Page 82 - JSOM Winter 2017

Efficacy of the Mnemonic Device “MARCH/PAWS” as a Checklist for
Pararescuemen During Tactical Field Care and Tactical Evacuation

John Kosequat ; Stephen C. Rush, MD *; Ian Simonsen ; Isabelle Gallo ;
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Alex Scott ; Kent Swats ; Colby C. Gray, DO ; Brock Mason, DO 5
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ABSTRACT
Background: The application of Tactical Combat Casualty and tactics were considerations that competed with or took
Care (TCCC) represents evidence-based medicine to improve precedence over clinical concerns.
survival in combat. Over the past several years, US Air Force

Pararescuemen (PJs) have expanded the mnemonic device The application of TCCC represents evidence-based medicine
“MARCH” to “MARCH/PAWS” for use during tactical field to improve survival in combat. 3,4 The Committee for TCCC
care and tactical evacuation (TACEVAC). The mnemonic and other organizations popularized the mnemonic device
stands for massive bleeding, airway, respiration, circulation, “MARCH” to aid PJs, corpsmen, and medics in providing im-
head and hypothermia, pain, antibiotics, wounds, and splint- mediate lifesaving care to combat casualties. However, it did not
ing. We undertook this performance improvement project to account for secondary treatments that needed to be addressed
determine the efficacy of this device as a treatment checklist. during TACEVAC. Over time during OEF, “PAWS” was added
Methods: The mission reports of a 16-PJ combat rescue de- based on feedback from operations and development during PJ
ployment to Operation Enduring Freedom (OEF) from Janu- medical training courses, often as an attempt to ensure covering
ary through June 2012 were reviewed. The triage category, (hypothermia prevention) patients and administration of early
mechanism of injury, injury, and treatments were noted. The antibiotics to combat trauma patients were not forgotten. Thus,
treatments were then categorized to determine if they were in- MARCH/PAWS was developed as a checklist-based approach
cluded in MARCH/PAWS. Results: The recorded data for mis- to the assessment and treatment of combat injuries by address-
sions involving 465 patients show that 45%, 48%, and 7%, ing immediate life threats first and then attending to injuries
were in category A, B, and C, respectively (urgent, priority, that could result in delayed morbidity and mortality. Essentially,
routine); 55% were battle injuries (BIs) and 45% were non- “MARCH” addresses the primary survey, and “PAWS” roughly
battle injuries (NBIs). All treatments for BI were accounted for addresses the secondary survey (Table 1).
in MARCH/PAWS. Only 9 patients’ treatments with NBI were
not in MARCH/PAWS. Conclusion: This simple mnemonic Table 1 The Acronym MARCH/PAWS Is Recommended to Guide
device is a reliable checklist for PJs, corpsmen, and medics to the Priorities in the Care Under Fire (Control of Life-Threatening
perform TACEVAC during combat operations, as well as care Hemorrhage Only) and Tactical Field Care Phases
for noncombat trauma patients. Massive hemorrhage—Control life-threatening bleeding (tourniquet,
direct pressure, pressure dressing, pelvic sling, junctional tourniquet)
Airway—Establish and maintain a patent airway (chin lift/jaw thrust.
Keywords: Tactical Combat Casualty Care; survival; Para- recovery position, sit up and lean forward for oral bleeding, NPA,
rescuemen; mnemonic; MARCH/PAWS; tactical field care; supraglottic device, ET tube, cricothryotomy)
tactical evacuation Respiration—Decompress suspected tension pneumothorax, seal
open chest wounds, and support ventilation/oxygenation as required
(chest seal, needle compression, bag-valve-mask, oxygen)
Circulation—Establish IV/IO access and administer fluids as required
Introduction to treat shock (diagnose and treat shock, IV/IO whole blood red blood
cells/fresh frozen plasma or Hextend 500 mL as needed, TXA)
Throughout OEF and Operation Iraqi Freedom (OIF), USAF Head injury/Hypothermia—Prevent/treat hypotension and hypoxia
PJs were tasked with performing personnel recovery and com- to prevent worsening of traumatic brain injury and prevent/treat hy-
bat search and rescue for coalition forces. Rescue PJs (usu- pothermia (diagnose increased ICP, prevent hypoxia and hypoten-
ally from Air Combat Command) generally received patients sion/Hypothermia Prevention and Management Kit (HPMK), elevate
directly from the point of injury on the battlefield or from off ground, remove wet clothing)
forward operating bases. In other instances, Special Tactics Pain—Administer appropriate analgesia or sedation to manage pain
PJs (generally from Air Force Special Operations Command) ([1] Mobic/Tylenol; [2] fentanyl OTFC; [3] ketamine or fentanyl
IV/IM)
supported various units from sister services and frequently Antibiotics—Administer battlefield antibiotics for early prevention of
provided care under fire in addition to tactical field care and infection (PO or IV/IO/IM for all open combat wounds)
tactical evacuation (TACEVAC). In many instances, minimal Wounds—Assess and dress additional wounds and check prior inter-
care was performed on patients before the PJs received them. ventions (clean and dress)
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Overall, patient assessment and treatment were often per- Splinting—Splint all fractures or provide support to limb dressings
formed in dynamic and chaotic environments in which time (SAM, KTD, spine, rigid eye shield)
*Address correspondence to stephencrush@me.com
1 SSgt Kosequat, SSgt Simonsen, SSgt Scott, and SSgt Swats are USAF Pararescueman out of the 106th rescue wing, Francis S. Gabreski Airport,
Westhampton Beach, NY. Lt Col Rush is a USAF Pararescue medical director and a USAF flight surgeon. Ms Gallo is affiliated with Stony
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Brook University. Capt Gray, USAF, MC, FS, is a USAF flight surgeon at Davis Monthan AFB, AZ. Capt Mason, USAF, MC, FS, is a USAF
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flight surgeon at Davis Monthan AFB, AZ.
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