— Do you remember that fighter who used to shout during TCCC classes that he knew everything from Afghanistan and didn’t need all this American bullshit? Do you remember arguing with him about Esmarch’s tourniquet and nalbuphine, which he boasted about? A strongly built guy with gray hair.
— You don’t forget something like that.
— He died. Can you imagine? A mine hit them, he was slightly injured, the tourniquet was perfectly placed, and they ran for a stretcher. While they were running, he injected himself with nalbuphine. He also took something else. In less than an hour, he was already in the hospital. His limb was intact. Everything was intact. But he did not come out of the coma. It was one of the most painful losses during that rotation. Because it was definitely avoidable. But then there was no document that would have regulated this properly. It was the instructor’s word against the soldier’s experience. And then it was up to the soldier’s discretion. Moreover, there could be several instructors within a few months. And, accordingly, several versions of what to do on the battlefield.
...In July of this year, the Ministry of Defense published a number of important orders. These include Order No. 436 “On Approval of the Volumes of First Aid Provided during Combat Operations and Training of the Security and Defense Forces for their Purpose in Tactical Conditions” and Order No. 506 “On Approval of the Lists of Medicines and Medical Devices Provided to the Personnel of the Security and Defense Forces for the Provision of First Aid.”
We talked to Denys Surkov, medical director of the Tactical Combat Casualty Care Course at the All-Ukrainian Council of Resuscitation and Emergency Medical Care, about the country’s ten-year journey toward the standards of first aid, the creation of the School of Tactical Combat Casualty Care, and how all this should influence the number of survivors and their quality of life.
— Denys, how did tactical combat casualty care begin in our country and how did you get involved? Was there any entry point?
— TCCC began with Russia’s attack on us. How I got there is another story.
In the summer of 2014, the wounded were already brought to the Illia Mechnykov Hospital. A traumatologist told me that, unfortunately, they were performing amputations where it could have been avoided: “Simple superficial wounds, and they wrap an Esmarch; a few hours later, the limb is gone...” Now they say that the post-tourniquet syndrome arose with the start of the full-scale war. No, it was back in 2014.
Another wounded man is brought in for amputation with an Esmarch, and he has an unopened Israeli bandage in his pocket. Why didn’t he use it? Because he had no idea what it was. Volunteers gave it to him, but no one told him how to use it.
Later, in July 2014, when the siege of Kramatorsk was lifted, there was a military base on the territory of the airport. The chief of staff of the Airborne Forces was Kryvonos. I think he was not yet a general. Some of the units that held the defense were from Dnipro. Volunteers then bought them a large batch of Israeli bandages. I went to them and in a day gave them some understanding of how to stop the bleeding. I read something, found the TCCC (Tactical Combat Casualty Care) protocols and taught them based on how I imagined it.
Fast forward to late September 2014, I was offered to go to a TCCC course in Munich, at the Bundeswehr Military Medical Academy. The Ukrainian American Medical Foundation paid for several places.
The course is international, there are a lot of people. The load was such that after the obstacle course we just fell. That’s where I got the call sign Flying Man.
Now about the test. We are running through an obstacle course with a two-meter high shield on it and a wounded man behind it. The instructor gets down on one knee in front of the shield and waves to me. He thought we were going to discuss the situation, run around the shield and help him. But I see the shield, I have to storm it. I jumped on the instructor’s knee, on his head, grabbed the shield and went to the wounded man. The instructors, who were watching from the side, were laughing: they had never seen anything like it. In short, I passed the test.
I returned with an understanding of what TCCC was and started teaching a little bit.
— Where did you start?
— At first, it was Kyiv. Then we found a huge bunker for 600 people in Dnipro. A real nuclear bomb shelter, a working one. With ventilation, water, light, six meters of reinforced concrete overhead. If we built such bunkers now, no one would die at all. We taught there mainly for special forces; people didn’t really want to learn.
In December 2021, we were even going to wind down the project, as there were no cadets. But in January 2022, we already had too many people because of the threat of a full-scale war. We didn’t have much time to hold the course in February 2022, it was scheduled for February 25...
— There was no single standard. How did everything happen in the first phase of the war? Did everyone provide aid the way they had learned it somewhere?
— Before the standards were approved, the Armed Forces had a semi-Soviet 1-IS-3. But, for example, the National Guard approved the TCCC back in 2016. And they have always taught it.
In general, everyone understood tactical combat casualty care in their own way. There was, for example, KOLESO, and some other methods. The main problem is that if there is no single standard, there are no uniform training plans and methods.
— At what juncture are we now? What good are the approved volumes of assistance?
— Four levels of pre-hospital care have been approved, which essentially correspond to the levels of the TCCC. We are finally bringing all this to a single standard. The volumes have been approved, and the standards for the first three levels are now being developed. They are called “premedical care” (all service members, ASM, for convenience) and “advanced premedical care” (basic – combat life saver, CLS, medium – combat medic/corpsman, CMC, and advanced – Combat Paramedic).
