← Journal of Special Operations Medicine - Podcasts
Journal of Special Operations Medicine - Podcasts
JSOM Conversations with Sam Patrick | Dr. Frank Butler on Tactical Combat Casualty Care
00:31:43
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- [00:00]
A
Good day, everybody. Welcome to the inaugural episode of the Journal of Special Operations Medicines Conversations with Sam Patrick. I'm your host, Sam Patrick. This podcast is designed to sit down with some of the the heavy hitters in the world of special operations medicine, or medicine in general that may have a nexus to the the community that is trying to do good medicine in bad places and how we can potentially help those who are doing that job right now with some lessons learned or stories or whatever else that may come up. We want to thank The Honor foundation www.honor.org for helping us bring this to you guys. It's a phenomenal foundation that focuses on helping service members as they transition out and figure out what their next mission is in life. So again, if you're curious about what they do or any ways you can help or going through the program yourself, check them out@horor.org all right, today's episode, I'm super thrilled to introduce somebody that probably needs no introduct, but Dr. Frank Butler. Dr. Butler is one of the the founding fathers or creators of the concept of tactical combat casualty care that many of us have used ourselves throughout our careers since we do not have the hours upon hours upon hours to go through the complete history of tactical combat casualty care. And I encourage you to check out his book, tell them yourself, it's not your day to die, written by Frank Butler, Kevin o' Connor and Jeff Butler. You can get that on the JSOMS website if you need. The goal of this episode is to look forward and see how we can inspire the next generation of medics and providers and anybody who might be working in the special operations medical space to figure out how we can carry the torch forward. So without further ado, I'm looking forward to this conversation. I hope you are too, and we'll see you on the other side. All right, guys, well, welcome to the show. I've got Dr. Frank Butler here with us. As you've seen in the intro, he's a man who needs no introduction, but super thrilled to have you on the show today because as you know, it's the 30th anniversary year of your creation, and I'm super excited to see what we can chat about and kind of inspire the next generation to take TC3 and carry it forward for the next multiple decades to come. So welcome to the show, sir, and thank you for taking the time.
- [02:25]
B
Thanks, Sam. I'm very glad to be here. We're at the point now where it is important that we capture accurately what happened with this project.
- [02:35]
A
Yes.
- [02:36]
B
And in creating the book, I thought writing the book would be the hard part. But finding somebody that was able to publish it and wanted to handle it the way that it needed to be handled, Breakaway Media was superb in that respect. So I'm very glad to be able to give back to them a little bit.
- [02:56]
A
Well, awesome. Yeah, it's a phenomenal book and it's amazing to see some of the histories and the stories that have been intertwined in that that have come to essentially drive one of the most revolutionary concepts in trauma medicine. And you see it spill over now in so many facets of medicine. So that has to be cool for. To watch the baby grow after, after the 30 years in 1996 when you were drafting this concept, you're reviewing the data, you're looking at Gothic Serpent, you're looking at all the, the events leading up to the concept. Did you think then that you would be where you are at now with like, revolutionary. Revolutionary. Excuse me, sir. Revolutionizing military medicine and quite frankly, medicine in general?
- [03:44]
B
No, not at all. A little background on how our research program was set up. The Navy SEAL Admiral had decided a few years before then that he wanted to have his own biomedical research program. And I was fortunate enough to have him give me the opportunity to lead it. And his direction to me was, I want something that Navy SEALs can take to the next war to help them win it. And so that was a very good vector. And at first we thought that the output from the program would be pretty much focused on SEAL, Corman and to a lesser extent, Special Forces and PJs and other special ops medics. But there was really no vision that it would go beyond that. And we just wanted to do a good job for our Special ops sponsors.
- [04:49]
A
Right. Well, that's, that's, it's, it's funny how a little idea can snowball rapidly, but I, one of the things you mentioned about the, the command emphasis, which I, I know is, is a big part of the book. And then. And we have some very non medical leaders to thank for the fruition of TC3 becoming gospel. Do you think had you not had that command team you had at the time, what do you thought TC, do you think TC3 would have even become a thing?
