I raise the question- "Since the TCCET wont have dedicated iron (their own aircraft), how is THAT conversation going to go with the experienced combat medic they are effectively kicking off?" I will tell you how it would go with me or my team. Short answer is "Not well."

4- I think I hit this in 2, but I will say it again- I am in the fight until I hand over at the hospital. Everyone is coming off target and getting treated. Telling me that I have some other air asset that we are going to put at risk for a situation that is already in the crapper only risks more Americans, it does not "get the PJ team back into the fight faster". 

5- Lets call a spade a spade here. A doctor, nurse, and anesthetist with 10 weeks training and some nifty multicams are not tactical. It's bordering on lying, and god forbid they actually get a mission that actually requires some sort of tactics. 

Because you know what's going to happen then? They're going to have to call another PJ team out, and put THEM in harms way.


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## HealwithSteel1 (Jun 5, 2012)

SOWT said:


> Let me add.
> I like if it reduces the PJ load; my question is why is this AMC and not ACC/AFSOC (manning?)
> Will they embed with the ERQS? and a manning decision gets made at launch (medevac=TCCAT) PR/Under fire=PJ)?
> It would be interesting to see if this added requirement suddenly became part of the CSAR-X RFP.  The HH-47 could suddenly reappear.



Good stuff.  Medical UTCs get manned from  all the commands.   AMC is the command tasked to develop patient movement medical capabilty, so it makes sense that the USAF/SG would direct AMC to develop TCCET.   Keep in mind, while they can support the ERQS, the TCCET was designed to support MEDEVAC missions.  CSARMEs in ACC and SOFME/SOCCETs in AFSOC already do this mission in support of the GAWS so TCCET will support MEDEVAC units most commonly.


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## policemedic (Jun 5, 2012)

I think a  lot of the controversy stems from the passages I've highlighted below.  Setting aside the fact that Iddins and McCarthy are (in my view) deliberately misrepresenting the capabilities of both conventional and SOF medical assets in theater, their quotes make it clear that they envision TCCETs receiving patients on the battlefield.  I understand that may not be accurate, as HealwithSteel1 has stated.  However, point of injury care is what they're purporting to provide.

If TCCETs are designed to provide a critical care interfacility evacuation asset, their personnel mix and capabilities make sense.  But that's not what a Brigadier General and the Major in charge of their training are saying.



amlove21 said:


> By Markeshia Ricks - Staff writer
> Posted : Saturday Jun 2, 2012 10:00:02 EDT
> The U.S. military is enjoying the highest casualty survival rate in the history of modern warfare, but medical officials believe they can save even more lives by getting advanced care sooner to injured troops.
> For nearly a year, a three-member team of Air Force health professionals has successfully evacuated and treated 299 severely wounded troops by taking the emergency department to the injured, and another team is set to stand up in the coming month.
> ...


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## Johca (Jun 5, 2012)

Suggesting TCCET is supporting the aeromedical capability is misrepresenting as the capability as described in the AFT article is better stated as enhancing aeromedical capability.

Enhancing is even somewhat misinforming as the article clearly infer the concept of operations is mission creeping into Echelon 1 trauma care to stabilize patient for movement to the higher or next level of support with the mixing in of “care under fire” and “combat casualty evacuation”. 

The capability being developed cannot be spun any other way.

See recruitment video http://www.youtube.com/watch?v=2AQ65I9FUPA

Aeromedical Evacuation the Air Force provides is the movement of stabilized causalities and patients who are prepared for airlift transportation from the forward airfields in the combat zone to other medical elements in the theater of operations. Patient movement is planned, coordinated and scheduled through Aeromedical Evacuation Coordination Center (AECC)/Theater Patient Movement Requirements Center.

This TCCET capability will be more operationally connected to mission tasking through the Air Operations Center as it will be a not scheduled tactical medical response. Please explain how it will not be as immediate response to the tactical location in an active combat zone. This will require flying through tactical airspace over and around the active combat zone. Consequently the mission is not aeromedical evacuation, but actually battlefield casualty surgery at the echelon 1 and echelon 2 level. Meaning the capability is expected to be survivable and effective in doing surgery at the battalion aid station level or on the battlefield as the commercial depicts.

The Air Force Medical Services has had an identity crisis ever since it established itself separate from the Army with the rest of the Air Force back in 1947. Congress never had intent of the Air Force also establishing a ground battlefield medical service in competition with Army and Navy Medical Services which has line (nonmedical) unit duty assignments and more specifically what is called combat medics.

Flight Surgeons have had a hair up their ass as they became more and more unimportant in the MTFs as they hid in their Flight Medicine fiefdoms with their 4F (flunky) aeromedical medics avoiding being a equal care provider capability with emergency medicine and family medicine clinics and more importantly the surgery rooms. Don’t get me wrong there were some good Flight Surgeons but the numbers of incompetent and lazy flight surgeons hating playing mobility games and being deployed was not unnoticeable in 1993 and 1994 and its not unnoticeable now when I visit the MTF and overhear conversations which BTW I overhear off base too. The Physician comes in as a Captain and all you hear the Captains do is bitch and complain about deployments and military exercises.

However and regardless of the not really wanting to be a military DOC in a MTF, the establishment of the Squadron Medical Elements and air transportable hospitals was more about Air Force Medical Service getting more budget clout equal to the Army and Navy’s medical service more than getting more timely effective and efficient care to the battlefield casualty. The same can be said about TCCET now that aeromedical evacuation is not dedicated aeromedical airlift but joint utilization airlift that becomes aeromedical airlift when needed.

My stronger concern however is with suggestions these tactical teams will fly most movement missions on rotary wing helicopters such as Black hawk helicopter. It isn’t the having this capability available on helicopters that concerns me, it is the potential collateral airframe acquisition impact such belief much more lives saved brings with it.

