P-MARCH-P OVERVIEW

TERMINAL LEARNING OBJECTIVE LEARN and DEMONSTRATE the PMARCHP algorithm, and be able to implement it in a simulated battlefield setting This is a good point to give a short personal story on how the use of this algorithm has been used by you and how it works

ENABLING LEARNING OBJECTIVES LIST each step of PMARCHP IDENTIFY where specific medical interventions fit into PMARCHP DEMONSTRATE PMARCHP on a simulated casualty Read slide

WHAT IS PMARCHP? Combat medicine algorithm Used to effectively treat battlefield casualties to prevent missing vital medical interventions Can be tailored to any environment and casualty Framework for ALL TCCC interventions Explain the importance of following the steps in order. They're set up in the order of what will kill the patient first..

PMARCHP Patient/Provider Safety Massive Hemorrhage Airway Respirations Circulation Head Trauma/Hypothermia Pain Management Briefly go over each step. Explain that you’ll go into detail later in the topic. As you go over each step make sure you demonstrate for the students using either a volunteer, or optimally, a dummy to perform interventions on.

PATIENT/PROVIDER SAFETY Is the scene safe? Fire superiority Can patient provide self aid/move to cover? Protect casualty from further injury Move casualty to Casualty Collection Point (CCP) Emphasize that the best medicine on the battlefield is rounds downrange. The HM’s job is to treat the casualty, to sling rounds and not hide behind a wall. If the patient can perform self aid, or move to any sort of cover, have them do that. Once you begin treating the casualty, your job is to look after their best interest which means shielding them from fire, returning fire etc.

MASSIVE HEMORRHAGE Only step done on the “X” (point of injury?) Stop massive bleeding Tourniquets Perform blood sweeps after PT has been moved off the “X” (Big pipes, little pipes down to the joints) Goal time to apply a TQ is 45 seconds. Keep in mind that you’re under enemy fire in this step and need to get the patient off the “X” ASAP The Massive Hemorrhage step continues after moving the PT: rechecking TQs and the blood sweeps

AIRWAY MANAGEMENT Check level of consciousness (LOC) Check carotid (Dead check) If patient is unresponsive, Look, Listen, Feel (LLF) Check for lacerations, obstructions broken bones, blood, and swelling (LOBBS) Clear obstructions. NEVER BLIND SWEEP Open airway with head tilt chin lift or jaw thrust If still not breathing, readjust a second time and LLF Breathing? = nasopharyngeal airway If STILL not breathing, consider cricothyrotomy Walk the students through the airway step several times, as this is the step that confuses the most. Re-emphasize that the PT has 6-1/2 minutes survivable time without oxygen so a definitive airway is critical

RESPIRATIONS Remove all gear and fully expose patient Inspect, Auscultate, and Palpate “Tiger Claw” Occlusive dressings to all sucking chest wounds Perform needle thoracentesis if applicable Reassess breathing after interventions PT will essentially become naked in this step Make sure the Tiger Claw method is shown in great detail as students have difficulty grasping this

CIRCULATION Big pipes, little pipes, treat as you go Secondary sweep Feel for Deformities, Contusions, Abrasions Penetrations, Burns, Tenderness, Lacerations, Swelling, and Crepitus (DCAP-BTLS+C) Chest examination: Clavicles, Sternum, Ribcage Abdominal examination: Tenderness, Rigidity, Distension, Swelling (TRDS) Pelvic examination (Look for facial grimace) Groin examination: Credit card swipe Bilateral radial pulses Fluid consideration IV/IO This step is a more complete blood sweep Cuts, shrapnel, fractures etc. are all treated as you go

HEAD TRAUMA/ HYPOTHERMIA DCAPBTLS of scalp, skull, and facial bones Assess eyes: Pupils Equal, Round, Reactive to Light and Accommodation. Extraocular Movements Intact, and Raccoon Eyes (PERRLA, EOMI) Assess ears :Blood, Cerebral Spinal Fluid, and Battle signs (CSF) Assess nose: Blood, CSF, Fractures Assess mouth for LOBBS HYPOTHERMIA Minimize exposure to the elements Use specialized warming blankets or improvise Replace PPE (Keeping in mind the casualties’ injuries) Many students will not know what accommodation is so make sure to go over it Accommodation and EOMI are not tests you can do on an unconscious PT

PAIN MANAGEMENT Consider pain management and it’s effects on the patient’s ability to move/fight Morphine/Fentanyl/Ketamine/Pill Pack Keep contraindications in mind Unconscious Allergic Hypovolemic Shock Traumatic brain injury Respiratory Distress Explain contraindications and make sure the reasons why those are contraindications are understood

Time Hacks for Each Step It is critical that each intervention is accomplished in a timely manner There are certain interventions that if preformed poorly or missed, will result in failure There are two major time sensitive interventions You must have control of major hemorrhage in under 2:30 You must have a definitive airway in under 6:30 Failure to accomplish these interventions in a timely manner in a real world situation would kill your patient During the FINEX, your time starts once you’ve made the scene safe and physically touch your casualty

Summary and Review What intervention(s) are used in each step of PMARCHP? What’s your goal time? Remember that practice makes perfect

Questions?