MARCH versus ABC

[LoneRider]

I accidentally double posted this thread a while back, and requested it be deleted and both copies were in fact deleted. So I'll repost my question again.

Sometime last week my unit held Combat Lifesaver Training (roughly akin to civilian first responder training) and learned how the US Army prioritizes trauma management.

Having gone through the US Navy Search and Rescue Swimmer and Repair Locker Leader courses where first-aid and trauma management were extensively covered, and having taken a basic first aid course at NOLS (National Outdoor Leadership School) in Lander Wyoming four years ago I'd always been taught ABCs (Airway, Breathing, Circulation) for patient assessment.

Army CLS has that in the curriculum only to tell us that such a prioritization is better suited to areas where hospitals are immediately accessible, i.e. most of the industrialized/post-industrialized world. The Army teaches us MARCH (Massive Bleeding, Airway, Respiration, Circulation, Head Injury/Hypothermia) as our priorities. They even told us that the MARCH system is making its way into the civilian EMT/Paramedic field, is this the case?

I can see where MARCH might be more useful than ABCs, i.e. industrial accidents, vehicular accidents, crime related injuries, etc...But what are the pros and cons of the MARCH versus the ABC in civilian emergency medicine?

[Ridryder 911]

I never heard of such and as well, doubt it will for at least another five to ten years. The reason being it is not contained within the new curriculum and before it makes it into traditional studies it will have to be reviewed and placed into standard courses such as ITLS/ PHTLS and so forth.

It might be placed into standard curriculum for military medicine, but doubtful for civilian at this time. The old saying and labelling of primary and secondary survey (replace initial and detailed) is just now returning after being gone for nearly a decade. There was much debate of even returning the traditional wording of what is already usually taught.

R/r 911

Edited July 13, 2009 by Ridryder 911

[EMT Foose]

I've been told by several military buddies their system is basically CBA rather than ABC. It makes sense when traumatic amputations are commonplace, like in a warzone.

Realistically, as a paramedic or lead EMT in charge of the scene, aren't you going to order another responder to address a major hemorrhage as you assess airway/breathing? At least by direct pressure with a gloved hand while dressings/tourniquets are opened up. PHTLS stresses that every RBC is precious in major trauma, and ideally major hemorrhage is controlled while A and B are assessed. That's assuming you have the manpower, otherwise it's still ABC outright in the primary survey.

I can see the MARCH system creating problems if street medics start focusing on controlling minor to moderate bleeds prior to airway/breathing control...which is a definitely a possibility.

[Doczilla]

M- Massive exsanguination. This is defined as heavy constant bleeding that is acutely life threatening and obvious on the most cursory inspection. Hemorrhage from an extremity is the most common cause of preventable battlefield death. Since we've debunked the myths surrounding tourniquets that have been taught in EMT school (and still are in many places by the unknowing), civilian EMTs are paying more attention to tourniquets as a method of bleeding control. The fact is that they are safe, and can more or less be applied with impunity. In the military setting, replacing lost blood is not nearly as easy as it is in the civilian setting, and since MEDEVAC may take many hours (or days), it is vital to preserve as much of the red stuff as possible since field transfusion may not be feasible. It may be easier to get a transfusion going at the trauma center, but it's much easier to save it in the first place. Bottom line is that civilian EMS should carry and be trained in proven combat tourniquet use. This goes in front of the airway because it is easily recognizable and very quick to deal with, as tourniquet application takes about 30 seconds.

A- Airway. Airway compromise is the second most preventable cause of combat death. And now we're hitting the traditional ABCs.

R- Respirations. This is to some extent respiratory rate, but also addressing tension pneumothorax, which is the 3rd most common cause of preventable battlefield death. For the purpose of calling the 9-line MEDEVAC request, you need to know if you need a ventilator if you are breathing for them.

C- Circulation. We don't tend to do CPR for massive trauma, but here we address vascular access and fluid resuscitation.