Paramedics have not been dealt with yet. Premedical care is also not quite a classic ASM. In order to adopt it, we had to rely on something. And so, we adopted a standard based on STANAG AMedP-8.15. Because of that, now we will have a bit of a mix.
At the level of BZVP (Ukrainian for “basic general military training”), it will be essentially the AC (All Combatants) standard. Everyone who receives the VOS-100 (military specialty “rifleman” – L.L.) will have 16 hours of basic training. I think it’s great. Now there are 13 hours, part of which is self-training.
That is, the volumes of assistance, the standard and the model program have now been approved. What remains to be done is an appendix for instructors. Additional hours will be given as part of the basic general military training, and the tactical combat casualty care will be two days long.
The next level, CLS, will be taught to all combat officers. I believe it is going to be a four-day course (although the hours are not yet scheduled) and will be mandatory for teaching at military universities and sergeant courses.
The standards for the next levels are almost ready, the last changes are being made. We have to finalize the standard programs with hours, schedule the skills and develop appendices on teaching methods. I think we’ll be done with this by the end of August or early September. I hope that the first three levels will be fully standardized by the end of this year. That is, the entire package of documents will be approved by orders. Then it will become mandatory.
The main problem was that people were trained in TCCC, they came to the brigades, and the chief medical officer told them: “Why should I do this? Where is it written? I have my own vision and recommendations.”
— There is a lot of talk about how the TCCC protocol was developed during the war in Iraq and is not very well adapted to the conditions of our war. How much has the protocol changed since then?
— First, there was ATLS – Advanced Trauma Life Support, the early hospital stage for doctors. From it, we developed PHTLS – Pre-Hospital Trauma Life Support for civilians at the pre-hospital stage. TCCC is PHTLS Military Edition, that is, the level of pre-hospital care with the addition of battlefield considerations.
At the beginning, there was no division into levels. There was just TCCC. And I went through it. This is the level we now call CMC.
Later on, they realized the main difference between civilian medicine and tactical medicine. The latter is multi-stage. Then the Americans took this protocol and simply broke it down into stages and, accordingly, levels of care and training. In 2016, I think, they developed the AC (for All Combatants) protocol, which we are now building on. And in 2021, we resumed the partition: All Service Members, Combat Life Savers and Combat Medics. There was no fourth level yet, it came into being only last year as a draft and was approved this year.
I happen to have a personal relationship with the main people in the TCCC committee. In particular, with Warren Dorlac, vice president of the Committee on Trauma (American College of Surgeons, Committee on Trauma – they develop all American guidelines for both prehospital and physicians) and with Frank Butler, who is the author of the TCCC.
When we started having these amputations, I said: “Let’s do something because this is not working.” Moving the tourniquets was a level higher than for all the soldiers.
The first level is a course for IQ Grade 5, where the words “or” and “if” are not allowed in the teaching process, i.e., there should be no decision-making branches. That’s why they taught people to put the tourniquets high and tight. Under their conditions, this was the norm. There hadn’t been a single amputation in 20 years, and they didn’t even think it could happen.
Last March, I met with Butler in America, and he wondered why we had so many amputations. I explained: it’s a time factor, we have evacuation delays.
Last August, the TCCC committee had a high-profile meeting on this issue. They allowed both conversion and moving tourniquets in CLS. However, they did not come to a common opinion on ASM, believing that since it is a one-day course, it is impossible to teach it at an appropriate level, which can lead to deaths.
Nonetheless, we solved this issue at the national level. The previous standard was used as the basis. It required moving and applying the tourniquets at once, i.e., 5–8 centimeters above the wound. This is how we do it in terms of volume.
— Why is it important?
— When the tourniquet is placed as high as possible, even if there is an amputation later, prosthetics can’t be used. And if the amputation is low, it can, and the person can return to social life. That is why we made the basic general military training course a two-day one and included targeted tourniquet placement and movement.
Starting from the second level of CLC, you have everything — both movement and conversion.
In general, they do heed our advice, but to justify changes in the protocols, we have to provide real statistics, which we do not have. Why? Because the TCCC card, which should be filled out starting with the first rescuer, is going be introduced only now. Form 100 is currently being filled out. And it’s already there, where the doctor enters the scene. Everything that happened before does not exist on paper. No one knows how many people died from what causes. We know how many limbs were amputated due to the post-tourniquet syndrome. But these are the survivors. And how many died because of unplaced or incorrectly placed tourniquets?
The International Legion has compiled some statistics. They have restrained access to the absolute data, but the relative data is simple. 90% of the dead died of bleeding from limbs, and among them, 90% had either no tourniquet or an incorrectly placed one.
Therefore, I believe that the adoption of volumes is a revolution. Finally, we have systematically paid attention to the pre-medical level, and there is hope that from now on we will have reasonable statistics. Americans are ready to accept this data and change protocols if necessary.
Our TCCC card will be called differently and will be slightly changed because the Americans took certain things into their injury registry. We will have another one, and we are working on it now. Instead of Form 100, there will be a primary medical card, which is currently being developed by the Medical Care Department of the Ministry of Defense.
