Tactical medicine is currently a popular and well-known term. In the Russian Federation, methodological manuals and guidelines are published on this subject, conferences are held.
Let's see where this term came from and why it is so common.
The appearance of the term "tactical medicine" in the Special Forces of the Armed Forces of the Russian Federation
The term tactical medicine appeared in 2009–2013 in the units of the Special Forces of the Armed Forces of the Russian Federation, simultaneously with the receipt of modern foreign samples of medical equipment to provide assistance at the pre-hospital stage.
To use these samples, original training materials were required - the TCCS manual (Tactical Сombat Сasualty Сare) - tactics of providing assistance on the battlefield.
Directly the term "tactical medicine" in combat units came as an abbreviated name for the leadership of the TCCS. During the period 2009-2013, it was obvious that the local application of the TCCS would lead to the further development of military medical training through the application and adaptation of this guide.
In the period 2014–2017 in Russia and a number of other post-Soviet countries, a large number of Russian-language manuals on military medical training were published based on the adapted TSSS manual.
In 2017–2021, the term "tactical medicine" has firmly entered the use of military doctors of the RF Armed Forces and received official recognition.
In 2009–2013, the leadership of the TCCS fell on fertile soil, a number of factors contributed to its widespread dissemination and use in the form of a draft technical translation:
1. An increase in the level of combat training in the Special Forces of the Armed Forces of the Russian Federation.
2. The low level of combat training of graduates of military medical universities arriving for service in the special forces in a number of disciplines: fire training, general and special tactics, topography, engineering training, communications.
3. Inconsistency of the military medical training program with the tasks of the Special Forces of the Armed Forces of the Russian Federation.
4. Long-term disregard by medical and military medical universities of the availability of modern means and methods of providing care in the pre-hospital level. As a result, there is a lack of knowledge and skills among the medical staff in this section.
The combination of these factors revealed the problem of the inconsistency of the level of training of medical graduates with the requirements of combat units and, as a result, the question of the advisability of having a medical staff in combat units has matured. Gaps in education meant that a special forces soldier who completed short courses lasting 1–3 days could be better prepared to provide assistance on the battlefield than a doctor after 7–8 years of training.
The problem of opposing classical military medical training and tactical medicine still exists at this point in time. It is solved by training the medical staff according to modern guidelines and recommendations for providing assistance.
The very process of adaptation of foreign guidelines and treatment and diagnostic algorithms in the systems of civil and military medicine is a standard practice.
International guidelines are more prevalent, often more effective, and have a higher level of credibility from an evidence-based medicine perspective. You can relate differently to foreign experience and leadership, but the fact remains - on the basis of TCCS (Tactical Сombat Сasualty Сare), manuals, guidelines and training programs in military medicine have been created in the RF Armed Forces, are being created and will be created.
Now we come to the following conclusion: the essence of tactical medicine is the adaptation and application of the TCCS (Tactical Сombat Сasualty Сare) leadership to the modern realities of the combat units of the RF Armed Forces.
Management - TCCS (Tactical Сombat Сasualty Сare) 1996
Since the content of tactical medicine is the TCCS manual, further we will analyze the adaptation and use of the primary sources directly - various editions of this manual.
The guidelines were first published in 1996 in the journal Military Medicine. The authors of the article "Tactical Combat Casualty Care in Special Operations" are US military medics - (Captain Frank K. Butler, Jr., MC, USN Lieutenant Colonel John Haymann, MC, USA Ensign E. George Butler, MC).
This work reveals the problem of tactics of providing assistance to victims during special operations. The study was carried out in the interests of the US SOF (US Special Operations Forces).
The essence of the study is the application of the principles of the ATLS (Advanced trauma life support) leadership on the battlefield and the creation, based on the ATLS, of a guide for providing assistance for the US MTR at the prehospital stage. The main analysis of US MTR prehospital care statistics was conducted over the period 1993-1995.
Features of the article and the first edition of the 1996 TCCS manual:
- The analysis and conclusions were carried out in relation to the US Special Forces Special Forces units.
- Factors of complicating the use of ATLS have been analyzed in detail: enemy fire, limited capabilities in medical equipment for US Special Operations Forces units during combat missions, significant variations in the time of medical evacuation, evacuation features by various modes of transport, the problem of providing assistance at night, regardless of the presence or absence NVV (night vision device).
- The problem of non-compliance of the ATLS program (program for training medical personnel of hospitals and hospitals) for military doctors of the US MTR is described in detail.
- The relevance of maintenance of skills by US MTR medics and their insufficient qualifications for effective medical evacuation is indicated, solutions are described.
- The need to monitor saturation (SaO2) and capnogram (etCO2) during air evacuation is indicated to assess the effectiveness of mechanical ventilation (artificial lung ventilation).
- The problem of evacuation by the medical personnel of the unit is described.
- The reasons for the low efficiency of CPR (cardiopulmonary resuscitation) in case of gunshot wounds are described (in the modern version of the TCCS, CPR is the 18th item in the order of events).