H- Hypothermia/Head injury. Hypothermic trauma patients do rather poorly compared to case matched controls. 1 degree of hypothermia will increase blood loss in surgery, so it's a very important aspect of trauma care. The providers are typically still in protective gear, not stripped naked on the cold ground, and then there's the aspect of a windy transport in a helicopter. So patient's should be warm and kept warm. Putting this in the pneumonic reminds them that they need to hood and wrap the casualty, and that addressing hypothermia is absolutely essential.

These recommendations grew from combat trauma, which is mostly penetrating trauma, rather than civilian trauma which tends to be blunt trauma. Life threatening hemorrhage from an extremity is fairly rare in the civilian setting, so this is probably why it's not catching on that fast. Still, there are important lessons in it, and I think that for civilian trauma, it should still be used.

The other thing is that the above is not nearly as applicable for civilian medical emergencies, which usually comprises the majority of EMS runs.

'zilla

[LittleMissEMT]

I've been told by several military buddies their system is basically CBA rather than ABC. It makes sense when traumatic amputations are commonplace, like in a warzone.

Realistically, as a paramedic or lead EMT in charge of the scene, aren't you going to order another responder to address a major hemorrhage as you assess airway/breathing? At least by direct pressure with a gloved hand while dressings/tourniquets are opened up. PHTLS stresses that every RBC is precious in major trauma, and ideally major hemorrhage is controlled while A and B are assessed. That's assuming you have the manpower, otherwise it's still ABC outright in the primary survey.

I can see the MARCH system creating problems if street medics start focusing on controlling minor to moderate bleeds prior to airway/breathing control...which is a definitely a possibility.

I absolutely agree, it will deffinately be a problem if we start treating bleeding before airway.

[LoneRider]

I absolutely agree, it will deffinately be a problem if we start treating bleeding before airway.

It depends on how traumatic a bleed we're speaking of. And I agree with the MARCH system's tourniquet methods.

These recommendations grew from combat trauma, which is mostly penetrating trauma, rather than civilian trauma which tends to be blunt trauma. Life threatening hemorrhage from an extremity is fairly rare in the civilian setting, so this is probably why it's not catching on that fast. Still, there are important lessons in it, and I think that for civilian trauma, it should still be used.

And don't car accidents/industrial accidents also have incidents of large amounts of bleeding too? Just curious. And car accidents are a fairly high incidence occurance. I would imagine they entail a lot of blunt force trauma, but can't life threatening hemorrhage also be entailed too?

RBC is precious in major trauma, and ideally major hemorrhage is controlled while A and B are assessed. That's assuming you have the manpower, otherwise it's still ABC outright in the primary survey.Realistically, as a paramedic or lead EMT in charge of the scene, aren't you going to order another responder to address a major hemorrhage as you assess airway/breathing? At least by direct pressure with a gloved hand while dressings/tourniquets are opened up. PHTLS stresses that every

In the case of a bleeding or amputated limb, a tourniquet can address that issue rather swiftly and decisively and then one can tackle the airway issue, again from what I've been trained on the CLS front.

[Kiwiology]

I can see the MARCH system creating problems if street medics start focusing on controlling minor to moderate bleeds prior to airway/breathing control...which is a definitely a possibility.

I would argue this says more above a provider's common sense and critical thinking than the mneomic itself. As it would be, an ED RN and myself were talking about this very thing on a flight to Phoenix.

I don't really see a problem with teaching any one method vs. another; the problem is not the method itseld but those using it.

If my patient is bleeding profusely and profoundly hypovolemic I'm sure as hell going to bust an artery clamp or tourniquet on that bleeder before I piss around counting respirations and applying oxygen! My side is that these aids and tools are helpful but if we worry that by teaching MARCH instead of ABC (for example) will create people focusing on things out of order (e.g. controlling a shaving cut before clearaing a FBAO) does that say more about what we are teaching or who we are teaching it to?

To prove a point -- if I see a patient who is bleeding heavily but looks very cyanotic and is grasping his throat in the classic "choker" position; I'm sure as hell going after that FABO rather than applying pressure onto that bleeder because you decompensate from lack of oxygen faster than you do from hypovolemia ... yes I THINK I learnt that in A&P class!