The AFT article statistics of lives saved is misleading pertinent to IEDs. These devices kill, but the blast trauma is such that survivability is mostly luck of what the shock wave, blast wave, shrapnel, burning heat did or didn’t do and subsequently how quickly the bleeding is stopped. The helicopter or fixed wing evacuation still has travel time involved in getting to the victims. With speed of getting cvapability there the more suitable airlift is a V-22 capability more than a helicopter capability. The V-22 also strongly favors the rapid response capability security forces wants for its missile field patrols and its convoy movements of the missiles and it 820th SFS rapid response air assault capability. Thus the acquisition politics will favor satisfying the common denominator more than getting the aircraft weapon system needed to go into hot LZ to execute combat rescue.
The HH-60 cabin area is unsuitable for CSAR (internal fuel bladders in cabin) and even more unsuitable to being a surgical suite. More mission impairing is getting a suitable replacement CSAR helicopter will now be competing with tactical aeromedical mission needs and common vertical lift support program (CVLSP). As the CVLSP gets more horse power from aeromedical throwing its influence into the mix, units like the 820th SFG will develop and putting in their air assault concepts of operations into the CVLSP requirements mix (yep everybody can now be a PJ without getting adequately trained and qualified, that’s what happens when quitters and failure to train members are classified into medical and security forces).

The AFT article discloses “evacuated and treated 299 severely wounded troops by taking the emergency department to the injured”, but post 11 in this conversation discloses the spin put on this number.

Regardless the TCCET surgical capability on the helicopter must be capable of providing a sterile surgery room environment. Most difficult on anything less than a heavy lift helicopter (H-47, H-43). The H-60 lacks the suitable surgical room configured cabin and lift capacity especially at terrain elevations above 10,000 feet above sea level.

I certainly get a chuckle from Air Mobility Command surgeon Brig. Gen. (Dr.) Bart Iddins’ implied or hidden assertion “Many of the casualties of Operation Enduring Freedom suffer blast-related injuries such as burns, lung trauma, traumatic amputation, blunt force trauma and head injuries”.

IEDs critically injure and kill, but the blast trauma is generally such that survivability is mostly luck of what the shock wave, blast wave, shrapnel, burning heat did or didn’t do and subsequently how quickly the bleeding is stopped. Consequently is the combat lifesaver trained solider, sailor, airman trained and qualified in the tactical unit or convoy giving immediate response tactical combat casualty treatment that is actually increasing survivability numbers available for the TCCET to be a difference.

Blast trauma typically produces moderate to severe traumatic brain injury and moderate to severe pulmonary contusion and significant penetrating shrapnel and penetrating debris projectile trauma to torso. This certainly-so requires a significant surgical capability. Having this capability also means equipment and consumables such as oxygen, anesthesia, drugs, and many pints of whole blood to be putting on a helicopter or fixed wing aircraft.

On the helicopter going into the hot landing zone this means a lot of equipment and consumables are exposed to be hot at with small arms, RPG, and man packable shoulder launched missiles. Nowhere in the TCCET marketing is there discussed what happens when a round or RPG hits the pressurized oxygen and anesthesia gas cylinders. Nowhere in the TCCET marketing is the basic concern existing since WWII of placement of physician in combat aircrew tactical operational risk of getting KIA or WIA to save a few impairs the hospitals ability to treat the many (“risk a critical item-the medical officer for a very questionable gain.” Tactical utility of physician is militarily unacceptable.”—not my words, but words prevalent in commander level discussions.)

This by the way is why the Air Force removed Parachute qualified Physicians from the PJ teams in 1949 along with Geneva Conventions of 1949 reasons. Since 1950 physician and nurse wartime service is being noncombatant military and this is why until SMEs were established the Air Force Medical Services lacked line unit assignments.

Anyhow the TCCET will be one significant funded Physician, Nurse, Physician Assistant, and enlisted med tech manpower bucket to fill and sustain at the expense of the MTFs and SMEs.


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## amlove21 (Jun 5, 2012)

JohnnyBoyUSMC said:


> So a question for those PJ's on here: what would be your preference were you to be suddenly promoted to the top of the AFSOC chain? How would you want the allocation of PJ's and their mission focus/training to go in light of units like this being stood up, the winding down of theaters of the GWOT, etc? I've seen a few things on here as to a general idea of what you'd like but wanted to hear some specific stuff you guys had in mind.


Null question. Most of the PJ's in the AF (vast majority) are in ACC. And a CRO will never, ever, everevereverever be at the top of the chain in AMC. Pilot's AF my friend. 

Good question, maybe for another thread. Im too short in the tooth to posit an answer.


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## JohnnyBoyUSMC (Jun 5, 2012)

amlove21 said:


> Null question. Most of the PJ's in the AF (vast majority) are in ACC. And a CRO will never, ever, everevereverever be at the top of the chain in AMC. Pilot's AF my friend.
> 
> Good question, maybe for another thread. Im too short in the tooth to posit an answer.


 
GTG. Well wasn't saying I was expecting a PJ to end up at the top of a pilot's AF, was more like wondering how you guys would run it in a hypothetical. Also, sent a PM, know your busy but wasn't sure if it made it through.


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## Johca (Jun 5, 2012)

Ranger Psych said:


> Going further, this sounds like Medevac on steroids.... which is something I've heard that PJ's don't do, you don't do casevac or medevac, you do personnel and equipment recovery.


Medevac is not the PJ mission utility purpose.  Care under fire, tactical emergency trauma field care and combat casualty evacuation is a mission utility purpose, but not as an enhanced medevac or permanently support sick call squad.

The medical capability utility is unchanged from WWII in that the capability is to have survivability and function during unmounted (on-foot) overland travel movement of survivors and survivors having injuries needing treatment during this movement.

The combat care under fire support to Army (primarily) but also marine Infantry has most concern with the initial assault phase  particularly during the lines of movement into the assault drop zone or assault air field in enemy controlled or occupied territory.

Although the most acknowledged beginning of Pararescue are the parachute missions done in the China-Burma-India (CBI) area of operations during WWII there are other contributing to capability developing missions done in the North Africa- Mediterranean area of operations, specifically parachute team activities of Air Rescue Unit 1 doing rescues of aircrews downed in Yugoslavia and other distant areas of eastern Europe. 

