The Evolution of Civilian High Threat Medical Guidelines

The multiple mass killing events over the past five years have become game-changers for the first responder community. Events that were commonplace in other parts of the world have, unfortunately, become an almost routine occurrence in the United States.

The emergency response community has been tackling these events since 9/11. This is the new reality and first responders must be properly prepared to face the challenge.

Despite the evolution in the risk, the preparation and paradigm of civilian operational medical response as a whole hasn’t evolved. Consider the traditional teaching for the reconnaissance and subsequent rescue of wounded victims in scenarios where there’s an ongoing threat. The overwhelming guidance and culture has been scene safety first for medical providers–”staging and waiting” for the all clear.

Considering the past few years and the subsequent knowledge first responders have on both the threat and the rapid nature of the fatalities, it would be reasonable to wonder if the first responders will actually follow the safe staging guidance.

The vast majority of fire and EMS responders, as has been demonstrated several times over the past few years, aren’t satisfied to stand by. They know there are injured in need of immediate care. They know the risk, and with that knowledge they’ve demonstrated a predilection for action. First responders are heroes and, as a whole, they’re going to go to work even when the risk is high.

If these first responders decide to effect life rescue and enter the scene, do they carry in the same items they would bring to a routine medical call–all the different medical bags piled on top of the stretcher with a monitor and oxygen bottle? Are they carrying the right medical and rescue equipment for high threat scenarios?

Has the traditional EMS medical training properly prepared these first responders to provide care under these conditions? There are multiple wounded and dead with the potential for additional explosions or other threats to safety. Are they trained to approach the patient in this scenario? Do they know how to appropriately change from their everyday medicine to a practice that is efficient and appropriate given the ongoing threat?

In essence, the question is whether a gap exists in how civilian first responders both train and respond to operational scenarios with an ongoing threat, direct or indirect, to provider and patient? The answer is simply yes. When considering medical and rescue operations in high threat scenarios, there’s an absolute gap in the traditional training and guidance to medical first responders.

Rejecting the Old Paradigm
Stage and wait? In trauma, time counts. Essentially, every minute with uncontrolled life-threatening traumatic injury decreases the casualty’s chance of survival. This is just common sense, but it also holds true in high threat scenarios.

The Wound Data and Munitions Effectiveness Team (WDMET) study completed in the early 1970s was the first dataset that clearly demonstrated the unique timing of battlefield deaths and emphasized the need for forward medical care. In the examination of a cohort of Vietnam era battlefield deaths, conclusions from WDMET showed that the greatest opportunity for lifesaving intervention on the battlefield is early on. The study showed that 90% of the studied deaths on the battlefield occurred before designated medical care was given to the injured: 42% immediately, 26% within five minutes and 16% within five to 20 minutes.1 That means 84% of the fatalities on the battlefield died quickly, within 30 minutes of their injury.

Additionally, only 10% of the fatalities in the dataset received medical care. The natural assumption then is that those who received care were less likely to die. The summary results from the WDMET study echoed common sense conclusions, “The greatest benefit is achieved through a tactical configuration that puts the caregiver at the patient’s side within a few seconds to minutes of wounding.”1

This conclusion doesn’t endorse the current paradigm of “stage and wait until everything is safe.” Instead, the operational response needs to be configured to get the caregiver to the patient’s side within a few seconds to minutes of wounding. Far-forward placement of medical assets is lifesaving.

The dataset used to define the need for a medical response paradigm shift in the military was actually combined from the WDMET study and Arnold and Cutting’s 1978 paper, “Causes of Death in United States Military Personnel Hospitalized in Vietnam,”2 and published by Champion in 2003 in the Journal of Trauma.3

Has the traditional EMS medical training properly prepared first responders to provide care under high threat conditions, such as the 2013 Boston Marathon bombing where there are multiple wounded and dead with the potential for additional explosions?

Has the traditional EMS medical training properly prepared first responders to provide care under high threat conditions, such as the 2013 Boston Marathon bombing where there are multiple wounded and dead with the potential for additional explosions? Photo courtesy Boston EMS


All causes of battlefield deaths were reported and included devastating injuries such as surgically uncorrectable torso trauma, injury to the central nervous system and blast/mutilating trauma. These injuries cause battlefield fatalities even immediate advanced medical care couldn’t prevent.

However, included in the epidemiology of combat deaths was 9% caused by exsanguination from an extremity wound.3 Also included was 1% from airway obstruction and another 5% from tension pneumothorax, both of which are relatively easy to diagnose and simple to manage in the acute setting. So, 15% of the combat fatalities from three etiologies (exsanguination from an extremity wound, tension pneumothorax and airway obstruction) were readily preventable with simple interventions if applied soon after wounding.