Once I saw an EMT run through SAMPLE OPQST with a chest pain/peri-arrest patient and he acted surpised when the patient collapsed infront of him. Again, I argue common sense and critical thinking! This patient was ashen, grey, sweaty, doubled over clutching his chest struggling to breate so why fuck around asking "oh sir when did you last eat?" well hotshot he aint gonna be eatin' again if you don't do something!

One of my friends had to argue and argue and argue with one of our simulation assessors about this very thing; she was failed because she decided to administer IM adrenaline to a refractory anaphylaxis patient before doing a blood sweep; both myself and the Advanced Paramedic (ALS) agreed with her; it was more important to use critical thinking skills and determine the need for this patient to recieve adrenaline before worrying about jerking around doing a blood sweep.

I think this whole thing says more about us as providers than the system itself.

[nremtp]

Having worked as a civilian paramedic attached to the military (Royal Marine Commandos) I have been taught MARCH which in my opinion is a far more useful method than ABC of approaching a casualty. ABC means nothing if your casualty is bleeding out and what is the point in compressing the chest if all you are doing is pumping blood out of the wound?

As civilian EMS is shaped, guided and in fact based on military medicine it is highly likely that this will become mainstream EMS practice. We wouldn't have EMS if it wasn't for the military battlefield medical care of Napolean and more recently we are seeing battlefield EMS hit the civilian streets.

[LoneRider]

Having worked as a civilian paramedic attached to the military (Royal Marine Commandos) I have been taught MARCH which in my opinion is a far more useful method than ABC of approaching a casualty. ABC means nothing if your casualty is bleeding out and what is the point in compressing the chest if all you are doing is pumping blood out of the wound?

As civilian EMS is shaped, guided and in fact based on military medicine it is highly likely that this will become mainstream EMS practice. We wouldn't have EMS if it wasn't for the military battlefield medical care of Napolean and more recently we are seeing battlefield EMS hit the civilian streets.

That's good to hear. When I transfer to the reserves in three years I intend to work in EMS for my local fire department (Orlando, FL). Good to hear that some of my military trauma management training will still be useful.

[AnthonyM83]

I would argue this says more above a provider's common sense and critical thinking than the mneomic itself.

I like the acronym just because it's more encompassing. The classroom way should be like the field way, otherwise it was a poor classroom way. Even if someone with common sense would disregard the order of ABC's, it's more satisfying to have the "ABC's" actually fit the situation.

if I see a patient who is bleeding heavily but looks very cyanotic and is grasping his throat in the classic "choker" position; I'm sure as hell going after that FABO rather than applying pressure onto that bleeder because you decompensate from lack of oxygen faster than you do from hypovolemia ... yes I THINK I learnt that in A&P class!

I'm not "sure as hell" doing that for sure.

Evaluate the bleed. Is it "MASSIVE"? Evaluate the level of hypoxia. Is he blue and about to lose consciousness? I would then make the decision.

There's a few steps to that process. Depends on the scenario. I can't bring back ischemia brain cells (whereas I can get patient to a hospital for a blood transfusion). BUT if he can handle the choking for 30 seconds while I slap on a TQ, then I might do TQ first. Depends.

One of my friends had to argue and argue and argue with one of our simulation assessors about this very thing; she was failed because she decided to administer IM adrenaline to a refractory anaphylaxis patient before doing a blood sweep; both myself and the Advanced Paramedic (ALS) agreed with her; it was more important to use critical thinking skills and determine the need for this patient to recieve adrenaline before worrying about jerking around doing a blood sweep.

I think this whole thing says more about us as providers than the system itself.

That's one of the classic problems with testing in EMS. Do we test to see if they know and can do the baseline order of procedures? Or do we test to see if they can treat a patient?

The latter scenario might be very incomplete. He might be able to save the patient, but barely, but not show knowledge of other things in the scenario because they weren't applicable.

The examining entity should make their testing methods very clear to the testees beforehand.