Trademark Trial and Appeal Board Electronic Filing System. http://estta.uspto.gov
`ESTTA596242
`ESTTA Tracking number:
`04/02/2014
`
`Filing date:
`IN THE UNITED STATES PATENT AND TRADEMARK OFFICE
`BEFORE THE TRADEMARK TRIAL AND APPEAL BOARD
`Notice of Opposition
`
`Notice is hereby given that the following party opposes registration of the indicated application.
`Opposer Information
`
`Washington
`
`Name
`Entity
`Address
`
`Deployment Medicine Consultants, Inc
`Corporation
`Citizenship
`2626 Point Fosdick Dr. NW
`Gig Harbor, WA 98235
`UNITED STATES
`
`Attorney
`information
`
`Randall Henderson
`Law Offices of Randall S. Henderson
`13681 Newport Avenue, Suite 8-441
`Tustin, CA 92780
`UNITED STATES
`rsh2@earthlink.net Phone:626.7989832
`Applicant Information
`
`Application No
`Opposition Filing
`Date
`Applicant
`
`86061164
`04/02/2014
`
`Publication date
`Opposition
`Period Ends
`
`03/04/2014
`04/03/2014
`
`Di Giorgio, Raffaele
`1681 Turtle Dove Trail
`Sevierville, TN 37862
`USX
`Goods/Services Affected by Opposition
`
`Class 041. First Use: 2006/02/01 First Use In Commerce: 2006/03/01
`All goods and services in the class are opposed, namely: Educational services, namely, conducting
`classes, seminars, conferences and workshops in the fields of medical care andemergency medical
`care and distributionof training materials in connection therewith
`
`Grounds for Opposition
`
`Priority and likelihood of confusion
`The mark is merely descriptive
`The mark comprises matter that, as a whole, is
`functional
`Other
`
`Trademark Act section 2(d)
`Trademark Act section 2(e)(1)
`Trademark Act section 2(e)(5)
`
`Applicant has failed to protect the underlying
`mark on which this application is based and has
`thus abandoned the underlying mark. 15 U.S.C.
`§1127. There are at least two dozen
`companies, including Opposer, that have used
`the written portion of the mark -- Tactical Combat
`Casualty CAre and TCCC - - since 2002 or
`earlier. 15 USC §1052(d) The graphic portion of
`
`

`
`the mark is merely background and does not
`function as a mark separate and apart from the
`words used. In re Grande Cheese Company, 2
`USPQ2d 1447, 1449 (TTAB 1986); General
`Foods Corp. v. Ito Yokado Co., Ltd., 219
`USPQ2d 822, 825 (TTAB 1983).
`
`Mark Cited by Opposer as Basis for Opposition
`
`U.S. Application/
`Registration No.
`Registration Date
`Word Mark
`Goods/Services
`
`NONE
`
`Application Date
`
`NONE
`
`NONE
`TACTICAL COMBAT CASUALTY CARE and TCCC
`Educational services, namely, conducting classes, seminars,
`conferences and workshops in the fields of medical care and
`emergency medical care and distribution of training materials in
`connection therewith
`
`Attachments
`
`Opposition Final.pdf(2526952 bytes )
`
`Certificate of Service
`
`The undersigned hereby certifies that a copy of this paper has been served upon all parties, at their address
`record by First Class Mail on this date.
`
`Signature
`Name
`Date
`
`/Randall S. Henderson/
`Randall Henderson
`04/02/2014
`
`

`
`Deployment Medicine International (“DMI”), a Washington corporation having its
`principal place of business in Gig Harbor Washington, believes that it will
`damaged by registration the mark applied for under Serial No. 86061164 and
`hereby opposes registration pursuant to 15 U.S.C. §1063(a). As grounds for its
`Opposition, DMI submits:
`
`DMI a leading provider of medical training for military combat medics and
`1.