- [05:20]
B
No, I think one of the biggest advantages that we had, in addition to having the leader of the Navy SEAL community say, this is my research program and we want it to have good outputs for the community. When we got done with research projects, we had his ear. So he was very willing to listen to all of the products that we bought brought back to brief him and his successors on to include TC3. So to have a medical product that envisioned changing the way that battlefield medicine was done and to have a Navy SEAL flag officer willing to sit there for two hours and listen to the plan, that's a huge advantage in and of itself. So, yes, the participation, the support, the encouragement of line commanders was absolutely essential to what we did. And not just the seals. The same was true in the Rangers and at the U.S. special Operations Command as well.
- [06:31]
A
Yeah, I still remember because I was an army medic for 21 years. I started in the conventional force in 2004 and the concept of TC3 was there. And that was 10 years after the initial papers, and it still was kind of percolating through the forest. I went through the OEMs course where we got exposed to the guidelines for the first. I think that was genuinely the first time I was exposed to the guidelines was OEMs and not at, not at the medic school, not AIT. And I was like, oh, that's awesome. Tourniquets. All like that. The evolution of stuff that came from that. And now seeing it, well, 21 years later post my career and just watching how it shifted then was awesome because I look back at casualty response when I was a young medic and it was not nearly what it is when I, when I worked with the Ranger regiment, seeing how they ran it, and it's, it's super cool to see that happen.
- [07:30]
B
Right.
- [07:32]
A
What were like. So we're, we're kind of seeing now as, as we're looking to the. Today's generation and the Walker dip is our favorite word to use is, are. Are you from your work, your, your position now, since you have lots of touch points with the community still are. Are you seeing the Walker dip happen in real time? Like.
- [07:52]
B
Well, so the Walker dip, for your listeners who may not be familiar with it, that term was coined by a British medical flag officer named Alistair Walker, who pointed out that during wartime, a military's ability to care for casualties would be really well honed. And so by the end of the war, we'd be very good at combat casualty care. But then when the war was over, you know, the emphasis shifted. There were not casualties to be taken care of. There were not field hospitals to be maintained. There were not all of the things that go with moving medical capabilities into a theater. So a natural consequence was as you deemphasize combat casualty care, you lose some of the capability that it had during the war. And I think that has been true with wars in the past. I think we were lucky in this war in that it had been recognized and publicized beforehand. So that when the war in wars in Afghanistan and Iraq concluded, we had a few things. We had the Joint Trauma system. The Joint Trauma System did not exist at the start of the war in Afghanistan and Iraq. And so when we first were trying to get feedback from the battlefield about how well TC3 was doing, many of those operations were classified. They didn't want to talk to the doctors. And so our best intel early on was special ops medics, right? People like Monty Montgomery, people like Ted Westmoreland, people like Harold Hill, people who had been to the war and came back and were willing to share what their casualty scenarios had been like. Right now we have a trauma conference every Thursday run by the Joint Trauma System. And as a matter of fact, we are going to have the 1000th iteration of our weekly conference coming up in a couple of weeks. And so if there's something that happens to a casualty, we have a chance to have medic surgeons, emergency medicine doctors, have eyes on what happened and try to envision or find ways to make sure that anything that was a preventably bad outcome doesn't happen again. And so I think we have. That we have a realization that the way to learn to take care of trauma victims is to take care of a lot of trauma victims. And so we're a 1/60th medic. You're not going over to the war. Where are the trauma victims that you're going to take care of? Well, they are in the civilian trauma centers. And our military has gotten very good at devising, arranging, setting up military civilian partnerships so that 1/60 and other medics will have trauma patients to take care of and have a chance to get better at their skills. And then lastly, I think that, I mean, again, command leadership is so important. We just had a new person take over as the head of the Defense Health Agency, Vice Admiral Darren Vai. And he put out his guidance to his commanders last week. And in that guidance, he included the reminder that we are we D8. The Defense Health Agency is a combat support agency. We're here to help the war fighter. And so having that direction from the top, I think, is critically important. So I feel very confident that we will go into, if there's a next war, we'll go into it prepared.
- [12:11]
A
Yes. And that's having sat on many of the JTS conferences as a fly on the wall. I like to say that my military career I was a professional fly on the wall with a badge that allowed me into rooms I didn't have to be in, but I could be in there. So overhearing some of the discussions was what drove a lot of my personal experience in my career. I actually uniquely got to sit on an annexq rock drill, which is a health service and support rehearsal of operational concepts in a place that was supposed to go very dynamic. And it was incredibly enlightening on some of the things that were glossed over or the planning assumptions actually on that regard. The JTS conferences. Do you guys ever have say, the non medical commanders associated with that casualty involved with those calls?
