Based on our experience in Ukraine, it is our opinion that Tactical Combat Casualty Care (TCCC), often considered the gold standard for battlefield trauma care, must evolve in order to stay relevant. TCCC is largely informed by the US combat experience of the last twenty years – combat that was largely fought against a non-peer or near-peer enemy. The US enjoyed superiority both on the ground with weapons, equipment, and training, but more importantly in the air. The US has long enjoyed the ability to dominate the skies and to rely on air evacuation platforms – primarily helicopters and Ospreys. The US combat experience was also one that saw wounds primarily caused by small arms fire and explosives. Finally, TCCC is based on reasonable medic/medical personnel to casualty ratios. In Ukraine, none of these things exist – Ukrainians are fighting a near-peer/peer enemy, one that is better armed and with more firepower than the Ukrainian forces. The two armies face off with similar equipment, similar tactics, and similar weapons. In Ukraine it is trench warfare – Russians pulverize the area with artillery before advancing with tanks that lay down suppressive fire. Dismounted infantry flanks the tanks, maneuvering on Ukrainian positions in an attempt to attack the trenches from the sides. All the while there is sniper overwatch, where Russian sharpshooters target anybody above the trench – such as a medic trying to evacuate a wounded soldier. For these same reasons, there is no rapid evacuation – no helicopters coming to casualty collection points, to say nothing of the point of injury. At best, the wounded are dragged out of the lead trench across open ground to the relative safety of the next trench, where additional care is provided. This is hardly the “yellow zone” TCCC advocates for a safer position – many medics told us directly that they are constantly under fire while providing care and there is no yellow zone when their adversary is shooting at their positions with tanks. After that, the wounded are evacuated – almost always at night – by road, or in many cases on foot. This is a treacherous movement of perhaps several miles – often under drone and artillery fire, often across ground that has been mined. At every step of the process, the casualties far outnumber the medical personnel – we often talk to medics who are the only provider for 50-100 servicemen.
This is the reality of near-peer conflict, a scenario that the US has not faced in earnest since Korea, arguably World War II. But the common caution is that the Department of Defense’s chief mistake is always fighting the last war – not learning and evolving to meet the current threat. This was seen in real time with the invasion of Iraq following the largely small-unit special operations success in the early invasion of Afghanistan. The same can be said for TCCC as we look to future conflicts. A conflict with say, China, would look a lot more analogous to the conditions currently seen in Ukraine than the more recent US combat experiences. The issues currently plaguing Ukrainian medics would be the same experienced by US medical personnel, especially in a conflict in or near Taiwan. US forces would find themselves facing a near-peer enemy without the same advantages in equipment, weapons, and training. Fighting at sea and far from infrastructure would mean no ability to perform expeditious extraction of casualties, and air superiority for cover would be unlikely. Finally, given the types of weapons used, American personnel would find themselves with overwhelming casualty numbers – and if shipboard – with few resources to properly treat and care for casualties.
Our recommendation would be that TCCC be evolved with these conditions in mind – with a specific focus on emphasizing mass casualty triage of both the wounded, but also triaging what equipment and medications should be used on what patients. Significant consideration should be given to prolonged field care, when rapid evacuation is not an option – decisions that will ultimately both inform and be informed by the triage process. This would by necessity include continuing to develop the walking blood bank program. This has remained challenging in Ukraine due to the high attrition rates – the ability to effectively type and screen is difficult given the current limitations of personnel and equipment, but would not necessarily be so for the US where such steps are taken during in-processing. As TCCC evolves, maintaining and improving this capability, to include mass storage of blood on ships and moving exclusively to whole blood transfusions is key. Finally TCCC should start to implement mass casualty/few provider scenarios. In short, the combat casualty scenarios of the future will look much more like Ukraine, and less like the US combat experience of the last 20 years, and TCCC must evolve to stay relevant.
