Tourniquet Management Beyond the Golden Hour: A Call for Doctrinal Change in TCCC

Winter 2025

Beerbaum M, White J, Henderson J

Abstract

Tourniquets have proven lifesaving in modern combat, particularly during the Global War on Terror, where rapid evacuation often mitigated the risks of prolonged and non-medically indicated application. However, in future large scale combat operations (LSCOs), prolonged field care and delayed evacuation will be common. Without timely reassessment, medically unnecessary or ineffective tourniquets may lead to avoidable morbidity, including limb loss, rhabdomyolysis, and compartment syndrome. Data from U.S. and Ukrainian surgical teams reveal tourniquet reassessment, conversion, and optimization are not being practiced in the field to effectively control hemorrhage. Despite this, current TCCC doctrine lacks sufficient emphasis on tourniquet reassessment, conversion (TC), and optimization (TO)-especially among non-medical personnel. This paper calls for doctrinal change to classify tourniquet reassessment, TC, and TO as Tier 1 (All Service Member) skills. We recommend updating TCCC training, emphasizing reassessment within 2 hours of application, incorporating TC/TO into training lanes, and revising the DD1380 TCCC card to document these interventions. Preparing for LSCOs requires shifting from the "fire-and-forget" mindset. Equipping all service members with the skills to reassess and manage tourniquets appropriately can reduce preventable morbidity and preserve lives in prolonged care environments without compromising the proven benefits of rapid hemorrhage control.

Keywords: military medicine; medicine; trauma; tourniquets; TCCC; LSCO

Maritime Applications of Prolonged Casualty Care Training Scenario: Burn Injury on a Destroyer During Distributed Maritime Operations

Winter 2025

Adams D, Tripp MS, Damin VH, Chambers J, Brower JJ, Aydelotte JD, Gurney JM, Cancio LC, Tadlock MD

Abstract

As the U.S. Navy further develops the concept of distributed maritime operations (DMOs), where individual components of the naval force will be more geographically dispersed, smaller vessels may be operating at a significant time and distance from more advanced medical capabilities. Therefore, Role 1 maritime caregivers will need to manage injured and disease non-battle injury patients for prolonged periods during current and future contested DMOs. We developed a hypothetical burn injury patient scenario to present an innovative approach to teaching complex operational medicine concepts including austere burn resuscitation, wound care, and Prolonged Casualty Care (PCC) to austere Role 1 maritime caregivers using the Joint Trauma System PCC and Tactical Combat Casualty Care clinical practice guidelines (CPGs) and other standard references. The format includes basic epidemiology of burn injury in the operational maritime environment. The scenario includes a stem clinical vignette, followed by expected clinical changes for the affected patient at specific time points (e.g., time 0, 1 hour, 2 hours, and 48 hours) with expected interventions based on the PCC CPG, appropriate guidelines, and available standard shipboard equipment. Through this process, opportunities to improve both training, clinical skills sustainment, and standard shipboard medical supplies are identified.

Keywords: prolonged casualty care; Tactical Combat Casualty Care; infective endocarditis; critical care; burn injury; MRSA

Medical Considerations in High-Risk Maritime Operations: A Narrative Review

Winter 2025

Granholm F, Lauria MJ, Melau J, Tin D

Abstract

Maritime operations conducted by military Special Operations Forces and civilian special weapons and tactics (SWAT) units present unique medical challenges. These missions often occur in unpredictable environments, far from immediate medical resources and with exposure to waterborne threats. This article examines the medical aspects critical to maritime operations, including hypothermia management, trauma care in confined and moving spaces, management of drowning and respiratory issues, and specialized training for maritime-specific injuries. A narrative review of literature from 2005-2024 was conducted across major databases and grey sources, with studies included by author consensus. The review identified core maritime medical challenges, hypothermia, drowning, confined-space trauma, respiratory hazards, motion sickness, and impact injuries. Medical support tailored to these environments is essential for maintaining operational effectiveness and responder safety. By examining both preventive and responsive medical approaches, this article highlights the need for maritimespecific medical protocols and training

Keywords: maritime; tactical medicine; transesophageal echocardiogram; prehospital; trauma; performance; transthoracic echocardiogram; SWAT; SOF; Special Operations

In-Theater Assessment of Resuscitative Balloon Occlusion of the Aorta (REBOA) Capabilities and Training