Rapid application of simple, appropriate, stabilizing treatment at or near the site of wounding plus expedient evacuation to closest appropriate medical facility, equals maximal survival rate for those injured. It’s just common sense.

Evolution of Combat Care
Essentially, the current concept is point of wounding care; rapidly provide stabilizing treatment where the wounded lies before evacuating to care. As with all advanced concepts in trauma care, the military leads the way through care of the wounded on the battlefield. U.S. military medics have been deploying to provide combat rescue and medical care since Union Army surgeon Jonathan Letterman deployed his ambulance corps during the Civil War’s Battle of Antietam.4

However, prior to the 1990s, there was no truly defined set of medical guidelines or rules specific to the battlefield. Combat medics were taught to manage battlefield injury using the same medical paradigm that was taught to civilian EMTs and paramedics.

The problem was that civilian prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) courses were developed to manage the common injuries and operational considerations encountered in the civilian trauma setting. Although the pathophysiologic process of dying is the same, these civilian medical courses failed to account for the unique considerations around trauma resuscitation in combat: the high lethality and high energy wounding pattern, multiple causes of wounding, preponderance of penetrating injury, persistence of threat, austere and resource constrained environment, and delayed access to definitive care.

High threat medical principles apply widely across multiple agencies including law enforcement, fire and EMS.

High threat medical principles apply widely across multiple agencies including law enforcement, fire and EMS. Photo courtesy E. Reed Smith


As a result of several high-profile, high-fatality operations in the military special operations community, the U.S. Navy funded a study in the early 1990s to examine the military paradigm of combat medicine and the application of civilian medical standards in the combat environment.

The results demonstrated significant issues with the application of civilian medical principles to the battlefield, especially the lack of provisions to allow for prioritization of the management of casualties with the ongoing threat and the ongoing combat mission.

The study’s conclusion was that the military needed a new paradigm for combat medicine and, in 1996, Frank Butler Jr., MD; Colonel John Hagmann and Ensign George Butler created and published military-specific combat medical guidelines called “tactical combat casualty care” (TCCC).5

The TCCC guidelines represented an operational paradigm that allowed for the prioritization and application of medical care on the battlefield addressing the three preventable causes of death identified in the post-Vietnam fatality studies while accounting for limitations and conditions of ongoing combat.

TCCC was quickly adopted throughout the special operations community, and, since the mid-2000s, was adopted throughout all branches of the military for deploying military personnel.

TCCC guidelines have been one of the major factors in reducing preventable death on the modern battlefield: the case fatality rate in current combat operations has decreased from approximately 15% in Vietnam to 7.6—9.4% during Operation Iraqi Freedom and Operation Enduring Freedom.6

In a memorandum dated Aug. 6, 2009, the Defense Health Board made note of several special operations where all members were trained in TCCC and had no reported incidents of preventable battlefield fatalities during the entirety of their combat deployments. American forces are now down from 9% to 2—3% killed in action due to exsanguination from an extremity wound; down from 5% to less than 1% killed from open/tension pneumothorax; and remain around 1% killed in action from airway obstruction (but these airway issues are more complex than those of the past).7

More than 10 years of data have presented continuing evidence to support TCCC. The guidelines are well known, well supported and ingrained throughout the military. The proven success of TCCC on the battlefield has led the civilian medical community, both tactical and conventional, to closely examine the tenants and consider integration of TCCC into civilian trauma care.

From Combat to Civilian
Is TCCC the right fit as a new civilian operational paradigm? It’s clear that current fire and EMS operational medical response is inadequate for atypical high-risk emergencies, and it would seem that because the bullets and bombs are the same, TCCC principles and practices should work in civilian operations as well. However, when truly considering the inherent differences between civilian and military operations, battlefield guidelines don’t seamlessly translate to civilian operations.

TCCC is based on evidence gleaned for an overall young and healthy 18—45-year-old military combat population. These soldiers aren’t obese. They don’t have diabetes or asthma or take aspirin, Motrin, Coumadin or Plavix. They aren’t pregnant. They aren’t elderly and they aren’t kids.

TCCC was written for the military combatant treating the military population in the combat environment, working under military rules, military liability and military laws. Thus, applying en bloc the military TCCC medical guidelines to civilian settings has the same fundamental inadequacies, albeit in reverse, as applying civilian ATLS and PHTLS to the combat environment. Combat doctrine doesn’t account for the civilian specificities, even for high-speed SWAT and tactical law enforcement operations.