- [13:00]
B
Yes, Sam, that's a great question. The answer is infrequently, not never, but not that often. And you know that. That's a great observation and maybe a way for us to continue to improve. As the book spells out, one of the reasons that TC3 has been so successful is that we have learned how to interact with two three, four star flag officers and general officers and have them understand that we are trying to help them take care of their soldiers and marines.
- [13:39]
A
Yes.
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B
And by the time somebody gets to be a four star flag officer, their, their bandwidth is pretty limited, so it's tough to get them to break loose for the JTS trauma conference every week. But your principal is right. A good commander knows what kind of care his troops are getting when they're injured. And the last chapter in the book starts out with a tremendous quote from General Votel who was commander of the Ranger Regiment, then jsoc, then the central command. And he said casualty care is a commander's business period.
- [14:26]
A
And I think that's the, one of the concepts that I drive home when I'm mentoring young medics and medical officers. The army model particularly is one that always has confused me because at the most austere conventional force unit, say the infantry battalion, we put the most inexperienced officers there that are scared of anything and they don't want to have to have any attention drawn to them. So where do they hide on their little JCR computer inside their Humvee at the forward aid station?
- [14:58]
B
It's not their fault, it's the system.
- [15:00]
A
Exactly. And I've been jumping up and down on the table trying to fix it as I've, I've. One of the. When I was with the 160th, I had this bad habit of going and sticking my nose in places I didn't really need to be.
- [15:10]
B
But like, good for you.
- [15:12]
A
Well, I, I observed, I observed a prolonged Field care experiment that was actually run by an Aussie doc Augmentee to first Core. And it, what really hit home one time is we did a 12 casualty inject on this cavalry troop and the commander of the troop came to us as the OCS and said, hey, can I cancel this inject so I can go back to war fighting? And that was, that was the light bulb moment where like, hey, the casualty response is a command problem, it's not a medic problem. Like, my job as the medic is to advise commanders on, hey, we can we do this? That does this person need evacuation? Render the best care I can in the environment. But that truly resonated with me that, hey, somewhere, especially in that formation, it wasn't being communicated to the commands that this, this is your problem. It's not just, it's not medical's problem.
- [16:07]
B
So there's a chapter in the book that spins about 20 pages, making largely the same point that you just made. If the, as we say, there are two times that you can plan for what to do to take care of a casualty before it happens and after it happens. Yes, and before is always better. And that sounds casual, but it's not One of the best examples in the book, and this is one that I stole From Admiral Bill McRaven's book that came out in 1980, 97, I think, called Spec Ops, if you remember the raid on Entebbe.
- [16:48]
A
Yes.
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B
And sadly, many of our young soldiers and medics do not remember that raid now. But the Israelis went to recover their hostages who were, had been taken by terrorists and were being held in the Entebbe airport. And as they got off their helicopters and began their assault, their commander, who incredibly was Prime Minister Netanyahu's brother, but at the time head of the Surat Macal, the first thing that happened as they approached the building was that he was shot in the chest. And the book poses the question, you are the medic. Do you stop the assault to recover the hostages and take care of your commander, or do you ignore your commander and go get the hostages and kill the terrorists? And the right answer is, as Admiral McRaven spelled out in the book, the right answer is complete the mission and then come back and take care of casualties. That's not intuitive. And I think it's something that we need to stress more than we do in casual or in combat medic courses today. But, you know, the. When young medics say, hey, come on, Tebi was 100 years ago, you know, don't, don't tell us about those old stories. So there's a new story in there about Master Chief Ed Byers Medal of Honor action that is not on the scale that Entebbe was, but it was incredibly successful. And it was successful because the SEAL medic did the right thing at the right time, took care of the operation and then stopped to take care of his fallen brother. So the tactical advantage is critical. And you know, we know about tourniquets, we know how many lives they've saved, we know about hemostatic dressings and how many lives they've saved. We do not know how many lives have been saved and how many missions have been saved because the medic does the right thing at the right time, right?
