FORT LEAVENWORTH, Kan. (Jan. 25, 2016) -- The Army is looking to save Soldiers' lives by making Tactical Combat Casualty Care, also known as TC3, training more realistic and accessible. Those efforts stem from an ongoing Army study, Squad Overmatch-TC3, which is exploring ways to improve warrior skills, achieve squad overmatch and save lives through cutting-edge learning techniques and state-of-the-art simulation technologies.

One of the study's findings was that Soldiers lack access to realistic TC3 simulation that could improve the individual and collective skills Soldiers and squads need to manage the complex environment of simultaneous combat and casualty management.

Squad Overmatch-TC3 training draws on the Army's experiences from Iraq and Afghanistan, said Maj. Gen. Mark J. O'Neil, deputy commanding general of the Combined Arms Center-Training, or CAC-T.

"Now the Army is taking those lessons learned and making them part of training. We need to have tough, realistic training to improve readiness and most important of all -- save Soldiers' lives," said O'Neil. CAC-T fields training systems, delivers leader training and sustains training capabilities.

During the wars, the Army's care for wounded Soldiers improved. At the start, 90 percent of casualties survived their wounds. Eventually, medical advances, command emphasis, improved evacuation and better training pushed survival rates up to 97 percent.

Yet other statistics from the recent wars point to areas for improvement:
• 87 percent of casualty deaths occurred before the casualty reached a medical treatment facility in the prehospital setting.

• Of the 1,096 casualty deaths from October 2001 to June 2011, 24 percent of the casualties who died in the prehospital setting potentially could have survived with the right assets and training.

• For Army Rangers, the rates for died of wounds and killed in action were 1.7 percent and 10.7 percent respectively. For conventional forces, the rates for died of wounds and for killed in action were 5.8 percent and 16.4 percent respectively.

The statistics underscore the importance of command emphasis and realistic combat casualty care training for all Soldiers, said Col. (Dr.) Daniel Irizarry, who has served as an 82nd Airborne Division brigade surgeon and a special operations battalion surgeon. He is a senior advisor to the Squad Overmatch TC3 study.

"While the Rangers have some unique combat enablers, the truth is that in the prehospital setting, survival in the first 10 minutes does not require advanced technology," Irizarry said. "It requires command emphasis, individual and collective training, and available individual first aid equipment."

Every Ranger receives individual training above the Army standard in stopping bleeding, opening airways and other life-saving skills, Irizarry said.

These skills are practiced in collective training events to reinforce the teamwork required to manage casualties effectively while continuing the fight. Ranger leaders also are trained in and held accountable for the commander's casualty response system.

"Now we need to spread similar concepts throughout the force," he said.

Irizarry is also the clinical adviser to the Army Program Executive Office for Simulation, Training and Instrumentation, or PEO-STRI. The Orlando, Florida, organization develops, acquires and sustains simulation, training, testing and modeling solutions. PEO-STRI and CAC-T collaborate to develop and field training devices to support the Army.


The Squad Overmatch-TC3 training methodology and technologies aim to make three days of progressive training more realistic through:
• Lectures and classroom demonstrations at the crawl stage.
• Video game-based virtual simulations at the walk stage.
• Live training at the run stage.

"The first day starts with time in the classroom where Soldiers learn the basics of advanced situational awareness, team dimensional dynamics, resilience training and TC3. But this training cannot be death by PowerPoint," Irizarry said.

"Soldiers need active training and they'll get that by analyzing and discussing simulated situations based on real experiences and practicing individual skills on a combat trauma mannequin." Irizarry noted one example of how Soldier TC3 training is ripe for improvement.

"The current Army standard for Warrior Skills training requires Soldiers to practice applying a tourniquet on their battle buddy. This is flawed because first, your buddy is not bleeding, and second you can't tighten a tourniquet tight enough because it is too painful," he said.

"In fact, this is actually negative training because in combat, you tighten tourniquets until the bleeding stops, which may require more than one tourniquet," Irizarry said.

To address this need, today's fielded combat casualty mannequins breathe, bleed and are visually modeled to be extremely realistic to show severe trauma. Their realism helps Soldiers get past the visual shock of war trauma to assess and identify life-threatening bleeding. They learn to apply tourniquets until the device's simulated bleeding stops.

"And that's exactly what a Soldier has to do on the battlefield, move past the horror, search for the bleeding and treat it," he said.

Besides teaching the correct way to apply a tourniquet, the training device helps Soldiers learn how to properly treat other preventable causes of battlefield death by placing a chest decompression needle and opening an airway with a nasal tube.

Today's combat medic (68W) training uses similar devices in training and validation at the Army Medical Simulation Training Centers, but there are not enough training devices to reach every Soldier.

A day of classroom training is followed by a day with video game scenarios in which Soldiers are immersed as avatars in the Army's flagship gaming program, Virtual Battlespace 3, or VBS3, to conduct missions.

Enhanced with a future TC3 plugin, VBS3 soon will allow for realistic casualty treatment by first responders, which creates the drive for squad coordination and reinforces individual skills for effective casualty management.

The Army is also developing a new TC3 stand-alone game for first responders that will build the knowledge skills required to decide how to treat casualties properly in the context of effective fire and in secure locations.

These game-based programs will provide higher-fidelity distributed training for medics and Soldiers. Both programs will be available later this year.


On the third day, Soldiers train in field exercises at local training sites augmented by Squad Overmatch technologies, combining combat operations with casualty care management using the Army's Multiple Integrated Laser Engagement System, or MILES.

To add realism, the Army is looking at replacing the 30-year-old paper MILES Casualty Card. The cards only reflect the moment of injury, but the new dynamic MILES Casualty Display Device, or MCDD, changes over time with treatment.


During the operation, when a Soldier is wounded, the MILES alarm will activate. Then the MCCD will automatically display the Soldier's wounds, pulse, pain, respiration as well as the abilities to shoot, move and communicate.

This starts an internal clock for treatment. The Soldier or the first responder must assess the card, decide the right treatment and apply it. The MCCD communicates with modified tourniquets, nasal airways tubes and chest decompression needles found in the Soldier's first aid kit that automatically changes the card to reflect the treatment's application.

"If Soldiers wait too long to apply the tourniquet, then the wounded Soldier bleeds out and the MCCD changes to dead," Irizarry said. "Apply it correctly, within time and the Soldier lives. That's realistic."

The MILES system sends data from the field to a commander for an After Action Review. Augmented with treatment data, the system begins to give leaders feedback on the commander's casualty response system -- a key feedback loop in Ranger training.

Incorporating casualty care into live training also helps leaders develop decision-making skills in a complex environment. "The squad sergeant or platoon lieutenant has to decide: How do I keep up the fight and treat the wounded at the same time?" Irizarry said.

The new video game and live training TC3 technologies represent the Army's effort to make home station training more realistic and challenging.

Coordinating with the Army Medical Department, proponent for first aid Warrior Skills training, CAC-T and PEO-STRI are working quickly to field an exportable TC3 training package. The training package could touch up to 294,000 Soldiers per year with better, more realistic training at home stations, Combat Training Centers and training institutions such as Basic Combat Training.

"By integrating these innovations, the Army can enhance training, improve unit performance and develop agile, adaptive leaders," O'Neil said. "And this type of training will save Soldiers' lives."