Page 84 - JSOM Winter 2017

Figure 3 Frequency of battle injuries and nonbattle injuries (NBIs) Figure 5 Mechanism of injury for nonbattle injuries.
in 465 patients. Battle injuries were sustained during combat and did
not include accidents using combat equipment or vehicles while not
participating in combat.

Figure 4 Mechanism of injury for battle injuries. GSW, gunshot
wound; MVA, motor vehicle accident. Values given as n values.

Figure 6 Adequacy
of MARCH/PAWS
to cover all
treatments.

Figure 7 Treatment rendered based on the MARCH/PAWS
mnemonic, showing Guardian Angel interventions performed in the
Helmand River Valley From January to June 2012.

the lack of flight time to complete treatment while performing
other treatments, forgetting to do it, and, in some instances, the
lack of a combat pill pack with certain ground units.

The diagnoses for 11 treatments not covered in MARCH/
PAWS but in specialized protocols are shown in Figure 8.

Discussion
The mnemonic device MARCH/PAWS was an effective check- to document the care and at the same time be reminded if he
list for all of the combat trauma patients and almost all of the forgot to do something.
patients with NBIs/nonbattle illnesses who were rescued by
the PJs. Massive bleeding (M) treatments performed 21% of the time
included tourniquets and direct pressure and pressure dress-
MARCH/PAWS was originally promoted to keep the PJs from ings with or without hemostatic gauze. The value of tourni-
forgetting things like blankets for trauma patients and antibi- quets became evidence based as OEF and OIF progressed. It is
otics for patients with wounds, based on direct feedback to hard for today’s young PJs, corpsmen, and medics to conceive
the PJ medical director from the Air Force trauma consultant. that not only were there no commercial tourniquets available
Around this time, the benefit of checklists in medicine were for several years but not all combatants were trained to use
becoming popularized to reduce human error. 6–12 This perfor- them. 13,14 Hemostatic gauze was validated in animal studies
mance improvement project validates the value of this check- and later by the Israel Defense Forces. 15–18
list for both combat trauma and NBI/nonbattle illness.
Pelvic binders were variably placed during M or later in the al-
To reinforce the checklist, we created a patient care card with gorithm. PJs began using pelvic binders during the time frame of
two sides (this does not replace the DOD 1380 form). It fol- this study due to the co-location with the British Medical Emer-
lows the AT_ MIST format so that the front includes the age, gency Responses Teams (MERTs), who aggressively used this for
time, MOI, injuries, signs and symptoms. The back included obvious pelvic fractures as well as any bilateral lower extremity
the treatments in MARCH/PAWS format. This allows the PJ amputee due to the high associated pelvic fracture rates. 19–22

82 | JSOM Volume 17, Edition 4/Winter 2017