After WWII the cold war reconnaissance activities of reconnaissance aircraft, extreme high altitude renaissance balloons, reconnaissance satellites and eventually unmanned drones (now called UAVs) resulted in the quick by 1949 enhancement of utility to do materiel recovery.




JohnnyBoyUSMC said:


> So a question for those PJ's on here: what would be your preference were you to be suddenly promoted to the top of the AFSOC chain?


Just to be a wise guy with tongue in cheek, when were PJs not at the top of the AFSOC chain?  Air Force Pararescue team and career field capability and mission utilization go back to 1947 before there was CTT (1953) or SOW (1963) and TACP providing the capability it has now grown-up into providing since 1977.   PJs as a career field and a tactical capability were top of the capability provided chain before AFSOC and USSOCOM existed. 

Digging through the official archives will lead to discovery of “In March 1952, an additional responsibility was given to the Air Resupply and Communications Service when all formal escape and evasion training in MATS was transferred to it from the Air Rescue Service.”  Further digging will find that although the PJs were assigned to Rescue units they were flying on “Black” helicopters and fixed wing aircraft flown by other units/agencies during the Korean War just as they did in Laos and Cambodia during the Southeast Asia conflicts.  They were doing a bit more than just being medics on those aircraft- http://usafhpa.org/581stARCS/581starcs.html-as the mission was bit more than rescue of downed aircrew  http://usafhpa.org/581stARCS/581starcs.html.  Further digging into the archives reveals a lot of PJ mission use on “black” aircraft.

Pararescue utilized to provide combat medical coverage for two airborne assault operations done by the 187th Airborne Regimental Combat Team (RCT). On 20 October 1950 paratroopers of the 187th RTC airdropped at Sukchon-Sunchon located approximately twenty miles north of P'ycogyang, the capital of North Korea.   On 23 March 1951 paratroopers of the 187th RTC airdropped at Munsan-ni located north of Seoul between the Han and Imjin Rivers.   A three man pararescue element inserted by helicopter as part of a reception party on the Munsan-ni drop zone prior to the airdrop.  No CCT or TACP there.

There are other interesting Pararescue utility finds such as: “The case for parachute landing of materiel and personnel as opposed to glider and air landing”, by Lt Col L. D. Buttolph, Command and General staff College.31 May 49.  http://cgsc.cdmhost.com/cdm/singleitem/collection/p124201coll2/id/204/rec/163
Page 9:
“e. Landing in airheads. Paratroops can jump and materiels be dropped anywhere, if the rate of loss will be accepted. This is proven by the U. S.A. F. Pararescue teams now in service, and the parachutist forest rangers who use this method for rapid transportation into isolated areas to fight forest fires.

Difficult terrain, either due to natural or man-made obstacles, will not eliminate parachute operations. In fact, it may be of assistance, as parachutists can assault any area within plane radius distance and therefore cause the enemy to disperse his forces. They can also use the surprise element to advantage by dropping on less desirable terrain where the enemy will not be expecting, or be prepared, for combat operation. In most, if not all airborne operations where the enemy is prepared, parachutists must be in the first assault to seize and secure landing strips for air-landed troops.

The context being PJs can hold their own along side all the other AFSOC  top of the chain capabilities and there is no promoted to considering the mission tasked to do and mission accomplished history going back as an Air Force career field and a tactical team capability to 1947.


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## JohnnyBoyUSMC (Jun 5, 2012)

Johca said:


> Just to be a wise guy with tongue in cheek, when were PJs not at the top of the AFSOC chain?





LOL, that was a tongue in cheek mistake on my part, meant top of AF command total. As far as the top of AFSOC, I don't wanna go getting any CCT or SWOT guys angry at me so I'll leave that opinion piece alone. The Corps despite what other may think did teach me humility


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## HealwithSteel1 (Jun 5, 2012)

policemedic said:


> I think a lot of the controversy stems from the passages I've highlighted below. Setting aside the fact that Iddins and McCarthy are (in my view) deliberately misrepresenting the capabilities of both conventional and SOF medical assets in theater, their quotes make it clear that they envision TCCETs receiving patients on the battlefield. I understand that may not be accurate, as HealwithSteel1 has stated. However, point of injury care is what they're purporting to provide.
> 
> If TCCETs are designed to provide a critical care interfacility evacuation asset, their personnel mix and capabilities make sense. But that's not what a Brigadier General and the Major in charge of their training are saying.


 
PoliceMedic,
I understand why you highlighted those points as a source of contention.  Words and definitions matter.  The TCCET goes to POI in support of MEDEVAC missions for appropriate patients consistent with the utilization of the Army’s Enroute Critical Care Nurse (ECCN) capability.   The MEDEVAC casualty on-load location is considered “POI” in the Enroute Care lexicon.   Obviously, immediately means as soon as the airframe can get to the site.  TCCET is a non-First Responder.  They are not trained as combatant medics or as rescue specialist (PJ).  They are delivered to the casualty by a MEDEVAC platform and can immediately begin casualty care.

TCCC employed by skilled PJ/ATP/combat medics has had a huge impact in saving lives that would have died on prior battlefields.  If the conventional medical forces are to fully capitalize on the hard won TCCC saves, it has to get trauma room level care to them sooner.  That is what the TCCET’s mission is.   On the second line of the article, they sum it up very well saying “…taking the Emergency department to the injured…”   The TCCET is designed to bring the capabilities of the trauma room forward so trauma care can begin as soon as possible.   TCCET is less about moving patients as providing trauma or ICU medical care while the “room” is being moved.  The 50% potentially survivable that died of wounds article (Google “Eastridge Died of Wounds on the Battlefield”) assumed that the Role 3 was close to the casualty.  The TCCET moves at least part of it (the ER) closer to the casualty. 

