When it comes to our military, Americans expect the best. We expect the best weapons, the best-trained soldiers, the latest and best equipment, and we fully expect to be the best fighting force in the world. And when our men and women in uniform are wounded in combat, we definitely expect them to receive the best medical care possible. When they do not, we expect heads to roll. What happened when housing for wounded servicemen at Walter Reed was found to be substandard in 2007? The hospital commander and the Army surgeon general were both quickly relieved of command.

The battlefield is a bit different. We expect the medical care received there to also be the best, sure, but who is it that defines what constitutes the best combat medical care? And just who is responsible for making sure that the medical care our fighting men and women receive meets that high standard? Military medical personnel command military hospitals, but U.S. troops are not wounded in military hospitals. They are wounded on the battlefield, and combat commanders own the battlefield. So who should be held responsible for making sure that our fighting men and women receive the best care? Medical personnel or combat commanders?

The birth of modern combat casualty care

In October 1993, a mostly special operations-led force of U.S. military units fought a fierce battle against Somali fighters in the Battle of Mogadishu, famously depicted in the book and movie “Black Hawk Down.” The relentless street-to-street fighting resulted in the deaths of 18 U.S. servicemen. An Army special missions unit medic during that battle, Specialist First Class Bob Mabry, was one of the combat rescue team members who fast-roped down to the first helicopter crash site and provided care under fire to the wounded for 15 hours.

Later, Second Lieutenant Bob Mabry, by then a medical student at the Uniformed Services University of the Health Sciences (USUHS), would write a paper that described the casualties sustained in Mogadishu and the shortfalls in casualty care that he observed during the action. Later still, fully 21 years after the Battle of Mogadishu, Lieutenant Colonel Bob Mabry, now an Army emergency medicine physician and a leading thinker in combat medicine, would author another paper titled “Challenges to Improving Combat Casualty Survivability on the Battlefield” that would highlight some of the reasons behind the shortfalls in pre-hospital trauma care.

Mabry observed, “Responsibility for battlefield care delivery is distributed to the point where seemingly no one ‘owns’ it. Unity of command is not established, and thus no single senior military medical leader, directorate, division, or command is solely focused on battlefield care, the quintessential mission of military medicine.” Furthermore, when “best-practice” medical care guidelines are developed for battlefield injuries, who is responsible for implementing them?

During roughly the same timeframe as the Battle of Mogadishu, but initially unrelated to that action since details regarding those casualties were not made public until later, a three-year research effort in battlefield trauma care was being conducted by the Naval Special Warfare Command, the parent command of the Navy’s SEAL teams, in partnership with USUHS, and later, with the U.S. Special Operations Command (SOCOM). That project—for the first time—brought evidence-based medicine to the study of battlefield trauma care, and resulted in the 1996 publication in Military Medicine of one of the seminal papers in the history of U.S. military medicine, “Tactical Combat Casualty Care in Special Operations.”

This 1996 tactical combat casualty care (TCCC) paper took what at the time was a unique approach, in that it took into account the unique aspects of casualty treatment in the tactical environment, and recognized the need to make battlefield trauma care consistent with good small-unit tactics. TCCC broke battlefield trauma care into three phases: care under fire, tactical field care, and casualty evacuation care, with prescribed care for each phase.

For example, TCCC emphasized that, first and foremost, one should maintain tactical awareness and return fire as needed during a gunfight, to prevent both the casualty and the medic from being killed by hostile fire, and to help prevent more unit members from being wounded or killed.