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 Table of Contents  
Year : 2019  |  Volume : 21  |  Issue : 2  |  Page : 105-107

Tactical combat casualty care in the navy – Challenges and way ahead

1 IHQ of MoD (Navy), New Delhi, India
2 HQWNC, Mumbai, Maharashtra, India
3 Director and Dean, Institute of Naval Medicine, New Delhi, India
4 Department of Onco Surgery, Research and Referral Hospital, New Delhi, India

Date of Submission21-Sep-2019
Date of Acceptance25-Sep-2019
Date of Web Publication07-Oct-2019

Correspondence Address:
Surg Capt (Dr) Sougat Ray
SSO (Health) HQWNC, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_67_19

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How to cite this article:
Singh M V, Ray S, Goyal S, Singh R J, Sharma R. Tactical combat casualty care in the navy – Challenges and way ahead. J Mar Med Soc 2019;21:105-7

How to cite this URL:
Singh M V, Ray S, Goyal S, Singh R J, Sharma R. Tactical combat casualty care in the navy – Challenges and way ahead. J Mar Med Soc [serial online] 2019 [cited 2023 Mar 24];21:105-7. Available from: https://www.marinemedicalsociety.in/text.asp?2019/21/2/105/268628

Humanity has fought battles at sea for more than 3000 years, and the oceans have witnessed as much violence and devastation as land battles. The first recordable sea battle occurred around 1210 BC. Suppiluliuma II, king of the Hittites, defeated a fleet from Cyprus and burned their ships at sea.[1] HMS Dreadnought, constructed in 1906, paved the way for a new type of warship and modern sea battle. This was followed by aircraft carriers and future naval wars evolved into fast-paced, high-intensity combat.[2]

The Battles of Pearl Harbor, Midway, Coral Sea, and Normandy defined the Great War. There were heavy casualties, and many ships were sunk along with men and material. The Battle of Leyte Gulf in the World War II considered to be the biggest and most multifaceted naval battle in history, involving air, surface, subsurface, and amphibious components, along with hundreds of ships and aircrafts, nearly 200,000 participants, and spanned more than 100,000 square miles in the ocean. The armamentarium used included bombs of every type, guns of every caliber, torpedoes, mines, rockets, and even a forerunner of the modern-guided missile.[2] Indo Pak War of 1971 and Falklands War in 1982 were the other two significant naval conflicts after World War II, which witnessed a large number of casualties. At present, the navy of different nations has been playing a significant role in the war against terrorism.[3]

  Evolution of Tactical Combat Casualty Care Top

Mortality due to injury has been classically described with a trimodal distribution, with immediate deaths at the scene, early deaths due to hemorrhage, and late deaths from organ failure.[4] The Tactical Combat Casualty Care (TCCC or TC3) is a set of evidence-based, best-practice, prehospital trauma care guideline customized for use in all the three distribution phases. It is an integration of tactics and medical practice with different sets of skills and equipment.[5] It includes aggressive use of tourniquets and hemostatic dressings to control external hemorrhage, enhanced fluid resuscitation for hemorrhagic shock, emphasis on airway positioning to manage traumatized airway, effective battlefield analgesia, and use of intraosseous vascular access and battlefield antibiotics.[6]

The goal of TCCC is to identify and treat patients with injury in austere environments that impose significant challenges in terms of medical workforce, equipment and evacuation capability, and keep them alive long enough to reach a hospital or a definitive treatment zone.[7] TCCC is divided into three phases of care, namely Care Under Fire (CUF), Tactical Field Care (TFC), and Tactical Evacuation Care (TACEVAC).[8] Casualty and medical actions that focus on gaining and maintaining the tactical advantage with only tourniquets are currently recommended as standard medical care in the CUF phase. The TFC phase consists of management of the airway by surgical techniques, needle thoracostomy for tension pneumothorax or cricothyroidotomy, and more such aggressive procedures for controlling bleeding and fluid resuscitation. TACEVAC care encompasses the same assessment and management included in TFC with additional focus on advanced procedures that can be initiated when en route to a medical treatment facility. TACEVAC can also include the evacuation of casualties on available nonmedical assets and not only in a helicopter.[9]

Although the concept was first adopted in the special forces in the 1990s, the transition to full-fledged implementation of TCCC for managing trauma in the tactical environment in the face of ongoing hostilities was only after the reports of success from different military units [10] in the first half of the 21st century. Holcomb et al.[11] found that 25% fatalities with potential preventable injuries could have been saved by the application of tourniquet during the special operations deaths in Iraq and Afghanistan in 2004. Kelly et al. found that 77 of 232 potentially preventable deaths from the first 5 years of the conflicts in Afghanistan and Iraq resulted from failure to use a tourniquet.[12] Another data obtained from 7 years of combat in Iraq and 8.5 years in Afghanistan, it was found that 10.7% were killed in action and 1.7% died of wounds in the regiment which implemented TCCC, and the rates were much lower than the Department of Defense, USA rates of 16.4% and 5.8%, respectively, during the same period.[13]