Table 1 lists some of these differences that are unaccounted for in TCCC. To begin with, each branch of the military is essentially one system with one scope of practice and one set of protocols applied across the board. In the civilian system, from jurisdiction to jurisdiction, region to region and state to state, there are different scopes of practice, protocols, operations, culture and liability. The civilian patient demographics are much wider and include pediatrics, geriatrics and other special populations.

Characteristics that distinguish civilian from military high threat prehospital environments

The baseline health of the civilian population is much worse and is complicated by polypharmacy, which has a direct effect on and is affected by trauma interventions. The medical supply resources and availability of transport assets and barriers to evacuation are also different. Wounding patterns are different. Even equipment and supply acquisition is much different. The military can dictate what all providers in all areas of operations and services have to use. For civilians, the selection and acquisition of equipment alters jurisdiction by jurisdiction, agency by agency.

Finally, the inherent military combat language of TCCC is different than civilian language. Civilians need a framework utilizing common operating language that can be applied across all first responder disciplines. Terms such as “care under fire” and “tactical field care” may be acceptable for law enforcement operations but are easily misunderstood to imply an unacceptable conditional threat and are thus easily rejected by other response disciplines.

Common language is essential across all disciplines during high threat response. Although a common argument by military TCCC personnel to civilians is to emphasize the principles and not to “get caught up in the language,” those with true civilian multidisciplinary operational experience understand the need for even the most simple generic common operating terms.

In 2005, several civilian first responder entities began discussing how TCCC could be transitioned into a civilian-appropriate format. In 2008, the George Washington University and Arlington County (Va.) Fire Department coined the term “Tactical Emergency Casualty Care (TECC)” for the translation of TCCC into a set of guidelines for use by civilian first responders in high threat scenarios. Emergency is a civilian term; combat is a military term.

The concepts in each set of guidelines are the same, but the language and the focus are different. As part of the process, development and continued evidence-based and best-practice-based growth of the civilian TECC guidelines, the founders of the TECC concept established the Committee for Tactical Emergency Casualty Care (CTECC)–a nonprofit committee of civilian operational experts. These experts first met in 2011 and established the first set of TECC guidelines by changing TCCC to civilian language and focus.

CTECC works as a nonprofit and nonproprietary grassroots effort to create and maintain a set of high threat medical guidelines that are open to and shared with all first responders.8

TECC is a medical care framework for high threat operations based upon the military dogma of TCCC, but adapted to allow for civilian language, protocols, population, scope of practice and operational constraints.

TECC isn’t in competition with TCCC, it’s the evolution of TCCC into the civilian realm. They’re the same principles and practices translated and evolved for civilian use and operations.

Adaptable Guidelines
Given the need for diverse operational protocols and considerations, TECC can be considered to be a set of bricks. As a whole, the military TCCC is dogma, applied without change despite operational or provider considerations. For civilian application, TECC is designed to allow for different agency-specific adaptations. Each agency should take the TECC “bricks” that fit into their protocols, scope, culture, liability, mission and operational considerations to build a high threat medical response program. In addition, each agency must select the right equipment and hemorrhage control items that best suit their clinical and operational needs. (See “Selecting Hemostatic Dressings: The decision-making process for wound control.”)

By using only the parts of the guidelines that fit into the agency’s needs, each TECC application will be slightly different and specific to the agency. However, overall, the application between agencies will be the same.

Although there are some generic TECC courses currently being taught, there’s no official TECC course, no need for instructor certification or for an official TECC provider course or card. TECC is less about what to do and more about when (or when not) to do something. The medical interventions inherent to TECC are common everyday trauma interventions standard to almost all prehospital providers. It’s the integration of these guidelines into an agency’s standard operating procedures that’s the foundation of TECC. Instead of a premade course, operationalizing TECC should be done in a manner unique to each agency.

The goals of TECC are to establish a medical care framework that balances the threat, the civilian scope of practice, the differences in civilian population, the medical equipment limits and variable resources for all atypical emergencies and mass casualties, to provide aggressive forward deployment and principles for point of wounding care in high threat and mass casualty environments, to provide care guidelines and account for the ongoing threat in operations and minimize the provider and patient risk while maximizing patient benefit.9

Individual first aid kits–with all supplies visible–are invaluable when care is needed rapidly.