— The approval of the volumes entails a change in training standards, just as the contents of first aid kits did. They are being developed and will be implemented in all military training centers. I know that in parallel with these processes, the training center where you are the medical director has finally received the official status of the School of Tactical Combat Casualty Care by a separate directive. What makes it unique?
— We are the only ones who teach all levels, including the instructor course. For two and a half years, it was a kind of “you know – I know – you know” game. Because formally, we did not exist. We had signed a memorandum of cooperation with 184 training centers, on the basis of which we taught. It was a volunteer story, although at the same time we were an internationally certified center with more than 45,000 students. And we are the only ones who train instructors.
At the last meeting at the General Staff, this issue was raised: how many instructors of different levels should be available to implement quality training.
There are almost no instructors who would teach CLC in a unified manner. As for the combat medic course, there is professional training provided by 205 training centers, and there is course training, which no one else provides except us. To be more precise, there is course training in the Special Operations Forces, but it is a separate structure.
We now have a formalized 21-day training program for basic level instructors, which has already been attended by more than 200 people. Now we need to write a training program for CLC and SMS instructors. We have the competencies to train all levels. We just need to have the resources to do so. We need to calculate who and how many we need. But this is almost impossible to do until the hourly programs are approved.
— And who are the instructors who are now teaching in the army?
— I don’t know. Their level of competence varies and is not checked in any way because there was no single standard. I don’t know how they are certified either. I know how it is done here. After completing the instructor course, there is a mandatory internship. Depending on the level, there are from two to eight internships. Only then do we write references for the person and submit it to the instructor level.
For ourselves, we have developed a formula: ASM instructor level training takes 21 days, CLS level (if the instructor is potentially capable) takes at least three months of full-time work, and CMC level takes from six to nine months.
Now the school of tactical combat casualty care will mainly be engaged in course training. Sooner or later, we will start conducting professional training for combat medics and issuing medical certificates. We will focus on the systematic training of instructors. This is something no one else is doing today except us.
But no one can say how many specialists are needed. Obviously, there are not enough servicemen in the ranks of the Armed Forces who could cover the need for instructors. But there are people who have already been demobilized for health reasons. Could they be a reserve for instructors? Yes, they could. But they cannot be hired because positions are allocated only for military personnel.
Or, for example, there are women with medical degrees who have children under the age of 14 and work for us on a volunteer basis. Could I officially engage them as instructors? How? I raised this issue during a meeting at the General Staff and talked to a lawyer. There is a legal possibility to do it, but the military unit does not have a budget for such expenses. It’s a dead end. There is a nightmarish shortage of instructors; there are people who could be engaged as instructors, but I cannot make it happen.
We are now launching volumes and programs. And who will implement them? The instructors will be appointed on a random “you, you, and you” basis and will formally report on what is being done. But you can imagine what the quality will be like.
— Are there any risks that your training center will simply be ordered to issue certificates to all those who have been sent there for training? It’s no secret that many military specialties are given in this way, according to the number plan and regardless of exam results.
- No, we won’t do that. The certificate will be honest. This is one of the conditions. We must have the best school in Ukraine with the highest level of education that meets the best standards. Our goal is to get NATO accreditation. We are now looking for motivated people who are ready to join the team on the basis of mobilization or transfer from other parts of the Armed Forces.
— Tactical medicine has made a huge step forward. What do you see as the next step? Besides recruiting people. What other revolutionary measures need to be taken?
— Even if we do not receive NATO certification, I would like us to become what is called a “center of military excellence.” And to have a status that would allow us to create new training programs and implement them in the Armed Forces. For example, there is no medical intelligence and planning in Ukraine in the true sense of the word. Therefore, there is definitely a need for some kind of unification. Because what is currently taught at the military medical academy is the doctrine of the Soviet army.
NATO has such a course, but it is based on their structure and functionality. It would be good if we could have some experts who teach medical intelligence and planning in NATO armies come to us now. So that we could work with them to develop an adapted course for Ukraine.
— Why is it important?
— For instance, the headquarters structure in Ukraine now corresponds to the NATO structure, i.e., down to the corps level, it is the so-called S-structure. It has nine groups, one of which, for example, is the S4 group, which is logistics. And now let’s look at the hands. In this group, all NATO countries have a medical planner or a medical logistician. In Ukraine, there is no such person. Our chief medics are supposed to do this. But this is not their job.
The main problem with evacuation in Ukraine right now is time. I ask everyone: do you have a medical planner in your S4 group? Do you want us to wager that at least one way your medical transport goes empty? Do you realize that non-medical transportation is also empty in at least one direction? And if you have a person from the medical unit in your logistics group who will make sure that the transport does not run empty, how much will the evacuation time decrease on average? Let’s assume it will be halved. It’s a simple organizational decision.
Therefore, in terms of revolutionary and future prospects, we need to introduce the position of a medical logistician in the S4 logistics group and launch training in NATO medical intelligence and planning for all chief medics. This would be a real revolution.