- [18:57]
A
The operational art that goes into military operations. That's when I went to the Joint Special Operations Planning course. It was basically all emphasis on operational art. It's not much of a science, even medicine. It's making the right decision at the right time and the right minutia. I think that's another thing too that I've noticed. I do a lot of work in the civil space, particularly in Washington state up here where we have the law enforcement has a duty to render aid. And you've seen a shift of basically these law enforcement officers who are essentially supposed to be doing like what a classic combat arms guy is, maintain security and presence, et cetera. And they start doing medical when it's not advantageous to the situation because they've been ingrained that they need to start rendering this aid. And you look in the military, the four tiers of tactical combat casualty care that have come to be. I am very glad that's a thing now because it emphasizes the important chain of survival. And for your, in your, in your opinion, if you're dealing with a formation that doesn't take tactical combat casualty care as seriously at the tier one, the all service member level and the CLS level, what are some ways that we can essentially as medics, inspire the command to take it seriously?
- [20:21]
B
So it brings to mind part of the story that I told in the book, which again is emphasizing the fact that the problem that you just enumerated, the non medical combatants are not taking TC3 seriously. That's not a medic problem, that's a commander problem. We talked about that for a few pages. And then there's a story about former Ranger medic Rob Miller explaining that in much more colorful NCO terms to a young officer who was asking, criticizing the medic for not having something done. And he said, hey sir, this is Your project, you are in charge of it, and if it doesn't work, it's your fault. His version was much more colorful, but we'll try to keep this G rated. But the concept is right. Everything that happens on the battlefield is owned by a line commander. And if medics think that they're in charge of the casualty, then they don't have a good small unit leader because the small unit leader is in charge of that mission and he tells the medic what to do and when to do it. And that includes sometimes delaying care until after, until it's appropriate in the tactical situation to render care. I briefed a group of SEAL friends who by that point, this was 1996, shortly after the paper came out, and this was all the East Coast SEAL team cos. And we made the point that, as you've noted in the TC3 guidelines, sometimes it's appropriate for the medicine to shoot first and treat later. And one of the SEAL team COs, who had been a special missions squadron commander, said, hey, Frank, you left something very big out of that. He said, what you said is right, but what you didn't say is important, and that is that the casualty should continue to function as a combatant if he's able to do that. Just because you're shot in the leg doesn't mean you get to lay down on the ground and shout for the medicine. And he was right. His name was Pat Tuohy and that chapter in the book is called the Tuohy Amendment. But, you know, if you read Medal of Honor stories, Bob Carey, leroy Petrie, these are guys who got pretty significantly wounded and didn't let that slow them down. They continued with the mission.
- [23:02]
A
Yeah, that's a, that's a mindset thing too, that a lot of the trainings, it, it's actually a training scar that if you are a role playing casualty and they make you a casualty, what did they all do? They lie down and play dead.
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B
Yeah.
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A
Now you're conditioning that mindset that if any little thing happens, my job is to lie on the ground and wait for the medic to come to me. Like, no, man, that doesn't look so bad. I'm back in the fight. Let's go.
- [23:27]
B
Yeah, Sam, that was one of the most important things that we emphasized in the, the TC3 book was that our training up to that point in time was predicated on civilian training, specifically the ATLS course and the military. This is maybe not a great choice of words, but had a little bit of an inferiority complex. If the Civilians are doing it. These guys are the experts, therefore it must be right. Well, not if you are in the middle of a gunfight and you think that you're going to go into a complete secondary survey of your casualty. I had a SEAL chief tell me that he had been faulted at the Sockham course for the problem that he was given was, okay, you've got this casualty, he's been injured by mortar fire. And as the. You move over to take care of him and you're getting ready to start your secondary survey as they do in atls, you could see the mortar fire being walked into the position. So the gunshots were landing closer and closer and closer. So they had a spotter. And the question that the instructor asked him was, are you going to finish your secondary survey or are you going to move you and the casualty to another place? And the SEAL chief gave the right answer. We're getting the hell out of there.
- [25:00]
A
Right.
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B
Because we don't want to be where the next round lands. That was the answer that he gave to the instructor, and he was failed.
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A
That is. Yep, that sounds like sock em. And actually building on that, because you brought up TC3 guidelines and you just listed somebody getting failed for basically a protocol failure. So we're getting close to time. But since the TC3 guidelines are guidelines, I've seen them used time and time again as hard steadfast protocols to fail people in medical trauma assessments in certain environments. When you hear that, what does that make you feel like?