`other field medical personnel, both in the United States and overseas. Such
`training is commonly referred to as tactical combat casualty care training or
`“TCCC.” DMI began teaching courses in tactical combat casualty care in or about
`2002, shortly after it was incorporated. DMI begin teaching courses in Tactical
`Combat Casualty Care, denominated as such, to pre-deployment military
`personnel at least as early 2006 if not before. DMI also offers services as a TCCC
`provider.
`
`The concept of Tactical Combat Casualty Care came into being in 1996
`2.
`with the publication of a study commissioned by the U.S. Naval Special Warfare
`Command, located in San Diego, California. A copy of that 1996 report is
`attached as Exhibit A. One of the three principals authors of that study was LTC
`John Hagmann, MC, USA. Dr. Hagmann has since retired and is the founder and
`President of Petitioner DMI.
`
`As described in the 1996 study, the principles of TCCC are fundamentally
`3.
`different from those of traditional trauma care and are based on the unique types
`and patterns of wounds suffered in combat and the tactical situations medical
`personnel face in combat. Prior to the study, military “pre-hospital” medical
`providers were not always provided with treatment protocols and interventions
`that were relevant to the parameters of actual combat or tactical scenarios.
`Guidelines recommended by the 1996 study focus primarily on the most common
`causes of preventable death on the battlefield and the most protective measures
`that can be reasonably performed in combat. Hence the name, tactical combat
`casualty care.
`
`The U. S. Army Combined Arms Center at Fort Leavenworth, Kansas,
`4.
`defines TCCC as follows:
`
`
`“First responder capability can be usefully divided into the three
`phases called tactical combat casualty care. Tactical combat casualty
`care occurs during a combat mission and is the military counterpart
`to prehospital emergency medical treatment. Prehospital emergency
`medical treatment in the military is most commonly provided by
`enlisted personnel and includes self- and buddy aid (first aid),
`combat lifesaver (enhanced first aid), and enlisted combat medics in
`
`

`
`the Army, corpsmen in the US Navy, US Marine Corps, and US
`Coast Guard, and both medics and pararescuemen in the US Air
`Force. Tactical combat casualty care focuses on the most likely
`threats, injuries, and conditions encountered in combat, and on a
`strictly limited range of interventions directed at the most serious of
`these threats and conditions. The tactical combat casualty care
`initiative originated with US Special Operations Command. Special
`operations forces do not have a dedicated, designed, and equipped
`medical evacuation capability. Therefore, they use nonmedical
`platforms augmented with medical personnel to perform the
`evacuation function.”
`
`
`TCCC was adopted for use by the Naval Special Warfare Command in
`5.
`1997 and guidelines for TCCC were adopted by the U.S. Special Operations
`Command (USSOCOM) in 1998. TCCC guidelines, designated as such, have
`been approved by both the American College of Surgeons (ACS) and the National
`Association of Emergency Medical Technicians (NAEMT).
`
`In 2001, USSOCOM recognized the need to update these guidelines, and
`6.
`based on research conducted by the Naval Operational Medical Institute, a
`Committee on Tactical Combat Casualty Care (CoTCCC) was established. This
`committee updated the TCCC guidelines in 2003 and republished them in the
`revised PHTLS manual, 5th edition.
`
`CoTCCC is an ongoing project conducted under the sponsorship of the
`7.
`Navy Bureau of Medicine and Surgery. The CoTCCC includes special operations
`personnel, including special forces medics, Navy SEAL corpsmen, Air Force
`pararescuemen, trauma surgeons, emergency medicine physicians,
`anesthesiologists, and medical educators, who collaborate to continually update
`TCCC guidelines. TCCC was established as the standard of care for special
`operations medic training in 2005. TCCC equipment and training also became
`mandatory for all deploying SOF, as the first responder to a wounded special
`operations warfighter on the battlefield is often not a special operations medic.
`
`The United States Navy began to implement training in Tactical Combat
`8.
