017 ASM

Respiratory Management Essentials in TCCC – Tier 1. You remain in a SAFE and SECURE location – The primary learning objective is to practice the Respiratory phase of care in the M A R C H algorithm: inspecting the chest for wounds and for any evidence of a tension pneumothorax (dropped lung) in a tactical field care resuscitation scenario.

You first started taking care of Private Kiara Mitchell in Care Under Fire, you moved the patient to safety, and no massive bleeding was identified on blood sweep. You then identified an airway obstruction, that improved with a head-tilt-chin lift. You already have personal protective equipment (gloves) on. No other interventions have been performed.

Initially, the casualty was near a drone explosion that occurred 8 minutes ago (it has been one minute since you last saw the patient). This scenario occurs in the Tactical Field Care Phase and covers the MA[R]CH portion(s) of care. Equipment Available: Individualized First Aid Kit (IFAK) U.S Version (x2). Evacuation/Disposition is possible through the tablet. Selecting the patient’s disposition will end the exercise. (This is Scenario 017).

Dynamic Physiology Disclaimer:
To obtain the most accurate and effective training experience, we recommend completing each scenario in one uninterrupted session. The virtual patients used in this training are powered by highly realistic physiological models that continuously adjust vital signs and overall condition. The scenarios have been modified to give you time to review instructional materials, and you will not lose points for delays in scenarios with instructional content. However, it is still possible that, depending on your completion pace, the scenario may not progress in perfect alignment with the guided prompts, and for critically injured patients, even moderate delays may result in deterioration or death before the scenario concludes. This is not meant to indicate you did not perform well; rather, it is because of how the high-fidelity engine performs.

Ongoing Development Disclaimer: In this package wording has not been updated to reflect new functionality to time and date tourniquets or for the non-adhesive burn bandage functionality. Additionally, it is possible other small updates or changes are not reflected in the wording. All grading is set to the current standard described in this package.

Patient Communication

Patient: Hey, I am here to take care of you.
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Can you tell me your name?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: What happened?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Are you hurting anywhere?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your throat hurt or feel tight?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Are you having a hard time breathing?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your chest hurt?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Did you pass out (lose consciousness)?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Do you have any numbness or weakness?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your head hurt?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your neck hurt?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your back hurt?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Does your abdomen hurt?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Do you have any allergies?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Do you take any medications?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Do you have any medical problems?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Have you ever had any surgeries?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: When did you last eat or drink something?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: Do you smoke, drink, or use recreational drugs?
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: I am going to remove your clothes to look for wounds.
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: I am here to take care of you.
Response: The patient isn't able to speak, and has noisy breathing
Location: Head
Patient: I’ll use the back of my hand to check under your breast
Response: The patient isn't able to speak, and has noisy breathing
Location: Head

Guided Steps

You started caring for Private Kiara Mitchell four minutes ago. You moved the patient to a more secure location, put gloves on, completed a blood sweep, and performed a head-tilt-chin lift. You are now in the Tactical Field Care phase of TCCC, starting the ‘Respiratory’ portion of the MARCH algorithm.
First, assess the patient’s respiratory effort (how hard they are working to breathe). Is this patient breathing slow, normal, or fast?
This patient’s respiratory rate is fast. The normal respiratory rate is between 12 and 20. This patient’s respiratory rate is faster than 20.
Next, assess (look at) the chest, upper back, areas under breasts, and armpits for any wounds that could cause a tension pneumothorax. You must open the patient's IFAK and remove the patient’s clothing using shears. You also must roll the patient over and respectfully (but quickly) move breast/mammary tissue. Did you find any wounds on this patient?
The patient has a wound on the right chest (front) and the right upper back! When you roll the patient over, their airway positioning shifts and stridor returns (indicating the airway re-obstructed). Perform a head-tilt-chin lift.
Next, see if the patient has unilateral chest rise and fall (only one side of the chest is rising and falling).
The right side of the patient's chest is not moving (this is called unilateral chest rise and fall).
Next, look for any tracheal deviation (windpipe shifted to one side or the other). Do you see any tracheal deviation?
This patient’s trachea is deviated (pushed) to the left.
Next, look for distended neck veins (neck veins bigger than usual). Are these patients’ neck veins bigger than usual?
The patient’s neck veins are more prominent than usual (jugular venous distention).  
Next, consider what you've seen in this patient. Do they have a tension pneumothorax (a dropped lung under pressure)?
The patient is showing several signs of a tension pneumothorax, an injury that can be rapidly fatal! Getting a Medic to this patient as quickly as possible is critical. Use your radio to call for a Medic now (activating the radio with the [TRIGGER] will give you credit for this step).
Radio Response: We are on our way! It will take us at least 10 minutes to get to you. Keep working your way through the MARCH algorithm in the meantime.
Next, open your tablet [X], select the disposition tab, and select Medical Evacuation to end this scenario. This concludes this training scenario on Respiratory Management in Tactical Field Care. After reviewing the feedback panel, exit this simulation and select scenario 018 to continue. 

Scenario Details

Scenario Package
TCCC Tier 1 Curriculum
Learner type
  • militaryMedic
Patient severity at start
Serious
Patient severity overall
Serious
Duration to complete
<5 minutes
Scenario difficulty
Standard
Environment
POI
Equipment
  • Bandage
  • Combat Application Tourniquet (1)
  • Combat Application Tourniquet (2)
  • Trauma Shears
  • Blanket
  • FoilBlanket
  • Nasopharyngeal airway
  • Chest Seal Package
  • Packing Gauze
  • Gloves
  • Eye Guard
  • Non-Adherent Dressing
  • Medication Pouch
  • Radio
  • Marker
  • Triage Tag (Minimal)
Available medications
  • Acetaminophen Pills
  • Moxifloxacin 1 g
  • Meloxicam 15mg
Injury type
  • Deep wound on the right arm
  • Gunshot entry wound, chest right
  • Gunshot exit wound, back right
  • Jugular vein, left side
  • Jugular vein, right side
  • Open fracture of the right thigh with visible bone
  • Tracheal shift to the right side
Pathologies
  • airway obstruction
  • pneumothorax, open, right
Scoring details
  • R-Exposure
  • Displace Mammary Tissue
  • Radio Medic
  • Disposition