Fall 2025

Koo AY, Hu J, Couperus KS, Eastman J, Kwolek T, Remick KN

Abstract

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technology indicated for temporarily controlling traumatic life-threatening, noncompressible abdominal, truncal, or pelvic hemorrhage. Through percutaneous access or cut-down to the femoral artery, an intra-aortic balloon catheter is fed into the aorta and inflated, occluding distal blood flow and, thus, bleeding. To determine specific barriers to REBOA in deployed environments, we conducted a quality improvement project and survey of ER-REBOA® placement and monitoring capabilities at four medical treatment locations in Iraq and Kuwait during the spring of 2019. Methods: The primary objective was to evaluate each in-theater medical site's ability to deploy REBOA, which was defined as having a provider capable of placing REBOA and the minimum equipment necessary. The investigators interviewed providers and through self-reported surveys, determined the personnel capable of placing a REBOA. REBOA equipment and monitoring equipment were identified through direct inspection of sites and interviews with logistical and equipment staff. Results: A total of 113 individuals participated in the evaluation and training. Three of the four sites had the minimum training and equipment requirements to complete the procedure: one REBOA-capable provider, an unexpired ER-REBOA® device, and an unexpired introducer catheter kit. Overall, 6 out of 32 physicians (18.7%) were capable of placing an ER-REBOA. Conclusion: This deployed site survey demonstrates that the minimal requirements and personnel for ER-REBOA placement were met at most studied locations in 2019. However, improvements in pre-deployment training of select medical personnel in REBOA and arterial blood pressure monitoring are recommended to ensure adequate resourcing and redundancy in training.

Keywords: REBOA; resuscitative endovascular balloon occlusion of the aorta; intra-aortic balloon; ER-REBOA; deployment; noncompressible hemorrhage

Antibiotic Concentrations After Massive Transfusion (ACME) Study: A Review of the Literature on Antibiotic Dosing During Transfusion and Study Protocol

Fall 2025

Huaman RJ, Mancha F, Anderson EL, April MD, Bebarta VS, Castaneto MS, Christians U, Darlington DN, Douin DJ, Glenn KR, Ke P, Kirkwood BJ, Long BJ, Maddry JK, Mendez J, Mireles AA, Ritter AC, Schauer KE, Schumaker AL, Smith MD, Wright FL, Ginde AA, Rizzo JA, Schauer SG

Abstract

Background: Trauma in combat or civilian settings often involves severe hemorrhage and open wounds, which carry a high risk of infection. Current clinical guidelines recommend prophylactic antibiotics for high-risk wounds. Adequate plasma antibiotic concentrations are necessary for tissue penetration, particularly into injured tissue. Blood loss from traumatic hemorrhage may impact plasma antibiotic concentrations. However, the association between blood loss, subsequent blood product transfusion, and antibiotic concentrations remains unclear. We hypothesize that antibiotic concentrations decrease in proportion to the volume of blood transfused, potentially leading to insufficient antibiotic concentrations, placing the injured patient at increased infection risk. Methods: We are conducting a prospective, multicenter study that will enroll trauma patients from two large trauma centers: Brooke Army Medical Center and the University of Colorado Hospital. We will enroll participants receiving antibiotics for wound prophylaxis and three or more units of blood products. We will also enroll a control arm comprised of participants receiving the same antibiotics who receive two or fewer units of blood. Blood samples will be collected from participants at predetermined time intervals after antibiotic infusion to assess antibiotic concentrations. Our statistical analysis will focus on the relationship between the volume of blood products administered and antibiotic concentrations. Results will inform the development of antibiotic dosing models for clinicians that adjust for the effects of blood transfusion. Conclusion: The goal of this study is to fill a significant gap in trauma care that could potentially lead to optimized antibiotic dosing and improved outcomes for trauma patients.