`Casualty in 1997. See Memorandum dated April 9, 1997 from Commander, Naval
`Special Warfare Command (attached as Exhibit B). The United States Marine
`Corps promulgated guidelines regarding Tactical Combat Casualty Case, referring
`to it as TCCC as well, at least as early as 2006. See Message dated 2 August 2006
`from CMC Washington DC to AL MARADMIN (attached as Exhibit C). The
`U.S. Army began promulgation its own handbook on Tactical Combat Casualty
`Care at least as early as 2006. See Cover to Handbook, Tactical Combat Casualty
`Care, May ’06 (attached as Exhibit D).
`
`

`
`
`9. While DMI was an early provider of TCCC training, it is by no means the
`only one. At a minimum, the following companies and organizations all offer
`training and/or goods and services directly related to Tactical Combat Casualty
`Care, using both that name and the acronym “TCCC” to denote their services:
`
`
`Florida Tactical Emergency Services of Fort Lauderdale, Florid.
`(a)
`http://www.floridatems.net/upcoming-courses.html
`
`The National Association of Emergency Medical Technicians, of
`(b)
`Clinton, Mississippi. http://www.naemt.org/education/TCCC/tccc.aspx
`
`The American Medical Academy of Miami, Florida.
`(c)
`http://ama.edu/tactical-casualty-combat-care-tccc-inital-course/
`
`The Orlando Medical Institute of Orlando, Florida.
`(d)
`https://www.orlandomedicalinstitute.com/index.php/tactical-combat-casualty-
`care-tccc/
`
`Trauma Training Fx of Virginia Beach Virginia.
`(e)
`http://t2training.com/trauma/tccc.aspx
`
`The Department of Defense Health Agency.
`(f)
`http://www.health.mil/tccc
`
`The Center for Medics in Cambridge, Massachusetts.
`(g)
`http://centerformedics.com/training/professional-development/tcc-tactical-combat-
`casualty-care/
`
`(h) Medicine in Bad Places LLC, located in Coram New York.
`http://www.medicineinbadplaces.com/site/index.php/classes/tccc
`
`The Tactical Support Institute in Mesa, Arizona.
`(i)
`https://www.tacticalsupportinstitute.com/training-courses/national-association-of-
`emt-courses/tactical-combat-casualty-care
`
`Triple Canopy of Reston, Virginia.
`(j)
`http://www.triplecanopy.com/services/training/programs/medical/tactical-combat-
`casualty-care-tccc/
`
`The Certification Center of Queens, New York.
`(k)
`http://store.thecertificationcenter.com/tactical-combat-casualty-care-tccc/
`
`Emergency Response Training International in Brandon, Florida.
`(l)
`http://tacticalcombatcasualtycare.org/
`
`

`
`(m) The Denver Health Paramedic Division in Denver Colorado.
`http://www.denverems.org/continuing-education/tactical-combat-casualty-
`care.html
`
`The U.S. Army at Fort Drum, New York.
`(n)
`http://www.drum.army.mil/10md/Pages/DS_TacticalCombatCasualtyCare_lvl3.as
`px
`
`(o) North American Rescue LLC of Greer, South Carolina.
`http://www.narescue.com/Tactical_Combat_Casualty_Care.htm
`
`Tactical Element of Lady Lake, Florida.
`(p)
`http://www.tacticalelement.com/tccc/
`
`Insights Training LLC of Bellevue, Washington.
`(q)
`http://www.insightstraining.com/view_course.asp?courseID=156
`
`Sector International of Carlsbad, California.
`(r)
`https://htpscourse.com/tactical-trauma-care
`
`The Texas Tactical Police Officers Association.
`(s)
`http://www.ttpoa.org/Training/TrainingDetails.aspx?cid=1842
`
`Commonwealth Criminal Justice Academy of Fredericksburg,
`(t)
`Virginia. http://www.ccjatraining.com/courses-
`training/tactical_combat_casualty_care_under_fire_course.pdf
`
`Security Solutions International of Miami, Florida.
`(u)
`http://www.homelandsecurityssi.com/tactical-medicine-training
`
`Cape Fear Tactical Medicine of Clermont, Florida.