This is similar to the British MERT concept as pointed out by JustAnotherJ.  The concept works as MERT patients spend about 30 minutes less in the ER prior to surgery because much of the trauma workup has been done enroute.    There are a number of statements in the article that describe the “mobile ER” concept (“…are equipped and trained to start trauma resuscitation treatment …in the tight confines of a helicopter with very little equipment.”  “…initiate emergency department/trauma department-level control resuscitation earlier and more aggressively than has traditionally occurred”, etc).   As a surgeon, if the TCCET delivers casualties ready to go to the OR sooner, I see the improved chance of survival as a huge win for all of us.


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## amlove21 (Jun 5, 2012)

Johca said:


> Just to be a wise guy with tongue in cheek, when were PJs not at the top of the AFSOC chain.....


 

I wont speak for him, but I think he meant, "what if a PJ (CRO) was in charge of AFSOC, and you could dictate your own path". At least, that's how I read it. And that's never going to happen. A CRO with 2-3 stars?


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## JohnnyBoyUSMC (Jun 5, 2012)

amlove21 said:


> I wont speak for him, but I think he meant, "what if a PJ (CRO) was in charge of AFSOC, and you could dictate your own path". At least, that's how I read it. And that's never going to happen. A CRO with 2-3 stars?


 
Yea that's pretty accurate as to what I meant, and didn't figure it was gonna happen, was meant as a "if you suddenly had God-level command power I.E. pentagon level, how would you dictate the direction of the PJ community as a whole mission wise."


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## Johca (Jun 5, 2012)

HealwithSteel1 said:


> PoliceMedic,
> As a surgeon, if the TCCET delivers casualties ready to go to the OR sooner, I see the improved chance of survival as a huge win for all of us.


Agree 100%, but to the operating room located where?

No mention in TCCET concept of operations is there mention of moving the functioning surgical capability with surgical team ready to perform surgery to echelon 1 tactical environment while transporting to echelon 2 or higher operating room capability.

Echelon 2 is the battalion aid station, medical company forward surgical capability, Division Clearing station. 

Echelon 3 is the operating room capability found in the MASH and air transportable hospitals.  The MASH and air transportable hospital is expected to provide immediate surgical treatment and post-operative care.

Echelon 4 is essentially a major military regional hospital having the additional capability to provide rehabilitation and reconditioning during the healing process.

Echelon 5 is definitive care in a military medical treatment facility located in the Continental United States. 


http://www.youtube.com/watch?v=mFXxiDyxCCo clearly states the gap being filled is delivery from forward surgical capability-Echelon 2 Battalion aid stations and medical companies to Echelon 3 in area of operations operating room capability.  Unfortunately the AFT article suggests and implies a future something much different capability.  Most of the helicopter TCCET patient stabilization and preparation wasn’t on the helicopter.  Nothing much different than was being done during CASEVAC or MEDEVAC on Air Force helicopters during the Korean War. ecept it is disclosed the Captain likes flashing the helicopter crew.  She can flash me anytime BTW.


Fixed wing and helicopter TCCET mission profiles differ considerably.

The moving forward of the trauma surgical center on an aircraft brings with it a considerable support requirement.  If any significant on the ground loitering in the forward tactical area happens for any reason a force protection requirement begins to raise its ugly head. 


The vertical airlift capability suitable for a functioning TCCET operating capability in flight is a heavy lift helicopter (H-47, H-53) and or the V-22.

Fixed wing operations is complicated by the potential FOD on landing or taxi damage to an engine and the fact any escort provided for rescue purpose of a long distance fixed wing mission profile and if going into an airstrip of convenience to include a road (essentially the C-130, C-141, C-5 SOLL I and SOLL II mission profile of the 1980s) a CCT will be needed on the ground in addition to force protection for the aircraft and crew and physician, nurses, etc.

Fixed wing capability is hampered by finding a suitable and convenient place to land (unless there is a parachute in capability not being disclosed).   Then it’s a matter of transportation time and if CASEVAC helicopter to the closest MASH or air transportable hospitals is the fasted ready to go delivery of patient on to the surgical table in the Operating Room. It also begs the question of if the fixed wing TCCET is to bypass Echelon -3 (level -3) locations and deliver direct to the Echelon 4 capability such as found at Ramstein AB Germany.


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## Johca (Jun 5, 2012)

amlove21 said:


> At least, that's how I read it. And that's never going to happen. A CRO with 2-3 stars?


Which is why I prefaced with me being a wise guy with tongue in cheek. I was doing some poking in fun.

As far as a CRO getting promoted to 2 and 3 star levels in the future, it is both possible and probable and just a matter of time.

Here’s a few Air Force Flag Officer bios, I worked either directly with them or for them when they were Captains or Majors CCT (before STO) officers during my active duty career.

http://www.af.mil/information/bios/bio.asp?bioID=7878

http://www.af.mil/information/bios/bio.asp?bioID=8640

In one of the bios you will find--4. November 1983 - June 1986, Chief, Combat Control and Pararescue Division, Headquarters 23rd Air Force, Scott AFB, Ill. (November 1985 - June 1986, Commander, Pararescue Military Freefall Training Team) . Me thinks I recollect being one of the MFF instuctors in that team.


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## DA SWO (Jun 6, 2012)

amlove21 said:


> I wont speak for him, but I think he meant, "what if a PJ (CRO) was in charge of AFSOC, and you could dictate your own path". At least, that's how I read it. And that's never going to happen. A CRO with 2-3 stars?


AFSOC will have a ST Wing soon (24th SOW), that should pave the way for ST BG's, which means (in theory) a CRO could get there.


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## Johca (Jun 6, 2012)

SOWT said:


> AFSOC will have a ST Wing soon (24th SOW), that should pave the way for ST BG's, which means (in theory) a CRO could get there.


Actually the career development needed to get to Flag rank has no requirement of a ST wing or rescue wing. The on the books CRO duty assignments fill the squares to get to O-6 and the path beyond is available if the CRO decides to go that path.

There is a CCT MSgt I worked with (both of us were MSgts) who is now an active duty Colonel and commanding an AETC Training Group at Lackland who could get promoted to BG if he stays around.There was a PJ to PA to CRO that made Colonel that could have gotten BG but he decided to retire as a Colonel after 30 years as he only had twenty years commissioned and he could have stayed around another 10.

