Beyond MARCH: Rescue and Prolonged Field Care 1000 Miles from Anywhere
How would you, your team, or agency handle a situation where you not only had to access a patient far from anywhere, but then had to care for them for many hours, or even days, before exfiltration was possible?
I recently spoke about just such a case at the Australian Tactical Medicine Conference in Brisbane, Australia (check out the work the Australian Tactical Medical Association is doing; they are amazing go-getters).
US Air Force Pararescuemen (PJs) were tasked to access and care for two critically burned men aboard a ship more than 1000 miles out to sea, halfway between New York and Portugal. They flew out in an HC-130, parachuted into the sea at night, boarded the ship from Zodiacs, and met their patients. Over the course of 32 hours, the men cared for these patients, who required airway management (ETI for one, crich for another), escharotomies, continuous pain control and sedation, frequent burn debridement and dressing changes, ventilator management, and more. They were eventually hoisted off the ship by a Portuguese coast guard helicopter on day 3 of the mission.
As complicated and difficult as this all sounds (and it was a massive effort), the medical care was based on the adaptation of a relatively basic tactical medicine construct – MARCH. This is a memory device that covers the major assessment and management priorities when caring for a patient in a tactical environment:
MASSIVE HEMORRHAGE – Control it!
AIRWAY – Open and maintain by whatever means necessary.
RESPIRATIONS – Support ventilations if needed. Cover any holes in the chest. Make holes if needed.
CIRCULATION – Obtain access and give fluids, blood, TXA.
HEAD INJURY / HYPOTHERMIA – Think of head injury and avoid hypoxia/hypotension. Control the environment: get the patient off the ground, keep warm.
Over the years of recent wartime experience, the PJs have refined this approach in order to better care for patients in the tactical and prolonged care environment with their paramedic skillset. So MARCH becomes MARCH / PAWS.
The PAWS adds:
PAIN – Provide pain control and sedation early and often.
ANTIBIOTICS (and) – Antibiotics for battlefield wounds, and other meds as needed (think antiemetics).
WOUNDS – Irrigate and debride battlefield wounds and burns as soon as feasible.
SPLINTING – Splint fractures, apply c-collars, eye shields, and spinal protection if indicated.
This framework as written is great in a tactical or prehospital environment when you can run through it, address the major issues, and then head right off to a trauma center. In the case of a prolonged care scenario, when you may be with the patient for hours or days, MARCH / PAWS must necessarily become a cycle: constantly reassess, continue to work the problems throughout the time you are caring for the patient. Keep going back to that airway, verify no tension pneumo is re-accumulating, tweak the vent as needed, maintain sedation and pain control, clean and redress wounds, etcetera.
More important than memorizing and using these acronyms is to anticipate that a prolonged care scenario will happen to you. This could be your next mission. So train for these situations, prepare yourself and your team for this eventuality. Find a way to stay organized and calm, and not miss any important elements of your patient’s care during the complexity and stress of the cases. MARCH / PAWS is one battle-proven way to not only keep it together, but to excel.
Relevant references, videos about this mission and pararescue in general, links to podcast episodes detailing this mission, and other resources for the original talk can be found in the lecture notes.