  Implementation of Tactical Combat Casualty Care in the Navy Top

The battlefield in the Navy is very different from that in the Army; hence, the nature of injury and its management also vary. The ship is an enclosed space with limited healthcare personnel and equipment and remains incommunicado from the rest of the world while at sea. Although basic life-saving procedures are available in the warships, they have not been validated because of lack of a full-fledged naval war in the recent past. Evacuation to a tertiary care facility in the land is difficult and at times next to impossible. Care of the injured with limited facility in an austere environment thus remains the primary objective of medical care in the navy. The casualty care thus needs proper planning, elaboration, and execution.[14]

There is a paucity of recent literature about the pattern of injuries in Naval warfare. Royal Navy data from Operation Iraqi Freedom revealed that of 221 casualties, there were 54 (24%) fatalities. Majority of deaths, i.e., 48/54 occurred immediately, leaving no scope for medical intervention. Of the survivors, 72% returned to duty.[15] This implies that most immediate deaths were unsalvageable while the injuries in survivors were less severe. More data might be needed to determine the applicability of TCCC in naval warfare, which has a bimodal rather than the trimodal spectrum of injuries seen in land warfare.

  Types of Injuries during a Sea Battle Top

Use of high-speed and precision-guided underwater explosive weapons or missiles can cause complex and multiple forms of injuries. Blast damage is the leading cause of death, especially in navy combat. Bomb blasts can cause multiple traumas such as head injury, fracture of the extremities, spinal injuries, and chest and abdominal injuries. Injuries might also be caused by hitting the bulkhead inside the cabins. Some weapons might cause a combination of injuries such as blast injury, burn injury, seawater immersion injury, and decompression injury. For tactical purposes, nonexplosive weapons such as infrasound weapons, laser weapons, electromagnetic weapons, and microwave weapons can also be used on the modern battlefield. In the surface ships, the accommodation for the crew is in the bunks, and the passages are narrow and small. With a dense distribution of the sailors, an attack will result in a substantial number of casualties in a short period. In certain situations, when the sailors jump in seawater, an unpredictable distribution of casualty might occur because of the waves. In such situations, it might become difficult to search and salvage the casualty, thereby delaying treatment further.[16] The battlefield is the ocean, far from land or shoreline. The characteristics of the seawater vary and include cold temperature, hypertonicity, pathogenic bacteria, and other harmful sea animals, which can cause additional damage to the casualty. The healing time of firearm wounds after immersion in the seawater can be delayed than compared to the same injury in the land.

  Diagnostic Challenges and Casualty Evacuation at Sea Top

Medical officers in the ship need to diagnose the casualty in the ship with simple medical equipment or only by clinical symptoms. Transport of the casualty to a hospital ship or a better-equipped ship is also challenged and depends on suspended transporters or limited helicopter availability in the face of enemy action. Thus, damage control by injury management is the best method to avoid further deterioration. An efficient, highly trained team of doctors and paramedics who can complete damage control intervention taking the TCCC principles independently have been proven to be highly effective.[16]

  Way Ahead Top

Implementation of TCCC is considered to be the best option in saving lives due to injury in the face of hostilities. It has been observed that units that have trained all of their members in TCCC have the lowest incidence of preventable deaths in warfare.[9] All officers and sailors, including medical personnel who are to be deployed in combat operations, must be trained and retrained in the latest TCCC guidelines. They would require to be trained in basic trauma life-saving interventions such as needle decompression for tension pneumothorax, use of tourniquets for control of bleeding, and cricothyroidotomy.[17] They should be able to provide the best possible care for the casualty, in a way that minimizes additional casualties and maximizes the probability of mission success for their ship.[9]

Epidemiological analysis of injury patterns and mechanisms, however, will be required to identify the expertise the naval doctors and the medics need in a combat setting at sea and accordingly help to adjust equipment and training requirements. A forward surgical team trained in TCCC should be deployed during combat operations at designated ships with the required medical equipment. The surgeons must have excellent skills in the fields of thoracic, visceral, and vascular surgery as well as practical skills in neurosurgery and oral and maxillofacial surgery. Other than training, the designated ship should be prefitted with basic surgical equipment as required for immediate wound management.[10]

Protective measures against a blast shock may be prefitted at the design stage in the warships. It is necessary to install antishock chairs and seat belts in ergonomic but functional positions in the cabins of the battleships. Cabins should have anti-collision materials installed on bulkheads and equipment surfaces to avoid secondary collision injuries. Combatants should be equipped with impact resistance helmets and cushioning shoes. The use of telemedicine [18] by deployed health-care providers to improve patient care has been increasing in recent conflicts and humanitarian missions. It has been shown that there is decreased time to evacuation for patients with telemedicine or live video feed available. Due to the lack of intensive combat experience, the pattern of injuries expected in naval warfare can only be surmised based on the experience of other countries. The US Navy has a combat trauma registry,[5] and the same can be implemented.