Take a look at a few more bios and the assignment history of other than the two I posted, the flag officer is expected to be a bit more than just a pilot or STO or CRO as that level of command can be of AETC, Security Forces or whatever wing.

Here’s a bio of the recent former AFSOC/CC http://www.af.mil/information/bios/bio.asp?bioID=7672 He was my aircraft commander as a Captain on a few operational missions back in the 1970s and in fact he was getting his pilot qual at Hill AFB in 1974 at thesme time I was getting my initial enlisted aircrew qual as a PJ/gunner on the H-3 and H-53.

Here’s a bio of my squadron commander back in 1977 to 1979 http://www.af.mil/information/bios/bio.asp?bioID=4918


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## HealwithSteel1 (Jun 6, 2012)

Johca said:


> Agree 100%, but to the operating room located where?
> 
> No mention in TCCET concept of operations is there mention of moving the functioning surgical capability with surgical team ready to perform surgery to echelon 1 tactical environment while transporting to echelon 2.



Johca,
While I know of three surgical capabilities that can work on an airframe as you suggest, the point is that TCCET reduces the time to the OR by doing trauma room work enroute.  For each casualty, there are two golden hours: the first is to get them to the trauma room and a second to get them from the trauma room to the OR.   In general, even with critically injured casualties, the average time in our deployed Trauma hospitals (Role 3) for ED to OR  usually exceeds one hour.   When enroute trauma room care like the TCCET is used, time in the ED is decreased 18 minutes for severely injured and 41 minutes for critically injured casualties.  
That time saved in the ED trauma room by putting trauma capabilty into the prehospital movement translates to better surgical outcomes including survival.


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## amlove21 (Jun 6, 2012)

HealwithSteel1 said:


> Johca,
> ...TCCET reduces the time to the OR by doing trauma room work enroute. ...  When enroute trauma room care like the TCCET is used, time in the ED is decreased 18 minutes for severely injured and 41 minutes for critically injured casualties.
> ...


I would like to know where those numbers came from. Can you share your source? And what is the context? The TCCET gathered those numbers in what control? In response to what variant? Who reviewed those figures? 

With the shift to goal-directed care and therapy, which is where the focus of our medical care is going, I would argue that the TCCET is not the owner of that information, nor it's sole purveyor. We (Pararescue teams) have ISTAT's, we have ETcO2, we have ultrasounds (for FAST's), and we understand and employ both damage control resus, goal directed therapy and treatment, and the preparation of injured for the operating room- not just the turn over. 

I dont want to be confrontational, but extraordinary claims require extraordinary proof. 



Johca said:


> Last 3 posts...


 
As always, thank you for the inputs, Brother. Lots of stuff I had no understanding on/education in.


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## surgicalcric (Jun 6, 2012)

HealwithSteel1 said:


> ...TCCET reduces the time to the OR by doing trauma room work enroute.  ...That time saved in the ED trauma room by putting trauma capabilty into the prehospital movement translates to better surgical outcomes including survival.


 
What trauma room work are you referring to that a PJ/18D isn't capable of performing?


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## TLDR20 (Jun 6, 2012)

I'm curious as well what these guys bring on a short flight that I don't? Other than an awesome beard obviously.


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## HealwithSteel1 (Jun 6, 2012)

Data on time to OR is from the Joint Theater Trauma Registry data base.    The question of what exactly is the difference is unknown.   There is no one procedure or protocol that has been demonstrated to be responsable for the difference.   

Comparing the TCCET to the GAWS is like comparing apples to oranges.   The TCCET is designed to support the army's DUSTOFF mission not the PR mission.    It does not do PEDRO mission.   High levels have directed this clearly.   Really, the only two ways I see a PJ  interfacing with a TCCET are: when TCCET is requested by the EQRS to assist on interfacility transfers ( and it appears a good portion of the PJ community would like to focus more on PR and less on patient movement) and in the very rare case that DUSTOFF with an EMT-B is the MEDEVAC platform and the PJ has to stay with the unit on the field.   If added value discussion is to be had, the comparison is best made to the capability they augment- DUSTOFF.


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## Johca (Jun 6, 2012)

HealwithSteel1 said:


> Johca,





HealwithSteel1 said:


> While I know of three surgical capabilities that can work on an airframe as you suggest, the point is that TCCET reduces the time to the OR by doing trauma room work enroute.


Not only is there unsupported assertions in the Air Force Times article and some of your comments, there is a significant difference in both utility (quality of being useful militarily or operationally) and operational availability between the briefing I linked to in a previous post and both Air Force Times article and the information you are providing. Putting a patient on a helicopter with no medic, physician or nurse onboard by itself reduces time to the OR.

Asserting knowing three surgical capabilities that can work on airframes is not disclosing the surgical procedures being performed and accomplish with effectiveness, efficiency and satisfaction. Neither does it disclose why only the TCCET is trained, qualified and capable of utilizing the surgical capabilities. For example amputation, suturing, cricothyroidotomy technique, Thoracentesis technigues, Debridement and dressing of wounds are essential emergency surgical procedures, but they (1) do not require being in a surgical operating room to perform such procedures and (2) can be done by any not in the medical service enlisted member who is trained and qualified to perform such surgical procedures and techniues.

The TCCETT is claiming in the AFT article to bring the operating room (emergency trauma center) to the patient who has just been injured (first responder) and giving immediate functioning operating room capability staffed with emergency medicine or critical care physician, a certified nurse anesthetist and an emergency department nurse or intensive care/critical care nurse.

The level and quality of surgical capability is being marketed is capable of surgically treating blast-related injuries such as burns, lung trauma, traumatic amputation, blunt force trauma and head injuries better than other not emergency medicine or critical care physician first responders (Paramedics (PJ, 18D, SEAL medic) or other suitably trained combat life saver enlisted soldier, sailor or marine.



HealwithSteel1 said:


> The TCCET is designed to support the army's DUSTOFF mission not the PR mission.