Individual first aid kits–with all supplies visible–are invaluable when care is needed rapidly. Photo A.J. Heightman


To address needs of the civilian population and mission that differ from the military, the TECC guidelines specifically address the care of pediatric patients in high threat environments. (See “Preparing for the Unthinkable: Tactical Emergency Casualty Care pediatric guidelines.”) There’s emphasis on the treatment of civilian-specific conditions such as smoke inhalation and civilian-specific operational considerations, such as priority and destination triage and establishing casualty collection points. And, similar to the “all hazards” approach of civilian fire and EMS service, TECC is a set of high threat principles for all operational hazards to be applied in any operational scenario where there’s an ongoing threat to the provider and patient.

TECC guidelines aren’t only for trained medical personnel. They can be easily limited to any scope and should be taught to all provider levels. In mass casualty scenarios, uninjured citizens often step forward to initiate care for the wounded.

These “first care providers” are one of the most important links in the TECC chain of survival for victims. Teachers, librarians and office workers should be taught appropriate level TECC principles. Law enforcement patrol officers are an untapped medical resource in mass casualty incidents and should be taught as well–not only for injured citizens but to also care for injured officers.

There are programs being implemented across the United States to do just that. In northern Virginia, during the second half of 2013, every patrol officer in northern Virginia law enforcement agencies–more than 4,000 total officers–were taught the TECC principles modified to the patrol officer scope of practice and were given a personal TECC individual first aid “blow out” kit, also referred to in many departments as an “individual first aid kit.”

Because the word “tactical” is in the name, many civilian operational personnel are under the misconception the intended audience is only law enforcement or specialized SWAT medical providers. “Tactics” are operational considerations and are used every day in normal fire and EMS operations. The word “tactical” is used not to limit TECC application to law enforcement operations, but to mean medical decisions that both have an effect on and are affected by any high threat operation.

The TECC guidelines are multiagency, multispecialty evidence- and consensus-based. TECC is civilian driven and civilian appropriate.

Its guidance, appropriate for use by all disciplines of first responders and first care providers in any scenario where there’s significant ongoing operational risk to providers and patients. It’s vetted, evolving and a great venue for future research.

The implications of high threat medical principles apply widely across law enforcement, fire and EMS operations. The principles should be built into the operational response for incidents including, but not limited to, active shooter/active killing events, medical response to explosive mass casualty, patrol officer first aid, SWAT/tactical medicine programs, technical rescue operations, wilderness medicine settings and large-scale mass casualty to identify and treat those casualties with preventable causes of death as soon as possible at or near the point of wounding to improve survivability and keep the victim alive long enough to get them to definitive medical care.

1. Wound Data and Munitions Effectiveness Team: The WDMET Study. Uniformed University of the Health Sciences: Bethesda, Md., 1970.
2. Arnold K, Cutting RT. Causes of death in United States military personnel hospitalized in Vietnam. Mil Med. 1978;143(3):161—164.
3. Champion HR, Bellamy RF, Roberts CP, et al. A profile of combat injury. J Trauma. 2003;54(5 Suppl):S13—S19.
4. Musto R J. The treatment of the wounded at Gettysburg: Jonathan Letterman: The father of modern battlefield medicine. Gettysburg Magazine. 2007;Issue 37.
5. Butler FK Jr, Hagmann J, Butler EG. Tactical Combat Casualty Care in Special Operations. Mil Med. 1996; 161(Suppl 3): 1—16.
6. Gerhardt RT, De Lorenzo RA, Oliver J, et al. Out-of-hospital combat casualty care in the current war in Iraq. Ann Emerg Med. 2009: 53(2): 169—174.
7. Eastridge BJ, Mabry RL, Sequin P, et al. Death on the battlefield (2001-2011): Implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431—S437.
8. Callaway DW, Smith ER, Cain J, et al. The Committee for Tactical Emergency Casualty Care (C-TECC): Evolution and application of TCCC guidelines to civilian high threat medicine. J Spec Oper Med. 2011; 11(2): 84—89.
9. Callaway DW, Smith ER, Cain J, et al. The Committee for Tactical Emergency Casualty Care (C-TECC): Evolution and application of TCCC guidelines to civilian high threat medicine. J Spec Oper Med. 2011; 11(3): 104—122.


  • E. Reed Smith, MD, FACEP, is operational medical director for the Arlington County (Va.) Fire Department and an associate professor in the Department of Emergency Medicine at George Washington University. He may be contacted at

  • David W. Callaway, MD, FACEP, is director of operational and disaster medicine in the Department of Emergency Medicine at Carolinas Medical Center. He may be contacted at

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