New AF TCCET Teams and Mission Creep Defined.

[HealwithSteel1]

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.

 

[Johca]

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.

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.

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.

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).

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.

 

[Johca]

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.

 

[PJSH]

Man I love having Johca on this site

 

[policemedic]

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.

 

[PJSH]

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.

 

[Johca]

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

 

[JClyde]

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*** :)

 

[JohnnyBoyUSMC]

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

 

[JClyde]

Thank you sir.

 

[surgicalcric]

*** 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

 

[JClyde]

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.

 

[surgicalcric]

...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.

 

[amlove21]

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.

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.