“Ninety percent of casualties that die do so before they
reach medical care” Sgt. 1st Class Clark Hitchcock announced to a group of
students at Camp Bullis. “Ninety-four percent die from hemorrhaging.”
Hitchcock emphasized the point that the first two steps in
combat casualty care are to determine if the patient is breathing and then stop
the bleeding. Hitchcock is the NCO-in-charge of the Combat Casualty Care
Course, also called “C4”, at the Defense Medical Readiness Training Institute
at Fort Sam Houston.
Camp Bullis is where military medical officers learn how to
care for injured in a combat situation. The military course conducts academic
instruction just like any civilian medical school, but sometimes the delivery
of medical care in the military is done under extraordinary circumstances, like
while under fire in a combat environment.
The C4 Course bridges the gap between what civilian-trained
medical students learn about caring for accident victims and what the military
has learned about caring for combat casualties.
Capt. (Dr.) Nicholas Drayer, an orthopedic surgeon assigned
to Madigan Army Medical Center at Joint Base Lewis-McChord, Wash., and a C4
Course student, felt the experience helped him better understand the connection
between pre-hospital care and the follow-on care received in a medical
facility.
“Coming from a civilian medical school we don’t really learn
about combat casualty care and a lot of the principles are different,” Drayer
said. “Understanding the principles of how soldiers are treated at the point of
injury allows the us to better care for
patients down the road. It’s likely my role will be downstream from the point
of injury, but I need to understand what my medics are doing and why they are
doing it so I can better fulfill my role in the team and better train my medics
in a deployed setting.”
Military medical officers from all the armed forces and some
allied nations attend the C4 Course. For some services the course is a requirement
to deploy overseas. In addition to surgeons, orthopedists, neurologists,
internists, and similar medical specialties pharmacists, dentists, physician’s
assistants, nurses and an occasional medical service administrative officer
also attend the course.
The two groups take different routes to the C4. The
dentists, pharmacists, nurses, and others in their group start by attending the
Pre-Hospital Trauma Life Support, or PHTLS, course or the Trauma Nursing Core
Course, or TNCC. The physicians attend the Advanced Trauma Life Support, or
ATLS, course. Students cannot attend C4 without attending one of these
preparatory courses.
Following completion of the preparatory courses, students
merge into a C4 class of approximately 75 students. They are then divided into
three platoons. After students finish the academic phase in the classroom, they
will practice military medicine in simulated combat situations. The students
are issued a high-capacity, hard rubber M-4 rifle and a helmet.
Over the next few days, the students come to appreciate the
challenges faced by medical personnel providing care under battlefield
conditions. The students conduct a simulated patrol, treat casualties while
under fire, and experience the urgency of getting the wounded to higher-level
areas of care. They learn the difference between Medical Evacuation, or
MEDEVAC, and Casualty Evacuation, or CASEVAC. The challenges of providing aid
in the dark during a battle are learned in the Military Operations in Urban
Terrain, or MOUT, simulation center.
There is a sense of urgency as the medical providers see how
combat casualties arrive from the field, are triaged, and prepared for
evacuation to higher medical facilities with greater capabilities.
Capt (Dr.) William Lassiter, a San Antonio Military Medical
Center anesthesiologist who attended the course, believes the course is an
excellent introduction to care in a resource-limited environment.
“I was impressed with the skills and abilities of the combat
medics and corpsmen that I worked with, and I was amazed at the strides that we
have taken to streamline the work and empower those individuals to get
casualties to a higher level of care with the least morbidity and mortality
possible,” Lassiter said.
Capt (Dr.) Zachary Skurski, an Army ophthalmologist assigned
to Walter Reed National Military Medical Center, reflected back on his
experience as a student in the course.
“I was very impressed with the C4 course and its
instructors. The scenarios we trained in drove home the principles of trauma care
and combat medicine. The scale and accuracy of the training to reflect the
reality of combat and mass casualty situations was key. I left feeling prepared
to respond to these situations thanks to the excellent instruction of the
cadre.”
Lt. (Dr.) Jessie Osborne Paull, Walter Reed National
Military Medical Center Navy general surgeon in Bethesda, Md., spoke about the
stages of moving a casualty from active combat to established medical
facilities outside the theater of operations. Then she described the impact of
her training.
“While we know of their (the casualty’s) course through
their medical history, that knowledge is acquired solely through paper; we have
no visceral experience with what they have gone through, from point of injury
to landing on our soil, C4 changed that,” Paull said.
“Going through the lanes and getting a taste, however brief,
of what our sailors, soldiers and medics go through from the point of injury
onwards gave me a new appreciation of just how much is done in such a short
amount of time for our wounded, and the unique challenges our health care
providers navigate to deliver that care,” she added.
“Now when I go to the bedside of our wounded warriors, I
feel a much greater understanding of their course; they are no longer patients
who have simply been flown in from another hospital,” Paull said. “They are
military members who started in a battlefield somewhere with just a medic and
medical bag. Making connections with patients is crucial to successful
healthcare delivery and patient and provider satisfaction. This course provides
that.”