`(v)
`http://www.capefeartactical.com/TCCC.html
`
`(w) The Asymmetric Combat Institute of Taylors, South Carolina.
`http://www.outcomes-basedtraining.com/training/tccc/index.html
`
`The Maryland Committee on Trauma in Baltimore, Maryland.
`(x)
`http://www.mdcot.org/training/tccc/
`
`The terms “Tactical Combat Casualty Care” and “TCCC” have been used
`10.
`continuously since 1997 by numerous companies and organizations throughout the
`United States to specifically refer to emergency medical treatment under tactical
`circumstances – the very uses to which Applicant proposes to put the terms.
`Given their wide spread use and their descriptive nature, however, these terms
`cannot, now or ever, achieve any meaning uniquely different or apart from tactical
`combat casualty care itself. The terms are merely descriptive.
`
`

`
`The terms “Tactical Combat Casualty Care” and “TCCC” have been in
`11.
`continuous use by numerous companies and organizations throughout the United
`States since at least 1997. Registration of the proposed mark in connection with
`the goods and services described by Applicant would so resemble the marks as
`used by DMI and others that confusion would be likely.
`
`The terms “Tactical Combat Casualty Care” and “TCCC” have been in
`12.
`continuous use by numerous companies and organizations throughout the United
`States since at least 1997. DMI and others used the proposed marks in commerce
`long before Applicant did.
`
`If registration of the proposed mark is permitted, DMI and others will be
`13.
`unable to properly and accurately advertise their goods and services without risk a
`claim of trademark infringement by Applicant.
`
`Insofar as DMI can determine, Applicant has never attempted to enforce his
`14.
`trademark rights under Registration No. 4228151 to the terms “Tactical Combat
`Casualty Care” and “TCCC” against DMI or any other users of the marks as
`identified in Paragraph 9 above. Accordingly, Applicant has effectively
`abandoned his previously registered mark. 15 U.S.C. §1127. See also Stuart
`Spector Designs, Ltd. v. Fender Musical Instruments Corp., 94 USPQ2d 1549,
`(TTAB 2009) (failure to police third party use of marks).
`
`Further, the mark proposed by Applicant is merely background and does
`15.
`not function as a mark separate and apart form the words used. See In re Grande
`Cheese Co., 2 USPQ2d 1447, 1449 (TTAB 1986); General Foods Corp. v. Ito
`Yokado Co., Ltd., 219 USPQ 822, 825 (TTAB 1983).
`
`
`
`

`
`
`
`EXHIBIT A
`EXHIBIT A
`
`

`
`Tactical Combat Casualty Care in
`Special Operations
`
`A supplement to Military Medicine
`
`bY
`Captain Frank K. Butler, Jr., MC, USN
`Lieutenant Colonel John Haymann, MC, USA
`Ensign E. George Butler, MC, USN
`
`

`
`MILITARY MEDICINE, 161, Suppl:3, 1996
`
`Tactical Combat Casualty Care in Special Operations
`
`CAPT Frank K Butler, Jr., MC USN*
`LTC John Hagmann, MC USAt
`
`ENS E. George Butler, MC USN+
`
`U.S. military medical personnel are currently trained to care
`for combat casualties using the principles taught in the Ad-
`vanced Trauma Life Support (ATLS) course. The appropriate-
`ness of many of the measures taught in ATLS for the combat
`setting is unproven. A l-year study to review this issue has
`been sponsored by the United States Special Operations Com-
`mand. This paper presents the results of that study. We will
`review some of the factors that must be considered in caring
`for wounded patients on the battlefield with an emphasis on
`the Special Operations environment. A basic management pro-
`tocol is proposed that organizes combat casualty care into
`three phases and suggests appropriate measures for each
`phase. A scenario-based approach is needed to plan in more
`detail for casualties on specific Special Operations missions,
`and several sample scenarios are presented and discussed.
`
`Introduction
`M edical training for Special Operations forces (SOF) corps-
`men and medics is currently based on the principles
`taught in the Advanced Trauma Life Support (ATLS) course.’