This is correct, but why does the Army need the Air Force involved in doing its dust off? In this regard how is the Air Force’s supporting of DUST OFF mission different than what Air Rescue was doing for the Army and Marines during the Korean war especially during the Battle of Chosin Reservoir during the Korean war when ARS helicopters and fixed wing (landing on roads, frozen water ways) were actually casevac from the battlefield and in one instance only 5o yards from enemy positions. Pertinent to the first known (12 October 1950) transfusion given during a rescue casevac (Helicopter was under attack as they went out and got the wounded) was accomplished by Captain John C. Shumate, USAF, MSC (a PJ). He was also credited in saving the life of the critically injured is credited as being the first to administer blood plasma in the treating of a patient on a helicopter. 


HealwithSteel1 said:


> If added value discussion is to be had, the comparison is best made to the capability they augment- DUSTOFF.


Fine with me. DUSTOFF is a line unit medical company, meaning purpose is to do medical evacuation from supported units to supporting medical treatment elements. DUSTOFF differs from medevac as the operational support focus is CASEVAC oriented 

The official TCCET briefing clearly and concisely it exists to initially enhance treatment and care in the movement of patient, specifically patient packaging needing critical intensive care (opposed to life saving surgery) during movement. The gap TCCET is filling in the official briefing is patient/casualty movement from TCCC (Echelon 1 and echelon 2) to forward surgical centers (the Echelon 3 field hospital) and subsequently patient casualty movement to theater hospitals (Echelon 4).

Cutting through all the marketing spin TCCET is an Air Force presence in the Army’s Echelon 3 operations providing a lite capability version of a Aeromedical Evacuation Coordination Center (AECC)/Theater Patient Movement Requirements Center service for Army medevac units with a bit of aeromedical crew member duties on a helicopter thrown in. The assertion in the AFT article is enhanced “critical care air transport teams, or CCATT” will now be flying on helicopters. The assertion TCCET supports DUSTOFF further assert a level of combat tactical training and utilization of doing CASEVAC during the firefight or immediately afterwards. 

“The new tactical teams, which will fly most movement missions on rotary wing aircraft such as a Black Hawk helicopter, are equipped and trained to start trauma resuscitation treatment immediately after injury. And they’re able to do that work in the tight confines of a helicopter with very little equipment.” This suggests or infers a higher level of definitive emergency trauma surgical procedures and treatments is available as a result of emergency medicine or critical care physician, a certified nurse anesthetist and an emergency department nurse or intensive care/critical care nurse and functioning operating room being on the helicopter.

“Unlike those trained in first-responder care or combat care, TCCETs are trained and equipped specifically for dealing with such emergency scenarios, Iddins said.” TCCC is inclusive of procedures, techniques and methods utilized throughout the continuum of emergency casualty trauma treatments from the combat life saver to the emergency medicine or critical care physician. Within this continuum is the PJ, 18D, SEAL medic and similar trained enlisted personnel.

In the TCCC operational environment there is also helicopter air assault operations generally involve insertions and extractions under hostile conditions, which BTW is not exactly DUSTOFF (an ambulance service which is why a Red Cross is on these helicopters and crew-served weapons may not be mounted on ambulances or air ambulances, even if mounting brackets are present.), but is the utility environment PJs, 18D, SEAL medic and similarly trained enlisted capability exist to function in.

There is also the pesky tactical operations Geneva Conventions of 1949 problem of “Medical personnel should attempt to make the attackers aware of their status rather than fighting back. (FM 4-02.6). This is why PJs are not members of the Air Force Medical Service (noncombat military service).



HealwithSteel1 said:


> Really, the only two ways I see a PJ interfacing with a TCCET are: when TCCET is requested by the EQRS to assist on interfacility transfers ( and it appears a good portion of the PJ community would like to focus more on PR and less on patient movement) and in the very rare case that DUSTOFF with an EMT-B is the MEDEVAC platform and the PJ has to stay with the unit on the field.


Within this comment is a misunderstanding concerning PJ wanting to focus less on patient movement.

Pararescue has always had and will continue to have focus on patient movement. Pararescue’s medical capability utility however does not exist with primary purpose to be the noncombatant military ambulance service clearing the battlefield of the wounded. Pararescue’s medical capability utility has no primary purpose to be permanent day-to-day medical support to units (SME as an AF example). The medical care, treatment and patient movement capability exists to be Echelon 1 functional and effective in the tactical operational environment as combatant concurrently perform SERE and providing security to survivors and isolated personnel once they find them and as they are moving them to the echelon 3 forward surgical center or in place and open for business air transportable hospital. The PJ has considerable not medical core skill qualifications to keep proficient. There are only so many hours in a day and days in a week, month and year to do so. Consequently the PJ less on air ambulance service patient movement conflicts and avoidance.


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## Johca (Jun 6, 2012)

BTW, I  Googled  “Eastridge Died of Wounds on the Battlefield” and the most significant findings to the ongoing conversation appear to be:

1.      “Hemorrhage is a major mechanism of death in PS combat injuries, underscoring the necessity for initiatives to mitigate bleeding, particularly in the prehospital environment.”

2.      The majority of deaths on the modern battlefield are nonsurvivable. Improved methods of intravenous or intracavitary, noncompressible hemostasis combined with rapid evacuation to surgery may increase survival.

I Googled as I thought perhaps you were tying TCCET into the argument of arming Army dust-off and medevac helicopters which is driven by the delay of getting a Dust-Off or Medevac helicopter into the area to do an immediate CASEVAC.




> It took a medevac unit 59 minutes to get U.S. Army Spec. Chazray Clark to a hospital in southern Afghanistan after receiving a call that a roadside bombing severed three of his limbs. Clark did not survive.  … the medevac could not swoop in for the pickup until another chopper with firepower arrived to provide cover.


The context being TCCET does nothing to remedy the helicopter first response getting to problem.  Had the medevac helicopter gone in immediately the TCCET has no more surgical capability available to utilize than the rescue helicopter with PJs on it or an armed air assault helicopter with an 18D or SEAL medic on it.  My concern is not the TCCET being there doing but rather the being there doing capability being exaggerated or embellished to sell it.


