Page 85 - JSOM Winter 2017

Figure 8 Beyond MARCH/PAWS: treatments rendered not covered partner forces were entrapped with major injuries, being able
in MARCH/PAWS. to administer intramuscular ketamine and take the edge off the
agitation made the extrication problem easier. We now carry
intranasal atomizers as an option, though one must be careful
if it is in the setting of a blast injury to ensure that dirt has not
clogged the nasal passages.

Antibiotic (A) use (15%) in trauma improved over time, with a
goal of being to administer antibiotics early to reduce the risks
of wound infection and sepsis. This is supported by data from
studies in animals and some data from OIF. Antibiotics were
34
also used for NBI with infections.
Wound care (W) (26%) cannot be overemphasized. While
antibiotics are effective and useful, the general tenets of re-
moving gross debris, irrigating, and covering the wound to
prevent further contamination are gold standards for prehos-
Airway management (A) was performed 7% of the time. This pital trauma care. This is done to buy time to get to definitive
included an NPA for all unresponsive patients, endotracheal wound care by surgeons.
intubation, placement of a supraglottic airway device (primar-
ily King LT during this time), and cricothyroidotomy. One Splinting (S) is the catch-all to include the place to document
23
key airway management change we made in rotary wing medi- cervical-spine or spinal motion restriction when indicated,
cal operations during OEF was the introduction of video la- placement of a rigid eye shield for penetrating eye trauma, and
ryngoscopy to facilitate intubating from the side of the patient other splinting and immobilization for fractures and signifi-
and increase first-pass success. 24–26 cant soft tissue injuries. 35,36 Although pelvic binders play a role
in hemorrhage control, they are included here as an orthope-
Respiratory management (R) performed 16% of the time in- dic aid as well.
cluded needle decompression, chest tube, chest seal, assisted
ventilation with bag mask or mechanical ventilator, and MARCH/PAWS did not come into widespread use until after
supplemental oxygen. The benefit of needle decompression the deployment discussed here earlier. Therefore, this project
is evident by the reduction in tension pneumothorax as an was performed to retrospectively validate its value as a conve-
important cause of potentially preventable death. 4,27 We have nient and thorough checklist.
subsequently standardized finger thoracostomy as an option
to a chest tube when time and tactics do not permit chest tube The implementation of MARCH/PAWS through Pararascue
placement but the patient requires decompression after needle has occurred over several years and essentially is a cultural
decompression fails. Guidelines for the management of open change. Presenting it in the new PJ Medical Operations Hand-
chest wounds with chest seals have evolved to be vented based book, discussing it at courses and the Medical Operations Ad-
largely on animal studies and experiments by Kherabladi visory Board, and the use of social media were all integral in
and colleagues to prevent subsequent development of a life- changing practices among practicing PJs. We also included this
threatening tension pneumothorax. 28,29 in the 2014 rewrite of our schoolhouse educational program
in Kirtland so new PJs were learning it at the beginning of
Circulation interventions (C), performed 35% of the time, was their career.
focused on establishing intravenous or intraosseous access and
delivery of blood (when available) for hemorrhagic shock or MARCH/PAWS fits into the Pararescue culture because of the
crystalloids for hypotension from medical problems. importance of TACEVAC in Pararescue Operations. The use
of checklists in the Air Force is also a cultural norm. The uni-
Severe TBI (7%) and hypothermia (26%) make up the Hs. Pre- versal adoption of MARCH/PAWS by PJs allows PJs coming
vention of hypoxemia and hypotension are the mainstays of from a different team to augment another team in a seamless
the care for severe TBI associated with increased intracranial manner. This may have the same carryover to other organiza-
pressure. More awareness of giving hypertonic saline is a more tions to improve standardization of care and increase the ease
recent effort. Hypothermia prevention to reduce coagulopa- of an Operator supporting another team and providing care
30
thy and the occurrence of the lethal triad in trauma patients the same way by all Operators.
have become more aggressive over time. 31
Various tools that can assist learning for the PJs, corpsmen, and
As noted in the Results, pain management (P) was the most medics, and make it more likely not to miss anything on patients
frequent intervention. During the time of this study, PJs be- are likely to improve patient care for our Warfighters. These
gan using ketamine more often—again, because of the influ- tools for learning and treating should be maximized, optimized,
ence of the MERT. The enhanced risk:benefit ratio compared and validated. It would be reasonable to validate this prospec-
with the use of opiates was a significant advance for managing tively in a future conflict with significant mission numbers.
traumatic pain in OEF. 32,33 Over time, we also became more
aggressive about ensuring that we ask Soldiers and Marines Conclusion
if they took their pill pack. It was routine for PJs to carry
two fentanyl lozenges in one shoulder pocket and a preloaded MARCH/PAWS is a mnemonic device that can serve as a valid
ketamine syringe in another. In many instances where US and trauma and medical care checklist for PJs, corpsmen, and

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