`The ATLS guidelines provide a standardized, systematic ap-
`proach to the management of trauma patients that has
`proven very successful when used in the setting of civilian
`hospital emergency departments, but the efficacy of at least
`some of these measures in the prehospital setting has been
`questioned.2-2g
`Even less certain is the appropriateness of extrapolating ATLS
`guidelines without modification to the battlefield: some of the
`shortcomings of ATLS in the combat environment have been
`addressed by military medical authors.21*30-36 The prehospital
`phase of caring for combat casualties is critically important,
`since up to 90% of combat deaths occur on the battlefield before
`the casualty ever reaches a medical treatment facility (MTF).37
`The importance of this issue was recognized by the Commander
`of the Naval Special Warfare Command in 1993 when he called
`for a study on combat casualty care techniques in Special Op-
`erations. The need for this research was validated by the United
`States Special Operations Command (USSOCOM). A a-year
`study of this issue was subsequently funded by USSOCOM and
`accomplished through literature reviews and multiple work-
`shops with SOF physicians, corpsmen, and medics. This paper
`presents the results of that study. A parallel and independent
`effort was found to be underway in the United Kingdom, where
`a moditied ATLS-type course is being developed for use by the
`British Special Air Service and Special Boat Squadron (personal
`
`*Naval Special Warfare Command, Detachment Pensacola, Naval Hospital,
`Pensacola, FL 32512.
`t Casualty Care Research Center, Uniformed Services University of the Health
`Sciences, Bethesda, MD 20814.
`t Uniformed Services University of the Health Sciences, Bethesda, MD 20814.
`The opinions expressed are those of the authors and should not be construed as
`representing the onlcial positions of the Departments of the Army or the Navy.
`This manuscript was received for review in September 1995. The revised manu-
`script was accepted for publication in March 1996.
`
`communication, Dr. John Navein, former Senior Medical OffI-
`cer, 22nd Special Air Service Regiment).
`Figures 1 through 4 describe several representative casualty
`scenarios that might be encountered in the conduct of Special
`Operations and illustrate the complexity of the casualty care
`that must be rendered by SOF corpsmen and medics, The need
`to consider signtficant modifications to the principles of care
`taught in ATLS is obvious when considering the management of
`these scenarios. Factors such as enemy fire, medical equipment
`limitations, a widely variable evacuation time, tactical consid-
`erations, and the unique problems entailed in transporting ca-
`sualties that occur in Special Operations all must be addressed.
`In addition, greater emphasis needs to be placed on the man-
`agement of penetrating trauma, since most deaths in a combat
`setting are caused by penetrating missile wounds3’ Although
`the Department of Defense is aggressively pursuing new tech-
`nologies that may result in improved management of combat
`trauma,38 the most important aspect of caring for trauma vic-
`tims on the battlefield is well-thought-out planning for that
`environment and appropriate training of combat medical per-
`sonnel.
`Initial training for SOF corpsmen and medics is currently
`conducted at the 18 Delta Medical Sergeants Course taught at
`Fort Sam Houston in San Antonio, Texas, although a move to
`the new Special Operations Medical Training Center in Fort
`Bragg, North Carolina, is planned for the near future. The 18
`Delta course structures its trauma care around the principles
`taught in ATLS. These principles are supplemented by trauma
`care training in a field environment, but the departures from
`ATLS appropriate for the battlefield have not been systemati-
`cally reviewed and presented in the literature. In addition, many
`of the unique operating environments and missions encoun-
`tered in Special Operations are not addressed. Another consid-
`eration is skills maintenance. After completion of their initial
`training, SOF corpsmen and medics are generally assigned to
`small operational units (SEAL platoons or Special Forces A
`teams), which are required to conduct training in a wide variety
`of combat skills and to participate in numerous training exer-
`cises and operational deployments, Usually lacking from this
`intense training regimen is an ongoing exposure to victims of
`penetrating trauma, so the skills learned in their initial combat
`trauma care training are very infrequently utilized in the ab-
`sence of armed conilicts. Some individuals attempt to supple-
`ment their unit training with rotations in a trauma center or by
`moonlighting as paramedics, but the intense operational tempo
`maintained in most SOF units has historically severely limited
`the effective use of either of these options.