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## PJSH (Jun 8, 2012)

Man I love having Johca on this site


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## policemedic (Jun 9, 2012)

I read the study when it was published in J.Trauma; while it has useful data I'm not sure it makes the argument for TCCET.  I'm attaching it for those without a subscription to read.


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## PJSH (Jun 9, 2012)

Spoke with a Doc, he is not on board with this concept and agrees there is nothing these guys can do in the pre-hospital setting that a 18D/PJ/SEAL corpsman cannot do. Additionally he understands that sending physicians out onto the battlefield creates a HUGE liability and the term "tactical" should not be associated with this concept whatsoever. This is all coming from a AF ER physician who was around during the discussion/fielding of this venture and knows those involved. Every intervention stated in their article are things that we are doing on a daily basis, I have personally turned patients over who have spent no more than 3 minutes in an ER and gone straight to surgery. The survivability rate within our careerfield of patients that were received with a pulse is extremely high (100% for every deployment I've been on). The place for these teams would definitely be in the realm of the facility to facility transfers. However within this environment if they are calling for a MEDEVAC the DUSTOFF guys or whoever is transporting them should not be accepting any patients that are not stabilized. IMO this is just a bunch of Docs attempting to get their hands into a different pot and possibly pull down some air medals. I have seen in too many cases where physicians have tried to get onto my aircraft for various reason wether it be they call for a CCAT qualified individual to be on board even though there were card carrying CCEMT-P's on board. Unless these guys are going to perform a surgery in the bird, they bring no added capability to the fight.

In relation to them covering down to assist the Army, that's all fine and dandy however they will fall into the same issues that they have I.E. sitting and waiting for an armed escort for x number of time. Numerous times this has happened and the Mission has not been passed off which has resulted in negative outcomes. Until the Army has a dedicated escort on alert with them or these physicians have dedicated aircraft at their disposal this concept will not work for their proposed POI mission. 

I have personally flown with docs onboard and guess who does all the treatment, under NVG's. Yup, myself and my team member because once you take a physician out of a controlled environment and place him\her into an environment where they can't use light, they can't hear and they don't have people handing them things they don't know what to do.

This is not a bash by any means just a straight forward first hand assessment. You cannot teach someone over a course of 10 weeks to change everything they have learned over the course of many years while going through med school. The first time these guys get shot at will bring a whole new perspective and reconsideration to what they are proposing to do.

Lastly, ERQS aircraft get very weary flying around theatre without us on board, which would mean that these teams should they get forced onto us would most likely require us to fly as well which would not relieve our workload by any way shape or form. 

My opinion, stay in the ED and OR and let the ppl trained in the pre-hospital setting do their job. How would you like a doc to roll around on a civilian ambulance? Though I don't believe we are being used to the best of our ability/capablitlty, I'd rather we do the POI's than put these guys at risk because they simply don't know what they are getting themselves into. I foresee these guys launching, getting hit with small arms/RPGS' (which happens a lot) realizing they can't go in and then calling us. This in turn increases the amount of time the casualty sits on the battlefield. Like AMLOVE said why would I transload to them once I have them vs going straight to the Role 3? Makes no sense whatsoever unless I am ore-positioned to provide direct support and cannot leave the area.


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## Johca (Jun 10, 2012)

Post 45 in this conversation included a download of “Died of Wounds on the Battlefield: Causation and Implications for Improving Combat Casualty Care”. A significant portion of the article focused on Traumatic Brain Injury (also known as intracranial injury) which was also emphasized in the conclusion “this comprehensive analysis of DOW combat casualties reiterates the necessity for operational strategies to enhance prevention, particularly for traumatic central nervous system injury.” The article unfortunately failed to delve into how the high explosive explosion causes traumatic injury to the brain.

High explosive explosion mechanism of injuries to the head, torso and limbs influences my focus on questioning what is the surgical interventions and treatments AF TCCET performs and accomplishes with effectiveness, efficiency and satisfaction on the helicopter.

The reasoning of my concern derives from the mechanisms of injuries caused by the high explosive explosion. Most military weapon and IED explosions are high explosive.

The high explosive explosion differs from the low explosive explosion in that the components of the actual blast are a supersonic over-pressure blast wave and a blast wind. 

When the high explosive explosion occurs, gases expand suddenly and spherically from the center of the explosion. Because of the compressibility of air, this expansion of gases compresses the surrounding air, creating a high-pressure front. This blast wave travels outward at supersonic speeds of more than 900 mph. There is no shrapnel or debris projectiles associated with the over-pressure blast wave, but this wave is powerful enough to injure individuals exposed to them. Although the organs most vulnerable to this type of injury are the gas-filled organs, namely, the ear, the lungs, and the gastrointestinal tract. If the over-pressure is sufficient there can and may be intracranial injury. Blast-induced mild Traumatic Brain Injury is the diffuse lesions that occur globally throughout the brain, not the discrete and focal brain lesions resulting from an impacting force to the head. Unfortunately I’ve not come across any data indicating how much PSI is needed. I did find the following:


5 PSI-- Possible tympanic membrane rupture
15 PSI-- 50% incidence of tympanic membrane rupture
30 PSI-- Possible lung injury
40 PSI-- Concrete shatters
75 PSI-- 50% incidence of lung injury
100 PSI-- Possible fatal injuries
200 PSI--Death more likely than not

I found this interesting information in an Army study: “Body armor does protect a person from shrapnel, but significant underlying blunt trauma may result from exposure to a wave blast coming from an explosion. (The advantages of body armor far outweigh this risk.) As the wave strikes the body of someone wearing armor, the energy is reflected against the inside of the body protection, producing injuries far greater than if no armor was worn at all.”