- Based on the results of the study, the zoning of the prehospital stage was proposed, depending on the degree of threat from the enemy (under fire, battlefield, tactical evacuation).
- Taking into account zoning, an algorithm is proposed to eliminate life-threatening situations.
- The principles of using some ATLS manipulations (tracheal intubation, immobilization of the cervical spine, etc.) have been revised.
- An algorithm for infusion-transfusion therapy at the pre-hospital stage has been compiled.
- Planning of the most realistic scenarios is proposed for the application of the TCCS.
The basic principles of the first edition of the TCCS manual have been preserved, have been further developed and are relevant at this point in time.
Currently, the TCCS is used by the US MTR, the United States Army, NATO countries and a number of other countries.
Modern editions of TSSS and application in the Special Forces of the Armed Forces of the Russian Federation
Modern editions of the TCCS are built on the basis of statistical analysis to eliminate preventable mortality within the framework of the concept of providing assistance in polytrauma. Elements of post-syndromic therapy of emergency conditions based on the basic principles of resuscitation (MARCH protocol) have been introduced into the primary algorithms of the TCCS.
A distinctive feature of the TCCS is a detailed guide to the algorithm of work on the battlefield and clear zoning of the prehospital stage (assistance under fire, assistance on the battlefield, tactical evacuation).
The TCCS analyzes the most likely (and not desirable) events on the battlefield. In the algorithms for the provision of care, elements of syndromic therapy are used: stopping external bleeding, therapy of hemorrhagic shock (including blood transfusion), elimination of respiratory failure (including mechanical ventilation), prevention of coagulopathy, differential treatment of pain syndrome (narcotic and non-narcotic analgesics, use of an antidote for overdose of morphine, etc.), antibiotic prophylaxis, etc.
This guide is fundamental to prehospital care and is regularly updated and published. Structurally, the TSSS is divided into two parts: the first part is for all military personnel, the second part is for medical personnel. Details of the level of assistance for all categories of trainees can be found in the TCCS table of the list of skills, an example is presented at the end of the article.
The tactical and treatment-diagnostic algorithms are accompanied by a complete nomenclature of the used standard equipment, medical styling and kits. The appendix to the TCCS contains teaching methods with a large number of diagrams and videos.
The main positive features of the TSSS are a pronounced practical orientation, the realism of the proposed tactical scenarios, a detailed nomenclature of the proposed medical property, the availability of a detailed teaching methodology, the standardization of treatment and diagnostic algorithms within the framework of the concept of care for polytrauma, ease of adaptation and application.
Negative factors of the TCCS, in relation to the Special Forces of the Armed Forces of the Russian Federation:
- The TCCS manual is built for a health care system with a higher level of care. In the context of federal standards of care in the Russian Federation, a doctor who has the basic skills of an A&R doctor (anesthesiologist-resuscitator) and a transfusion doctor can fully apply the TCCS algorithms.
- The discrepancy between the categories of medical personnel in the USA and the Russian Federation, the discrepancy in the level of proficiency between similar categories of medical personnel.
- TCCS was originally built within the framework of the features of the MTR and the US Army. These are relatively short contracts for US military personnel. The presence of elements of continuous education in the system of combat training of medical personnel. The absence of a specialized medical education among the representatives of the majority of medical military registration specialties (VUS) in the United States, the presence of several categories of nursing staff, the elitism of the doctor's profession.
The negative factors are indicated in more detail, since they are a stumbling block to the holistic application of the TCCS.
Problems of adaptation of the TSSS leadership in the Special Forces of the Armed Forces of the Russian Federation
Let's sum up the intermediate result: for the Special Forces of the RF Armed Forces, the TSSS is a progressive and implementable leadership.
However, its adaptation and application in the conditions of the Special Forces of the Armed Forces of the Russian Federation encountered a number of problems:
1. Absence of medical staff in the majority of editions of TCCS programs in the category of trainees.
2. A high level of care within the framework of this algorithm, which is fully available in the Russian Federation only to A&R doctors.
3. The need to train medical staff at clinical sites to fully master the skills. For example, the 1996 TCCS manual cites research data that paramedics trained on dummies in ideal operating room conditions with fully relaxed patients had an initial rate of 42% successful intubation.
4. The difference in the systems of categories of medical personnel in the United States and the Russian Federation.
5. The basic (initial) level of leadership of the TCCS in the concept of providing care for polytrauma at the prehospital stage.
6. Problematic issues with the actual norms of the provision of medical property and medicines for the Special Forces of the Armed Forces of the Russian Federation. The problem itself is organizational, since most of the analogues, copies of the nomenclature of medicinal assets and original medicines specified in the TCCS are produced in the Russian Federation.
There are successful examples of adaptation of the TCCS leadership to the systems of military medicine in a number of other countries: England, France, Israel, Poland. At the same time, in the Israeli army, the categories of medical workers are similar to the Armed Forces of the Russian Federation. Also, Israel is one of the few states with a developed system of civil and military health care that recognizes Russian-style medical diplomas.