`Bearing these considerations in mind, this paper will begin by
`attempting to describe a basic casualty-management protocol
`that is appropriate for the battlefield. Necessary modifications to
`the basic management protocol will then be discussed for each
`of the four scenarios mentioned previously.
`
`3
`
`Military Medicine, Vol. 16 1, Supplement 1
`
`

`
`4
`
`Tactical Combat Casualty Care in Special Operations
`
`Ship attack operation launched from coastal patrol craft 12 miles
`out
`One-hour transit in two Zodiac rubber boats
`Seven swim pairs of SEALS
`Zodiacs get wlthin 1 mile of the harbor
`78°F water (divers wearing wet suits)
`Surface swim for a half-mile, then begin dive with closed-circuit
`oxygen SCUBA
`One swimmer shot in the chest by patrol boat as he surfaces to
`check his bearings in the harbor
`Wounded diver conscious
`
`Fig. 1. Scenario 1.
`
`Twelve-man Special Forces team
`Interdiction operation for weapons convoy
`Night parachute jump from a C- 130 aircraft
`Four-mile patrol over rocky terrain to the objective
`Planned helicopter extraction near target
`One jumper sustains an open fracture of his left tibia and fIbula
`on landing
`
`pig. 2. Scenario 2.
`
`Stages of Care
`
`In making the transition from the standards of ATLS to the
`SOF tactical setting, it is useful to consider the management of
`casualties that occur during SOF missions as being divided into
`three distinct phases.
`1. “Care under fire” is the care rendered by the medic or
`corpsman at the scene of the injury while he and the casualty
`are still under effective hostile fire. Available medical equipment
`is limited to that carried by the individual operator or by the
`corpsman or medic in his medical pack.
`2. “Tactical field care” is the care rendered by the medic or
`corpsman once he and the casualty are no longer under effective
`hostile fire. It also applies to situations in which an Injury has
`occurred on a mission but there has been no hostile fire. Avail-
`able medical equipment is still limited to that carried into the
`field by mission personnel. Time prior to evacuation to an MTF
`may vary considerably.
`3. “Combat casualty evacuation care” is the care rendered
`once the casualty (and usuaIly the rest of the mission personnel)
`have been picked up by an aircraft, vehicle, or boat. Additional
`medical personnel and equipment that have been pre-staged in
`these assets should be available at this stage of casualty man-
`agement. The term “CASEVAC!” (for combat casualty evacuation)
`should be used to describe this phase instead of the commonly
`used term “MEDEVAC” for reasons that will be explained below.
`
`Basic Tactical Combat Casualty Management Plan
`
`Having identified the three phases of casualty management ln
`a tactical setting, the next step is to outline in a general way the
`care that is appropriate to each phase. The basic tactical casu-
`alty management plan described below is presented as a generic
`sequence of steps that wilI probably require modification in
`some way for almost any casualty scenario encountered in Spe-
`cial Operations. This is expected and necessary, but the basic
`plan is important as a starting point from which development of
`specific management plans for the scenarios to be discussed
`later may begin.
`
`Military Medicine, Vol. 161, Supplement 1
`
`Care under Fire
`A more complete description of the SOF tactical setting will
`help provide a better understanding of the rationale for the
`recommendations made for this phase. Care under fire will
`typically be rendered during night operations and will take place
`in the middle of an active engagement with hostile forces. The
`corpsman will be hampered by severe visual limitations while
`caring for the casualty, since the use of a white light on the
`battlefield will identify his position to the enemy and is not
`generally recommended. Night-vision devices may provide some
`assistance, but they are not always carried on night operations
`because of weight and other considerations.