  Conclusion Top

TCCC has changed battlefield trauma care from basic care for the injured to that developed for injuries in the combat zone. It has helped combat units to achieve unprecedented casualty survival rates with aggressive use of tourniquets when these units trained all of their combatants in these techniques. The Naval battle scenario is different. Blast injuries are common which results in immediate death without giving a chance for survival. The distribution of injuries is mostly bimodal rather than trimodal. However, training on TCCC guidelines is required to be implemented for all personnel before being deployed on board, and the medics should be properly trained in use of tourniquets, chest tubes, and undertaking cricothyroidotomy. Future work should include epidemiological research on the analysis of injuries onboard. The future development portable equipment used in medical rescue at sea must be powerful enough to save more people. Equipping all officers and sailors, including the medics with prehospital life-saving skills and successful evacuation of the casualty to a higher medical facility, will be huge force multiplier in any deployment setting in the navy while at sea.

  References Top

The History of Naval Battles – Part 1. Available from: https://warthunder.com/en/news/4276-fleet-the-history-of-naval-battles-part-1-en. [Last accessed on 2019 Aug 23].  Back to cited text no. 1
Heres How 10 of the Largest and most Important Naval Battles in Modern History Played Out. Available from: https://www.businessinsider.in/Heres-how-10-of-the-largest-and-most-important -naval-battles-in-modern-history-played-out/articleshow/63346130.cms. [Last accessed on 2019 Aug 23].  Back to cited text no. 2
Naval Tactics. Available from: https://en.wikipedia.org/wiki/Naval_tactics. [Last accessed on 2019 Sep 18].  Back to cited text no. 3
Gunst M, Ghaemmaghami V, Gruszecki A, Urban J, Frankel H, Shafi S. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Bayl Univ Med Cent) 2010;23:349-54.  Back to cited text no. 4
Handbook on Tactical Combat Casualty Care. Available from: https://call2.army.mil/toc.aspx?document=6851&filename=/docs/doc6851/12-10.pdf. [Last accessed on 2019 Aug 23].  Back to cited text no. 5
Butler FK. Two decades of saving lives on the battlefield: Tactical combat casualty care turns 20. Mil Med 2017;182:e1563-8.  Back to cited text no. 6
Puryear B, Knight C. EMS, Tactical Combat Casualty Care. StatPearls Publishing; 2019. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532260/. [Last accessed on 2019 Sep 07].  Back to cited text no. 7
Butler FK Jr., Holcomb JB, Giebner SD, McSwain NE, Bagian J. Tactical combat casualty care 2007: Evolving concepts and battlefield experience. Mil Med 2007;172:1-9.  Back to cited text no. 8
Butler FK Jr. Blackbourne LH. Battlefield trauma care then and now: A decade of tactical combat casualty care. J Trauma Acute Care Surg 2012;73:S395-402.  Back to cited text no. 9
Butler FK, Bennett B, Wedmore CI. Tactical combat casualty care and wilderness medicine: Advancing trauma care in austere environments. Emerg Med Clin North Am 2017;35:391-407.  Back to cited text no. 10
Holcomb JB, McMullin NR, Pearse L, Caruso J, Wade CE, Oetjen-Gerdes L, et al. Causes of death in U.S. Special operations forces in the global war on terrorism: 2001-2004. Ann Surg 2007;245:986-91.  Back to cited text no. 11
Kelly JF, Ritenour AE, McLaughlin DF, Bagg KA, Apodaca AN, Mallak CT, et al. Injury severity and causes of death from operation Iraqi freedom and operation enduring freedom: 2003-2004 versus 2006. J Trauma 2008;64:S21-6.  Back to cited text no. 12
Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK Jr., Mabry RL, et al. Eliminating preventable death on the battlefield. Arch Surg 2011;146:1350-8.  Back to cited text no. 13
Gawande A. Casualties of war – Military care for the wounded from Iraq and Afghanistan. N Engl J Med 2004;351:2471-5.  Back to cited text no. 14
Blackbourne LH, Baer DG, Eastridge BJ, Kheirabadi B, Bagley S, Kragh JF Jr., et al. Military medical revolution: Prehospital combat casualty care. J Trauma Acute Care Surg 2012;73:S372-7.  Back to cited text no. 15
Lechner R, Achatz G, Hauer T, Palm HG, Lieber A, Willy C. Patterns and causes of injuries in a contemporary combat environment. Unfallchirurg 2010;113:106-13.  Back to cited text no. 16
Mabry R, Frankfurt A, Kharod C, Butler F. Emergency cricothyroidotomy in tactical combat casualty care. J Spec Oper Med 2015;15:11-9.  Back to cited text no. 17
Weymouth W, Thaut L, Olson N. Point of view telemedicine at point of care. Cureus 2018;10:e3662.  Back to cited text no. 18


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