The M part of MARCH
Stop leaking the red stuff.
I’ll be upfront about it. My goal with this article is to get you to take a class, that might someday save your or another person’s life. Maybe even mine. And no, it’s not a CPR class…
Does anyone think that riding a motorcycle is safe?
The definition of safety is “absence of risk”.
So it is impossible to ride with an absence of risk.
Ok, so we are here to learn how to do risk mitigation.
While we really can’t avoid all risks in life, we can work towards managing the consequences when they occur. Especially in those low-probability but high-impact events. Training can make the difference between life and death.
Now that I caught your attention with some drama, let’s find out what am I talking about.
“Only 10 to 20 percent of untrained people can stay calm and think in the midst of a survival emergency.”
― Laurence Gonzales, Deep Survival: Who Lives, Who Dies, and Why
As a Search and Rescue medical specialist, I opted to train as both a wilderness (WFR) and urban first responder (EMR). In both pathways, the primary lifesaving method taught is the application of the ABC mnemonic:
These priorities make sense since your brain needs a constant supply of oxygen (O2) to function. You breathe it in through your airway, to your lungs where it gets infused into your blood, pumped by your heart, and circulated through your arteries.
ABC works well when rescuing people choking on food, experiencing anaphylaxis, or even drowning. But if your plumbing is massively hemorrhaging blood from a traumatic injury, then securing the airway becomes a secondary issue. Maintaining an open airway to oxygenate the blood, not surprisingly, works best while the blood is still inside the patient’s body.
But when I say massive hemorrhage, I am not talking about something as benign as a bloody nose. I mean:
Steady bleeding or spurting blood from a wound.
Blood pooling on the ground or blood-soaked clothing.
Bandages soaked with blood.
The bleeding has stopped and the casualty is now in shock.
I am talking about traumatic injury. Yes, they happen in the battlefield and active violence incidents, but unfortunately, they can also occur in day-to-day urban and wilderness environments. For example, construction accidents, chainsaw mishaps, or automobile collisions. Even the acute orthopedic injuries that one might sustain while skiing, especially in the pelvis, hips, or the long bones of the legs.
With this level of bleeding, death can occur much faster compared to airway and breathing complications, so the rescuer's priorities must change. As rescuers, we need to train to handle these cases. Instead of ABC as our mainstay, consider a protocol derived from lessons learned in the military world.
When the military analyzed data from combat deaths, they found that a large portion of deaths due to massive hemorrhage were potentially survivable. And the key to survival is a first responder's skill in quickly occluding blood loss.
The data also showed that the proper interventions need to be performed quickly since most of the preventable deaths occurred within 5 minutes of being wounded. Considering that the response time for urban EMS is (if you are lucky) around 4 to 6 minutes, these interventions are worthwhile learning in the civilian environment.
The U.S. Department of Defense Defense Health Agency created the Tactical Combat Casualty Care (TCCC) course, to teach the needed life-saving techniques,
TCCC improves on the ABC approach by introducing the MARCH mnemonic for casualty evaluation of immediate life threats.
MARCH involves the following steps:
Note, that we are still evaluating the same items as ABC, but with MARCH we prioritize controlling massive blood loss. These TCCC skills are not just for medics, they are beneficial for all servicemen, and civilian rescuers.
Plugging the leak
The goal here is to control the bleeding long enough to get the patient to definitive care. But what does it take to control a massive hemorrhage?
The first thing the rescuer needs to do is determine the source of the bleeding, with a quick blood sweep of the patient. In the case of penetrating trauma, we look for both entrance and exit wounds.
Once the wound(s) is found, the best method to stop the bleeding is to hold direct pressure until a clot is formed. How much pressure is that? The normal range for blood pressure from the heart is about 120 mmHg of mercury; approximately 2.3 psi. Roughly equivalent to plugging the spray from a toy squirt gun. So theoretically, it shouldn’t take much pressure at all to completely occlude arterial flow.
But in practice, we need to get through all the soft tissue (and bone) in the way.
For non-extremity wounds, such as bleeding around the neck, armpit, or groin our best option is wound packing. That topic is something I might cover in a later article. But for now, let’s focus on arms and legs.
