Combat Medicine
Nov 15, 2013

It is said that if you want a new idea, read an old book. I have a picture of an old WWI poster produced by the American Red Cross Society in April, 1918 stating that every soldier should be issued and trained to use a ‘garrot’ (tourniquet). It says “Many men die unnecessarily from hemorrhage on the battlefield.” The more things change, the more they stay the same.

Why are lessons hard learned on the battlefield so easily forgotten when the conflict ends, only to have to be relearned again during the next conflict? It seems we have short memories.

Back in 1993, after the Battle of Moga­dishu (the Blackhawk Down incident), a seed was planted for something that would become revolutionary in the military medicine community. This was the concept of an environment-specific approach to casualty care that later became known as Tactical Combat Casualty Care (after a 1996 paper of the same title by Navy Captain Frank Butler). That paper, and the guidelines explained within, would very slowly diffuse into the medical procedures of the Canadian Forces.

Prior to deploying to Afghanistan, the Canadian Armed Forces was in what I’d call a ‘Bosnian Peacekeeping’ ­mentality. Now granted, there were certainly casualties on peacekeeping missions, but as a combat mission, Afghanistan required a different mindset.

Afghanistan was the first combat mission since the Korean War half a century earlier, and some of those hard-learned ­lessons had clearly been forgotten. If you look at all the Canadian casualties from Afghanistan since 2002, the catalyst of relearning the lessons of past wars was the incident that took the first four lives of the conflict. The lessons started very early, though this story doesn’t start or finish there.

In early 2002 I had the honour and privilege of deploying to Afghanistan with my unit at that time, 3PPCLI.

Preparation, from a medical training perspective, consisted of what was called ‘Combat First Aid’, which in reality was re-labelled civilian first aid with two large bulky military field dressings, that hadn’t really changed since WWII. The content was neither combat applicable nor appropriate, and specifics taught were based on dogmatic medical practices that had evolved from decades of theoretical civilian-­based classroom instruction and training scenarios – with almost no real experience or context of effectively treating combat casualties.

Prior to our first Afghanistan deployment in 2002, we were given a 3-hour presentation based on the TCCC topic by the Battle Group physician. It stressed the importance of a tourniquet in controlling hemorrhage on the battlefield. The data showed the leading cause of preventable combat death was bleeding to death from an extremity. In fact, during the Vietnam War it is estimated that 2500 American ­soldiers died by bleeding from isolated extremity injuries. However, at no time during pre-deployment training, nor during deployment to Afghanistan, were tourniquets issued or training conducted, beyond that short awareness-level presentation.

On 17 April, 2002 an American F-16 would mistakenly drop a 500lbs bomb on my platoon conducting a training exercise just outside of Kandahar airfield. That bomb would cause the first four Canadian deaths in Afghanistan and injure eight others. The most serious injury was to Sgt Lorne Ford, who had a popliteal artery injury (lower thigh) from shrapnel, and life threatening bleeding. Remembering the presentation and the importance of tourniquets, I pulled out the tourniquet I had acquired from a medic friend, handed it to the medic helping me treat Sgt Ford and told him I think we should put this on. Making a long story short, the tourniquet was eventually placed without any of us knowing or realizing that the said tourniquet never had a chance at stopping the bleeding in Sgt Ford’s leg. It was an IV tourniquet not capable of generating the pressure needed to occlude an artery, especially in such a muscular leg as Sgt Ford’s. A very short MEDEVAC distance and duration saved Sgt Ford’s life and he was in surgery just in time to receive a blood transfusion. In the end, it was a very hard lesson learned for me. I would find out well after the incident, and only after extensive research, sifting through a significant amount of misinformation and just wrong information (much of which still is propagated in civilian first aid courses) about effective and ineffective tourniquets and the potential consequences of not tightening a tourniquet adequately. How can one ‘do no harm’ when one doesn’t know what ‘harm’ is? My training had failed me. My supply system had failed me. I felt let down by the system, so I set out on a mission to make sure it didn’t fail anyone else in what would turn out to be a decade-long deployment with higher per capita casualty rates than any other coalition country.