`SOF medical personnel carry small arms with which to defend
`themselves in the field. In small-unit operations, the additional
`fIrepower provided by the corpsman or medic may be essential
`in obtaining tactical fire superiority. The risk of injury to other
`patrol personnel and additional injury to the previously
`wounded operators will be reduced if immediate attention is
`directed to the suppression of hostile fire. The corpsman or
`medic may therefore initially need to assist in returning fire
`instead of stopping to care for the casualty. The best medicine
`on any battlefield is fh-e superiority. As soon as he is directed or
`is able to render care, keeping the casualty from being wounded
`further is the first major objective. Wounded SOF operators who
`are unable to participate further in the engagement should lay
`flat and still if any ground cover is available or move as quickly
`as possible to nearby cover if able. If there is no cover and the
`casualty is unable to move himself to find cover, he should
`remain motionless on the ground so as not to draw more fire.
`There are typicaIly only one or two corpsmen or medics present
`on small-unit SOF operations. If they sustain injuries, no other
`
`‘We&y-four-man Special Forces assault team
`Night assault operation on hostile position in dense jungle
`Estimated hostile strength is 15 men with automatic weapons
`Insertion from rivertne craft
`Three-mile patrol to target
`As patrol reaches objecttve area, a booby trap is tripped,
`resulting in a dead point man and a patrol leader with massive
`trauma to one leg
`Heavy incoming fire as hostlles respond
`Planned extraction is by boat at a point on the river a half-mile
`from the target
`
`Fig. 3. Scenario 3.
`
`Sixteen-man SEAL patrol
`Planned interdiction operation in arid, mountainous Middle
`Eastern terrain
`Two trucks with SAM missiles expected in convoy
`Estimated hostile strength is 10 men with automatic weapons in
`accompanying vehicle
`Helicopter insertion/extraction
`Six-mile patrol to target
`Planned extraction close to ambush site
`While patrol is in ambush position, one patrol member is bitten
`on the leg by an unidentified snake
`Over the next 5 minutes, the bitten SEAL becomes dizzy and
`confused
`Target convoy expected in approximately 1 hour
`
`Fig. 4. Scenario 4.
`
`

`
`Tactical Combat Casualty Care in Special Operations
`
`5
`
`medical personnel will be available until the time of extraction in
`the CASEVAC phase. With these factors in mind, the proposed
`management of casualties in this phase is contained in Figure 5.
`No immediate management of the airway should be antici-
`pated at this time because of the need to move the casualty to
`cover as quickly as possible. It is very important, however, to
`stop major bleeding as quickly as possible, since injury to a
`major vessel may result in the very rapid onset of hypovolemic
`shock. The importance of this step requires emphasis in light of
`reports that hemorrhage from extremity wounds was the cause
`of death in more than 2,500 casualties in Vietnam who had no
`other injuries.3g These are preventable deaths. If the casualty
`needs to be moved, as is usually the case, a tourniquet is the
`most reasonable initial choice to stop major bleeding. Although
`ATLS discourages the use of tourniquets, they are appropriate
`in this instance because direct pressure is hard to maintain
`during casualty transport under fire. Ischemic damage to the
`limb is rare if the tourniquet is left in place for less than 1 hour,
`and tourniquets are often left in place for several hours during
`surgical procedures. In any event, in the face of massive extrem-
`ity hemorrhage it is better to accept the small risk of ischemic
`damage to the limb than to lose a casualty to exsanguination.
`Both the casualty and the corpsman or medic are in grave
`danger while a tourniquet is being applied in this phase, and
`non-life-threatening bleeding should be ignored until the tacti-
`cal field care phase. The decision regarding the relative risk of
`further injury versus that of exsanguination must be made by
`the corpsman or medic rendering care. The need for Immediate
`access to a tourniquet in such situations makes it clear that all
`SOF operators on combat missions should have a suitable tour-
`niquet readily available at a standard location on their battle
`gear and be trained in its use. This may enable them to quickly
`put a tourniquet on themselves if necessary without sustaining
`further blood loss while waiting for medical assistance.
