Page 83 - JSOM Winter 2017

MARCH/PAWS is an acronym that stands for massive bleed- treatment within 1 hour from the time of injury and accounted
ing, airway, respiration, circulation, head injury/hypothermia, for 45% of patients. Category B patients were stable and re-
pain, antibiotics, wounds, and splinting. While MARCH/ quired definitive care within 4 hours, accounted for 48% of
5
PAWS was developed to address BIs, we realized it was ap- patients (Figure 2).
plicable to NBIs and nonbattle illnesses as well. This is impor-
tant because during the height of OEF, approximately half of Figure 1 Patient demographics.
the rotary wing evacuations performed by PJs were NBIs and
nonbattle illnesses. This project was undertaken to validate
MARCH/PAWS as a checklist for medical care provided by PJs.

Methods
This report is the result of a process improvement study, which
was approved by the Air Force Research Oversight and Com-
pliance Division.
Patient care reports (PCRs) completed by PJs deployed in Hel- Table 2 Injury Categories
mand Province, Afghanistan, during the time of 1 January A: Life-threatening injuries that generally required a MARCH
2012 through 30 June 2012 were reviewed. PCRs were filled intervention and included severe traumatic brain injury, severe
out immediately after each mission by the PJs directly involved burns, spinal cord injury; patients are often unstable; evacuation
in the treatment of the patient. Information extracted from required within the hour
the PCR included mechanism of injury, injuries and findings, B: Severe injury that is not life threatening and vital signs are
treatments, and timelines. The treatments were categorized by stable. This includes injuries such as open fractures, evisceration,
eye injuries, etc.; 2- to 4-hour evacuation
the letter in MARCH/PAWS and noted if they fell outside of C: Minimal injury but requires medical care beyond patrol
that. This project focused on this latter point to validate the medicine; stable patient; evacuation acceptable up to 24 hours
efficacy of MARCH/PAWS as a checklist.
Four hundred sixty-five consecutive PCRs written by 16 dif-
ferent PJs during the noted deployment were reviewed. Infor-
mation on patient sex, age, evacuation category, mechanism
of injury, injuries, and treatments received was collected from
each PCR. The treatment each patient received included all Figure 2
treatment recorded from the point of injury (provided by Patient category
distribution.
ground forces or PJs) until the PJs turned the patient over to
a higher level of medical care. Ground care not given by PJs
includes treatment performed prior to the arrival of PJs, such
as self-aid and buddy care, or treatment by a ground medic.
Each treatment was tallied according to its category in the
MARCH/PAWS algorithm to provide a perspective of the rela-
tive frequencies of injury types and the relative frequency of
treatments performed. Of the patients from this study, 240 (55%) sustained BIs and
225 (45%) had NBIs and nonbattle illnesses (Figure 3). The
It should also be noted that any category C patient who that most prevalent BIs were gunshot wounds (20.2%) and blast
received treatment by PJs was included because they were injuries from improvised explosive devices (IEDs) (21.6%).
transported with at least one category A or B patient; no mis- Injury from IEDs was subdivided into mounted (in a vehicle)
sion was executed exclusively for a category C patient. The (8.7%) and dismounted IEDs triggered while outside of a ve-
treatments delivered per MARCH/PAWS are summarized in hicle (12.9%) (Figure 4). The most prevalent NBIs were illness
Table 1; most are essentially consistent with the TCCC guide- and accidents (motor vehicle accidents and falls). Illnesses in-
lines and the USSOCOM Tactical Trauma Protocols (TTPs) cluded a wide variety of problems ranging from infections to
(published in the Journal of Special Operations Medicine/Ad- cardiac issues (Figure 5).
vanced Tactical Paramedic Protocols [ATP-P] Handbook). 5
Overall, 98% of all treatments were covered by MARCH/
PAWS (Figure 6). And 100% of BI treatments and 95% of
Results
NBI treatments were encompassed by MARCH/PAWS (Fig-
During the 6 months observed in this study, the PJs trans- ure 6). The most common interventions were P (pain man-
ported a total of 465 patients. Of these 465, 437 underwent agement) and C (vascular access and fluid administration) in
treatments. The basic demographics of the patients are shown 59% and 34% of patients, respectively . These were followed
in Figure 1. by W, H, S, and the remaining letters in the mnemonic (Fig-
ure 7).
The patients were given standard combat casualty categoriza-
tions of A, B, or C by the parties requesting CASEVAC be- It is important to note that some treatments in this theater of
fore launch in order to determine urgency. The nature of a operation were not performed due to short flight times. For in-
patient in each category and time for evacuation are explained stance, there was more wound care performed than antibiotics
in Table 2. Category A patients required definitive surgical given. When discussed with the Operators, this was due to either

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