Polytrauma care concept
For a more holistic understanding of the TCCS leadership, we will briefly analyze the concept within which it is built.
The concept of polytrauma care is international and unified for civilian and military healthcare. The principles of intensive care, resuscitation and emergency surgery are widely implemented in it.
The concept is conditionally divided into two parts: the first part - providing assistance at the pre-hospital stage; the second is the provision of assistance at the hospital stage.
The first section contains two main guides in military and civilian versions: International trauma life support (ITLS) and Prehospital trauma life support (PHTLS). The second section contains the main guide - Advanced trauma life support (ATLS), which has general principles of emergency care for polytrauma in hospital with ITLS and PHTLS.
In the ITLS, PHTLS and ATLS guidelines, the principles of resuscitation and intensive care of emergency conditions prevail, there are a number of surgical procedures. The original word of the original translation of the manuals "trauma" has been replaced by "polytrauma" - for a more accurate transmission of the semantic load.
The concept is systematized according to the sections "treatment tactics", "dosage of drugs" in two directions: the first direction - within the prehospital stage, the second direction - between the prehospital and hospital stages. Within the framework of the ITLS leadership, a number of programs of different levels of study are presented. The presence of related ATLS and ITLS courses, as well as military versions of the ITLS, PHTLS and ATLS manuals, is indicative.
On the basis of the general fundamental guidelines of ITLS and PHTLS and their military versions, a large number of private guidelines (manuals) have been developed, including TCCS. For all categories of medical workers, military, emergency services, training methods are presented, depending on their level of training, indicating the algorithm of actions, the required set of tools, medicines and their dosages. These guidelines are integrated into the military and civilian health care system. They are regularly updated and systematized within the prehospital and hospital stages.
Elements of the concept of rendering assistance in polytrauma are used in the civil health care of the Russian Federation - in the system of trauma centers and sanitary aviation.
From this analysis of the concept, the conclusion follows: TCCS is an entry-level guide in the structure of guides of this concept. For the successful application of the concept at the prehospital stage, it is required to apply military versions of ITLS, PHTLS, ATLS and a number of specialized evacuation courses (ЕМS SAFETY, TNATC, TPATC, CCEMTP, etc.).
Special operations medicine
Special operations medicine is a comprehensive medical support for groups and larger special forces units at the pre-hospital stage when they perform combat missions. Special operations medicine includes a number of courses of medical disciplines:
- anesthesiology and resuscitation with a course of intensive care;
- elements of emergency and outpatient surgery, traumatology, a course of actual dental procedures;
- a course of infectious diseases;
- actual military hygiene and epidemiology;
- special physiology in relation to the activities of special forces;
- course of actual psychology and psychiatry;
- a course in sports medicine.
More detailed content of the subject "Special Operations Medicine" and the latest trends can be found in the specialized edition focused on the US MTR.
It follows from the brief description that the term “special operations medicine” is broader and more specialized than the term “tactical medicine” (and its actual content is the TCCS manual).
It follows from the list of tasks of medical workers in special operations indicated in the previous article that TCCS does not solve all the problems of special operations medicine. That is, the terms “special operations medicine” and “tactical medicine” are not identical to each other.
Tactical medicine is a rapidly developing area. The training of military personnel, junior and middle medical personnel according to the TM methods in the Specialized Forces is an issue that has either already been resolved or will be resolved in the near future.
The main discourse of TM development in SPN: will the adaptation and application of the TCCS (Tactical Сombat Сasualty Сare) manual develop systematically (within the framework of the Federal standards of medical care in the Russian Federation and the concept of care for polytrauma)? Or will TM develop as a separate branch of medicine?
Elements of the concept of polytrauma care are used in the Russian Federation in the system of trauma centers and medical aviation and continue to develop. The use of advanced resuscitation and surgical teams in the prehospital level within the framework of this concept is regulated in foreign sources of military medicine. Advanced resuscitation and surgical teams are the forces and means of the hospital level, which are used to strengthen the pre-hospital level for a limited period of time to perform specific tasks.
The main problem of special operations medicine in the Armed Forces of the Russian Federation at the moment is the preparation of the medical staff of the Special Forces to work in the specified personnel niches:
1. Unit doctor: a medical officer is located directly in the combat formations of the Special Forces, including performing the function of an instructor in military medical training.
2. The doctor of the primary medical center at the prehospital stage.
3. Doctor of the tactical evacuation link: doctor-operator of the resuscitation and evacuation module based on a car / armored vehicle / helicopter.
4. Doctor of the admission / anti-shock department of the primary field hospital.
5. Doctor of the search and rescue group.
The program for the training of a doctor of special education for the specified personnel niches can be implemented either by successively completing additional courses in the system of postgraduate education, or by separating a separate VUS and training in the system of postgraduate education. Both options have both positive and negative sides. The basis of the result is the content of the training program for a specialist in special medicine. The doctor is a fundamental element of special operations medicine.
All information for this article is obtained from open sources.
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