Keywords: antibiotic; concentration; drug; massive antibiotic; blood; blood transfusion; hemorrhage; anti-bacterial agents; wounds and injuries

Definitive Field Care: The Modern Application of a Historical Strategy

Fall 2025

Hiles JM, Hofmann LJ, Grant AA, Hardin RD

Abstract

Definitive Field Care (DFC) is a medical strategy required when evacuation is impossible due to tactical, environmental, or political constraints. Unlike Prolonged Field Care (PFC) or Prolonged Casualty Care (PCC), which assume eventual evacuation, DFC places full responsibility for definitive treatment on the initial provider. Historical examples, such as the Yugoslavian Partisans in World War II and Afghan resistance fighters during the Soviet invasion, highlight the necessity of DFC in austere, high-risk environments. Key considerations include operational constraints, risk tolerance, and provider mindset. Without evacuation, medical priorities shift, requiring difficult decisions. Providers must adapt to scarce resources, hostile conditions, and the absence of Geneva Convention protections. The mindset required demands resilience, adaptability, and acceptance of non-Western medical standards. As irregular warfare becomes more prevalent, formally recognizing, studying, and integrating DFC into military and humanitarian medical planning is essential. Training personnel for DFC will enhance operational effectiveness and improve survival rates in extreme conditions.

Keywords: field care; austere surgery; irregular warfare; PFC; PCC

Undersea and Hyperbaric Medicine Case Studies and Review

Summer 2025

Day M, Radi J

Abstract

There is a dearth of studies in undersea and hyperbaric medicine (UHM), likely due to the limited number of clinicians currently specializing in UHM. Due to the high-consequence nature of diving and the effects of pressure on the human body, medical clearance is of the utmost importance. Despite all efforts to mitigate the possibilities of dive maladies, divers occasionally succumb to the effects of prolonged submersion. This article provides an in-depth look at three individuals who suffered from separate dive-related medical events. In each example, UHM was applied and successfully mitigated short and long-term medical consequences. The manuscript then reviews common and life-threatening dive maladies, with an in-depth examination of decompression strategies and diving clearance.

Keywords: undersea and hyperbaric medicine; hyperbaric medicine; diving medicine; dive; recompression chamber; emergency evacuation hyperbaric stretchers; pulmonary overinflation syndrome; decompression sickness; decompression illness; barotrauma

"The Future of Special Operations Forces Medicine": Review of the Paris Special Operations Forces Combat Medical Care Conference, Fall 2024

Summer 2025

Pasquier P, Mahe P, Josse F

Abstract

Keywords:

Effects of Whole Blood Donation on Physiological Responses and Physical Performance at Altitude

Spring 2025

Jones D, Roberts N, Weller RS, McClintock RJ, Buchanan C, Dunn TL

Abstract

Background: The impact of single-unit blood donation (BD) on donor physical performance at sea level is well-studied. However, no studies have evaluated the impacts of BD on warfighter performance at higher elevations. This study evaluated the effects of BD on high-altitude combat-load carry performance in acclimatized military personnel following BD. Methods: Thirteen acclimatized military personnel (age: mean 28 [SD 6] years; height mean 175 [SD 7] cm; weight: mean 78.4 [SD 9.1] kg; residence elevation 2,100m) completed two 3.2-km rucksack carries (mean 24.2 [SD 2.1] kg from 2800 to 3,050m, one without BD (control) and one after BD. Total ruck march time, heart rate (HR), oxygen saturation (SpO2), respiratory rate (RR), minute ventilation (VE), rating of perceived exertion (RPE), thermal sensation (TS), and acute mountain sickness (AMS) symptoms were analyzed. Results: There were no differences between control and BD for ruck march time (F(1,11)=2.13, P>.1, η2G=.03), HR (P>.1), RR (P>.1), VE (P>.1), RPE (P>.1), and TS (P>.07). AMS symptoms were not impacted by either condition. SpO2 was lower in the control scenario than after BD (b=-4.23 [SE 2.4], P=.007). Conclusions: A single-unit whole blood donation does not impact donor physical performance in acclimatized participants during combat-load carries at elevations up to 3,050m except with respect to SpO2

Keywords: military; blood transfusion; elevation; exercise; performance; resource-limited settings

An Update on Best Practices for the Prehospital Management of Exertional Heat Illness

Spring 2025

Norton C, Moreh Y, Sperry N, O'Connor FG, Degroot D, Rhodehouse B, Bartlett SI

Abstract

Exertional heat illness (EHI) describes a spectrum of acute medical disorders, frequently encountered in Servicemembers throughout the Armed Forces, that poses a pervasive threat to individual and unit military readiness. In June 2024, the Consortium for Health and Military Performance Warrior Heat and Exertion Related Event Collaborative published a Joint Clinical Practice Guideline for the prevention, diagnosis, and management of exertional heat illness, which outlines best practices in the diagnosis and management of EHI, including prevention, prehospital care, emergency department care, inpatient hospital care, and return to duty guidelines. In the Special Operations community, recognition and early treatment via rapid cooling to a body core temperature of 39.0-39.2°C (102.0-102.5°F) within 30 minutes from the time of injury recognition are the most crucial concepts to follow to reduce the morbidity and mortality of EHI. This article introduces the recommended best practices from the Clinical Practice Guideline, which are most relevant to the Special Operations community.