- [25:45]
B
So if you go back and reread the 1996 paper, and I recommend that you do, it's always. It's good to go. I do it too. It's good to go back and reflect. But it makes the point that no paper, no medical officer can ever tell a soft medic or any medic exactly what situation he's going to be in. Therefore, whatever advice you give to that medic, it's got to be contingent upon the tactical situation being appropriate for it. And, you know, there are a number of situations that, or scenarios that were spelled out in the, in the paper that emphasize that point. The TC3 guidelines are a starting point for the medic. They were never meant to be a rigid. You can never change this protocol. And I, in our early training courses, I had a great quote from. I don't know if you remember Peter schoomaker.
- [26:42]
A
Yes.
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B
Former U.S. sOCOM commander, former Special Missions Unit commander. He had a great quote that we put into the. It was actually the last slide of the training course. We have to teach people how to think, not what to think.
- [27:01]
A
Yep. I love that because all too often everybody wants it to be black and white. Like, no, you gotta like critical thinking. Like high stress. Critical thinking is kind of like. That's the crux of TC3 right there. Since we're coming towards the end, sir, and I thoroughly appreciate your time. As we're looking at retrospectively 30 years of TC3, what would you like to pass to the next generation? And basically what challenge would you like to issue to the people who have to carry your torch forward for you for the next millennial? Maybe not that far, but hey, thanks
- [27:40]
B
for that little soapbox. I will take full advantage of it. To you and to anybody else who gets that book, skip ahead to chapter 30. You know, TC3 could very easily be lost by the time that the next war rolls around. If you don't believe it, go back and read medical history from the previous wars. So how do we keep that from happening? And the number one thing, and the chapter starts out with that quote from General Votel that I mentioned line combat commanders have to truly own battlefield trauma care. So if you are a 04 doctor and you come and you have ideas that or you think you have a better way to do medical care on the battlefield than TC3, you should have to convince that commander and he would, should understand completely why you would vary from that protocol. And he should also hold that O4 new doc very much responsible for making sure that TC3 is well executed. And there's a great example of TC3 not being well executed is happening in Ukraine ever since 2014. Colonel Stacy Shackelford's paper emphasize that if you have a wound, if you've got a tourniquet on a leg, you have to go back and reassess that tourniquet. You can't leave it and forget about it. You have to reassess it at least by two hours and then as often as you can thereafter. The Ukrainians did not do that and they lost terribly many arms and legs as a result. It wasn't that we didn't know what to do. It was that nobody held, not just the medics, but every Ukrainian combatant responsible for executing TC3 as it was intended.
- [29:50]
A
I've read all those studies and I've jumped up and down on all those tables as well. And I think that's the parting shot here is it's casualty response is. Is not medical's problem.
- [30:02]
B
There's a great paper that, you know, General Votel has written about that. Russ Coatwall and Sergeant Master Sergeant Montgomery have written about it in their casualty response paper. Nobody has demonstrated that better than the Ranger Regiment. And I, I think that's the model for the rest of the military to follow.
- [30:21]
A
I, I 100% agree. Because you look at the Ryan Davis case study that's right there, there's plenty of them, but that one is kind of the gold standard on how that system works.
- [30:30]
B
So.
- [30:30]
A
Well, sir, the book that we've been referencing is tell them yourself. It's not your day to die. We plugged it earlier, but we're going to put it up there again. So read this, because if you don't, we're going to forget the hard lessons learned and it's going to be paid in blood of our allies. Well, Dr. Butler, again, I really appreciate you taking the time out of your busy schedule to come on here and share the pearls and, and enjoy the journey. And I also want to congratulation, excuse me, Congratulate you on the year at your Presidential Citizens Medal that you got back there in 2025. That's a Bravo Zulu on some, on a very storied career in life and ensuring that many of the people that I was able to treat made it to the next echelon of care because of the hard work you put in on the front end. So thank you, sir.
- [31:20]
B
Thanks, Sam. And I'll turn that around by saying that there's speaking for an awful lot of Special Ops guys. We were very happy to see the 1/60 guys show up when something bad was going on.
- [31:31]
A
Well, you know, we do bring the best drinks and snacks in town, so. All right, sir. Well, I appreciate you. We'll. We'll go sign off here and I will hopefully be in touch.
- [31:42]
B
Sounds good. Take care.