Major Daniel Dupuis (right) from Rivière-au-Renard, Québec, a nurse at 5e Ambulance de campagne, assists with the transport of a casualty into the R3 MMU in Afghanistan.

It wouldn’t be until 2006 when manufactured, proven effective arterial ‘combat’ tourniquets would be issued, first to medics, then eventually to every deployed soldier. Retrospectively, the tourniquet and widespread training in its use, is now considered the single most important innovation of the war, and responsible for influencing casualty survival rates in such a significant manner, the likes of which had previously remained unchanged in the last 200 years of warfare.

In late 2002, early 2003, a grass roots campaign was conducted to create and run a pilot course in what would eventually become the Tactical Combat Casualty Care Course in the CAF. What started as an idea while I defragged on post deployment leave, evolved, with the help of countless dedicated and passionate individuals, into the program that eventually turned into the standard qualification course, mandatory for at least one or two soldiers per deploying Section. While there are too many people to list here that were integral to the program’s development and eventual implementation and continuation, without LGen Stuart Beare’s (1 Brigade Commander at the time) open mindedness and forward thinking that provided a budget and support for the TCCC Pilot Course, it wouldn’t have gotten off the ground.

With the TCCC Course as a foundation, it allowed a shorter, more appropriate ‘Combat First Aid’ program (that looked nothing like its inadequate predecessor) to be developed. This would be delivered to every deploying soldier, along with being issued an effective combat tourniquet, hemostatic dressing and bandage.

The new challenge was who teaches the TCCC courses? The course was intended for soldiers and supposed to be taught by medics, but the medics didn’t have a course of their own. There was no school teaching them the TCCC paradigm, so in January of 2007, in the midst of some of the most intense combat of the war, the pilot TACMED program was created and run for Medical Technicians.

The pilot course was a unique arrangement that turned out to be more successful than anyone could have imagined. The students were deploying Medical Technicians. The venue, administration and logistical facilitation was provided by the Counter Terrorism Training Center at CFB Suffield, and the curriculum and instruction was outsourced to a private company that focussed on tactical medicine research, development and training. This allowed the CAF to focus on operations and the private firm to focus on curriculum development and refinement to meet the changing operational conditions and requirements, and delivery of that relevant content. What started as, for lack of a better term, an experiment, very quickly evolved into a mandatory two-week pre-deployment training course for all Med Tech’s. The program lasted five years with 23 courses being run in that timeframe to train more than 800 Med Tech’s.

The TACMED program’s validation would come in the form of anecdotal stories from theater; stories from medics, casualties, soldiers and the chain of command. Med Tech’s attached to combat units were not seen as liabilities that required ‘babysitting’, but rather essential competent asserts to the team. There would be commendation letters from U.S. Marine Corp Generals and Afghan Governors on exemplary treatment of their casualties, and decorations awarded to a good number of brave medics. The Canadian medics broke rank and stepped forward, further solidifying a reputation as the best in the world at what they do – and I like to think that the TACMED program played a small role in that. Many people are alive today due to the selfless service of countless un­named CAF Medical Technicians.

At the Special Operations Medical Association Conference in Tampa, Florida in 2012, retired Navy Captain Frank Butler presented his annual update on TCCC, making the statement that only the U.S. Army Rangers and the Canadian Armed Forces have established an estimated 100% capture of preventable combat deaths. In a ­testament to the CAF, he attributed this to a ­successful training and equipping program with a TCCC based approach.
If necessity is the mother of invention, and war necessitates improvements in casualty care, it’s not a stretch to realize that Afghanistan took the Canadian Forces Health Services leaps and bounds forward in battlefield medicine. This article is only a keyhole, snapshot perspective of significant changes and improvements that were made. The question remains however, will we remember our lessons learned? Or will we be forced to relearn them once again during the next conflict, as history continues to repeat itself?

Retired from the CF in 2006, Chris Kopp is the founder and CEO of CTOMS, a mission-essential medical training company.
© FrontLine Defence 2013