Keywords: heat injury; exertional heat illness; prehospital care; exertional heat stroke; heat exhaustion

Successful Management of Battlefield Traumatic Cardiac Arrest Using the Abdominal Aortic and Junctional Tourniquet (AAJT): A Case Series

Spring 2025

Androshchuk D, Verba A

Abstract

The Russo-Ukrainian war's prolonged warfare, resource constraints, and extended evacuation times have forced significant adaptations in Ukraine's medical system - including technological advancements and strategic resource placement. This study examined if the Abdominal Aortic and Junctional Tourniquet - Stabilized (AAJT-S) could manage traumatic cardiac arrest (TCA) at forward surgical stabilization sites (FSSS) as an adjunct to damage control surgery. Six patients in severe hypovolemic shock presented at an FSSS during fighting in Bakhmut (July 2022) and Slovyansk (May 2023). Following TCA due to exsanguination, the AAJT-S was applied 2cm below the umbilicus. Cardiopulmonary resuscitation (CPR) and transfusion (blood and/or plasma) were initiated. All six patients were resuscitated. None required vasopressor support post-resuscitation. Five survived to the next level of care. One died awaiting evacuation, and another of wounds after 10 days. Four survived to discharge. Three were followed and neurologically intact, and no death records matched the fourth's name and date of birth at 18 months. Follow-up was limited, but one patient was neurologically intact at one year. The AAJT-S effectively resuscitated TCA patients. It increased mean arterial pressure, focused resuscitative efforts on the upper torso, simplified care, and preserved crucial field resources. An alternative to traditional emergency thoracotomy, AAJT-S could replace or complement resuscitative endovascular balloon occlusion of the aorta in pre-hospital settings, given its ease of application by combat medics. AAJT-S, alongside blood transfusion and CPR, achieved 100% success in return of spontaneous circulation and effectively managed TCA in a wartime FSSS.

Keywords: traumatic cardiac arrest; hemorrhagic shock; damage control surgery; damage control resuscitation; abdominal aortic and junctional tourniquet-stabilized; AAJT-S; resuscitative endovascular balloon occlusion of the aorta; trauma management; emergency thoracotomy

Rethinking the Operational Blood Bank Dilemma: Out of the "Box" Blood Storage and Transportation Evaluation

Winter 2024

Hughey S, Kotler J, Bollinger JW, Cole J, Itani Y, Hughey A, Nagata T, Checchi K

Abstract

Background: Blood transfusion is critical in modern trauma care. However, unreliable access to robust blood banking in austere military and disaster medicine settings remains challenging. Stored whole blood and components have strict refrigeration guidelines; any cold-chain storage liability that results in blood products deviating from their target temperatures affects patient safety. Refrigeration in a typical blood bank requires large, specialized devices. Transportable, battery-operated devices are available, but they have limited battery life. This study evaluated the possibility of using passively cooled devices (commercially available food coolers) to store blood components. Methods: A commercially available 45-liter capacity cooler was used. Saline bags (500mL) were precooled to 1-6°C and placed in the cooler. A thermometer placed in the cooler adjacent to each saline bag measured the cooler temperature throughout each trial. The primary outcome was the hours of adequate refrigeration (between 1 and 6°C). Results: There were four trials, each lasting 168 hours. Trials 1-3 maintained the goal temperature range for >142 hours, while trial 4 maintained temperature range for 78 hours. Conclusion: Passive refrigeration using commercially available coolers and ice is a viable alternative to traditional blood storage solutions in austere, disaster, and military operational environments. Further studies should investigate prolonged blood storage using this technique with the periodic addition of ice.

Keywords: blood transfusion; operational medicine; unmanned aerial systems; transfusion; passive refrigeration