`Transport of the casualty will often be the most problematic
`aspect of providing tactical combat casualty care. Although the
`civilian standard of care is to immobilize the spinal column prior
`to moving a patient with injuries that might have resulted in
`damage to the spine, this practice needs to be re-evaluated in
`the combat setting. Arishita et al. examined the value of cervical
`spine immobilization in penetrating neck injuries in Vietnam
`and found that in only 1.4% of patients with penetrating neck
`injuries would immobilization of the cervical spine have been of
`possible benefit2 Since the time required to accomplish cervical
`spine immobilization was found to be 5.5 minutes, even when
`using experienced emergency medical technicians, the authors
`concluded that the potential hazards to both patient and pro-
`vider outweighed the potential benefit of immobilization.2~21
`Kennedy et al. similarly found no cervical spine injuries in 105
`gunshot wound patients with injuries limited to the calvaria.40
`Parachuting injuries, fast-roping injuries, falls, and other types
`
`Return fire as directed or required
`Try to keep yourself from getting shot
`Try to keep the casualty from sustaining additional wounds
`
`Take the casualty with you when you leave
`
`of trauma resulting in neck pain or unconsciousness should
`still be treated with spinal immobilization unless the danger of
`hostile fire constitutes a greater risk in the judgment of the
`treating corpsman or medic.
`Standard litters for patient transport are not typically carried
`into the field on direct-action Special Operations missions be-
`cause of their weight and bulk. Transport of the patient is cur-
`rently accomplished with a shoulder carry or improvised litter.
`Since there will often be only 8 to 10 men on the operation,
`having additional operators engaged in transporting a wounded
`patient any significant distance presents a major problem.
`There should be no attempt to save the casualty’s rucksack
`unless it contains items that are still critical to the mission. His
`weapons and ammunition should be taken if at all possible.
`
`Tactical Field Care
`The proposed management plan for the tactical field care
`phase is described in Figure 6. This phase is distinguished from
`the care under fire phase by more time with which to render care
`and a reduced level of hazard from hostile tire. The amount of
`time available to render care may be quite variable. In some
`cases, tactical field care will consist of rapid treatment of
`
`1. Airway management
`Chin-lift or jaw-thrust
`Unconscious casualty without airway obstruction:
`nasopharyngeal ah-way
`Unconscious casualty with airway obstruction:
`cricothyroidotomy
`Cervical spine tmmobilization is not necessary for
`casualties with penetrating head or neck trauma
`2. Breathing
`Consider tension pneumothorax and decompress with
`needle thoracostomy if a casualty has unilateral
`penetrating chest trauma and progressive resptratory
`distress
`3. Bleeding
`Control any remaining bleeding with a tourniquet or direct
`pressure
`
`4. N
`Start an 18-gauge N or saline lock
`5. Fluid resuscitation
`Controlled hemorrhage without shock: no fluids necessary
`Controlled hemorrhage with shock: Hespan 1,000 cc
`Uncontrolled (intra-abdominal or thoracic) hemorrhage: no
`N fluid resuscitation
`6. Inspect and dress wound
`7. Check for additional wounds
`8. Analgesia as necessary
`Morphine: 5 mg N, wait 10 minutes; repeat as necessary
`9. Splint fractures and recheck pulse
`10. Antibiotics
`Cefoxittn: 2 g slow-N push (over 3-5 minutes) for
`penetrating abdominal trauma, massive soft-tissue
`damage, open fractures, grossly contaminated wounds,
`or long delays before casualty evacuation
`11. Cardiopulmonary resuscitation
`Resuscitation on the battlefield for victims of blast or
`penetrating trauma who have no pulse, no respirations,
`and no other signs of life wtll not be successful and
`should not be attempted
`
`pig. 5. Basic tactical casualty management plan phase one: care under tire.
`
`Fig. 6. Basic tactical casualty management plan phase two: tactical field care.
`
`Military Medicine, Vol. 161, Supplement 1
`
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`6
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`Tactical Combat Casualty Care in Special Operations
`
`wounds with the expectation of a re-engagement with hostile
`forces at any moment. The need to