With most extremities, we can provide enough pressure just by interlocking your fingers to form a clamshell and squeezing. This should stop almost all massive bleeding. The downside of this method is that it ties up both of the rescuer’s hands, effectively preventing us from managing other issues and wounds. This includes transporting the patient.
We should be ready with some other mechanical means such as a tourniquet.
The twisting stick
Tourniquets go way back. They have reportedly been used on the battlefield since 1674. With over 10,000 applications of tourniquets in the Global War on Terror (GWOT), they are considered the most effective lifesaving tool available in combat today.
And yet in some circles, there is still misinformation about its usage. For example, the myth about tourniquets resulting in amputation. The general conclusion is that if applied properly, a tourniquet can be left in place for up to two hours with little risk of permanent ischaemic or nerve injury.
Another myth is that using a belt is just as good as a commercial tourniquet, it’s not. Yes, sometimes you need to work with what you have, it’s neither professional nor always effective. Get a real commercial tourniquet.
I happen to be a fan of the Gen-6 or 7 Combat Application Tourniquet (C-A-T) from North American Rescue. There are others out there, and it behooves the rescuer to be familiar with them all, but the overall function is the same. My personal opinion is that the differences are more related to patent issues than functionality.
The bottom line is that a proper tourniquet needs to be about 2 -4 inches wide, tightened with some form of a windlass, and a way to secure it from unwinding.
Some other useful thoughts about tourniquets
I don’t consider the H&H SWAT-T an effective tourniquet (don’t sue me), although I do carry one as a tool to secure a pressure bandage. I actually used the SWAT-T once to fix a radiator hose leak, if that counts.
There are such things as counterfeit tourniquets, be aware and avoid them. The C-A-T is so popular that there are quite a few fakes from China being sold online. Buy direct from the manufacturer if you can.
The C-A-T is available in a few colors. I strongly suggest selecting Rescue Orange. It is much easier for emergency personnel to see and identify them, but another less obvious reason exists. In an active violence incident with high adrenaline, the orange item is less likely to be mistaken for a weapon.
When applying a tourniquet, you need to pull the band tight, before cranking the windlass. This might seem obvious, but it can get neglected in the heat of the moment. Practice!
A properly applied tourniquet is uncomfortable and most likely painful, and there is a chance that the patient will attempt to remove it. Remind that patient that this is there to save their life, and do what is necessary to keep it in place.
In a Hot Zone, apply the tourniquet high and tight (proximal) on the extremity. Once the patient is evacuated from there, if you feel that time to definitive care might be prolonged, you might consider applying a second tourniquet 2-3 inches above the wound and then judicially removing the high one.
In just about all cases, the patient will fare better when warmer. Warm blood clots better. An ingenious technique attributed to GSG-9 is to slide a space blanket up through the crotch and under the front and back of the patient's shirt to slow down heat loss.
MARCHing in the woods
Many Search and Rescue organizations have updated their protocols to employ the MARCH mnemonic over ABC and adopted the use of tourniquets as standard equipment for their rescuers.
Although, I noticed that the 7th edition of NOLS Wilderness Medicine still gave tourniquets lip service: “tourniquets are rarely needed outside a combat situation”. Their WFR class glosses over it too, and the text mostly focuses on improvised methods with a cravat and stick. A tourniquet was not yet part of their best medical kit. I have a personal opinion on this, but I’ll leave it to your imagination.
For SAR, given the difficulty of evacuating a patient from a remote location, the tourniquet is an indispensable tool and needs to be in their kit.
One other note. When doing training, once the basic skill of applying a tourniquet is learned, it’s a good idea to do some pressure testing of the rescuer. Patients sometimes offer resistance.
Be Trained or be Chained
I recently had the opportunity to supplement my training with an in-person course from Mike Shertz of Crisis Medicine. Mike knows his stuff, not only is he an emergency physician practicing in one of the busiest emergency departments in Oregon, he was a seasoned US Army Special Forces Medic (18D).
Mike has made a number of his courses available online. I was particularly impressed with his online Tactical Casualty Care TC2 course. The organization of the material and the way Mike presents it is outstanding. He cuts through all the dry BS and gives you a distilled version of what skills you need and how to apply them.
TC2 applies to a wide variety of audiences. I didn’t feel like there were a lot of prerequisites. For folks in the WFR/EMR world, TC2 offers 7.5 CAPCE credits.