Hollow organs are disrupted by the rapid increase in atmospheric pressure. As the pressure wave strikes the body, it compresses the air-filled organs and collapses them. Gas-filled organs are like balloons filled with air. If they are squeezed by applying hard pressure rapidly (as during the impact of a pressure wave), they will burst. The resulting force causes shearing of vascular beds, pulmonary contusions, pneumothorax, and gastrointestinal hemorrhage. Consequently for the TCCET to be enhancing surgical capability there would be need of a functioning surgical operating room on the helicopter or fixed wing aircraft.

Putting the emergency trauma surgeon on an aircraft treat a small number of patients is taking the surgeon out of the hospital that can triage and get a larger number of the battlefield injured into surgery for life saving treatments. This gets back to previous quotes of “risk a critical item-the medical officer for a very questionable gain” and “Tactical utility of physician is militarily unacceptable” from similar discussions happening during and after WWII. The Geneva Conventions of 1949 combined with Executive Order 10028 January 13, 1949 “Defining noncombatant service and noncombatant training” essentially removed Physicians, Nurses, Physician Assistants and etc from being utilized to conduct tactical military operations as lawful combatants. 

This is why MSC replaced physicians on PJ teams in 1950 and essentially resulted in the MSC being removed from the Pararescue Teams shortly after the Korean War and the aeromedical medical technician was removed as crew members from all rescue aircraft effective 30 July 1956. 

http://www.bordeninstitute.army.mil/published_volumes/conventional_warfare/ch07.pdf <--- Conventional Warfare Ballistic, Blast and Burn injuries-Chapter 7

http://www.cdc.gov/masstrauma/preparedness/primer.pdf <--- Explosions & Blast Injuries


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## JClyde (Jun 27, 2012)

I am not a PJ, nor will I try and say I have a vast knowledge of POI. Initially back in 2010, I was selected to be part of the Pilot program of the TCCET mission.  The team was supposed to be set up with a Paramedic (Myself), and ICU nurse, and/or a CRNA or MD. The idea was strictly for intra-theatre transport from FST/FOB/COP to a Major Theatre Hub i.e. CJTH at Bagram. This team was not supposed to be doing any POI. We were not trained for that. I went to Hurlbert to attend the CASEVAC course at the TOMS lab. I attended Water survival, and I had to also get my altitude stamp of approval. CCT paramedic course, Flight Paramedic course and  SERE at Fairchild werealso required, but the program never made it that far. Initially I was on board with this idea of placing this team on a HH-60 or V-22 when the team was 2-3 people (ICU/ER Nurse, MD, EMT-P). It was designed to be Mogular (If the pt didnt require everyone then we could scale it down). A certified CCT paramedic with a nurse is standard of care in the states.  We were never supposed to a mobile FST. Even now, they ARE NOT a mobile FST. They have an ER doc (which I work with) on the team. They took the Paramedic off because they said that we didnt have enough and could not field enough of us for the program. IMO it makes no since to have 2 CRNA's/ICU/ER nurses and an MD on the bird. The only training they have gone through is CSTARS for CCATT and JECC with the ARMY.

*** I may be a little butthurt since I was takin off the team and replaced by Nurse with no field/ Pre-Hospital Exp*** :)


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## JohnnyBoyUSMC (Jun 27, 2012)

Welcome JClyde, beating the admin's to the punch here but you might wanna go and post a intro post first please.


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## JClyde (Jun 27, 2012)

Thank you sir.


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## surgicalcric (Jun 27, 2012)

JClyde said:


> *** I may be a little butthurt since I was takin off the team and replaced by Nurse with no field/ Pre-Hospital Exp***


 
Butt-hurt and it is showing a bit in your ability to think outside your own situation...

Since the purpose of the TCCET wasnt to do POI care the Pre-Hospital experience of the nurse really is a null point really.  How much experience did/do any of the MDs or CRNAs have prior to being chosen for the program? With the exception of doing ride alongs with EMS during Residency/hospital rotations or their having been enlisted SOF/line medics I would guarantee they have none either.  By your own admission, you have no POI treatment experience and apparently also have very little to no flight experience either since you had to attend the CCEMT-P and Flight Paramedic courses as part of your train-up.  So now, what was the value added of having you, a paramedic, as part of the TCCET crew?

Lastly, while CCEMT-P/Flight RN is the standard in the states, they arent by and large dealing with the same type of patients as are seen in combat theaters.  Apples and oranges... 

Just a couple things to think on from someone with POI and flight experience in both the military and civilian arenas.

Crip


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## JClyde (Jun 27, 2012)

Surgical, you are correct, I do not have, IMO the quals needed to effectivley manage all of the patients I would come in contact with. That being said, I was willing to take a year or more to get as much training as I could via schools, ride alongs, OJT with Hurlbert, Nellis, Moffet Field and Cannon, which we were setting up. These MD's/Nurses are not required to do any off this. The Nurses do not have to be certified CCRN's either. The EMT-P's were motivated because they were volunteers. The Nurses/MD's were told they would be on this mission. The same level on commitment is not there.


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## surgicalcric (Jun 27, 2012)

JClyde said:


> ...The same level on commitment is not there.


 
Commitment to what: pt care, education, training, the TCCET mission, etc...?

I surely would hope you arent equating paramedic school, CCEMT-P and flight med courses to the training and experience a MD or BS, RN with 3+ years of ICU/surgical experience.


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## amlove21 (Jun 27, 2012)

JClyde said:


> Surgical, you are correct, I do not have, IMO the quals needed to effectivley manage all of the patients I would come in contact with. .


So we cleared up the "should you be on the flight" issue with this. Not qualed. 



JClyde said:


> These MD's/Nurses are not required to do any off this....The same level on commitment is not there.


They dont need the training because they are already qualified for the mission set as it stands. I would watch your assertion that the MD/Nurses dont have the same level of commitment because they weren't volunteers. I know several MD/nurse types that would smoke you on that. Unless you're speaking of a specific person, in which case it need not be referenced here. Simply stated,  "That dog wont hunt".  

This thread is about the necessity for the TCCET teams, as referenced in the article (mainly their ability to perform tactically). We arent anywhere near vetting that point, and I feel your comments are off base in several different ways.


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