1. P-MARCH-P OVERVIEW

2. 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

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

4. 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..

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

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

15. Questions?