This is your first time taking care of Jessica Hale. You are in a secure location. This scenario summarizes Circulation management in the MARCH Algorithm during TCCC Tactical Field Care.
Jessica Hale was just injured and has internal bleeding (bleeding inside the patient’s abdomen that needs surgery). The severity of that bleeding has been set very high, so you can quickly see the patient go through phases of shock. Because of this, the patient will become unresponsive and die approximately 4 minutes after starting the scenario for training purposes.
Informational Step: Shock happens when insufficient blood (and oxygen) reaches the patient’s organs. This can rapidly lead to death. At the TCCC Tier 1 level, your goal is to be able to tell if a person is in shock. If they are in shock, then you need to get them more advanced medical care as quickly as possible.
Informational Step: It is essential to assess for shock, as some injuries (such as internal bleeding) are not visible, and the presence of shock is the only indication that the patient needs more medical interventions very soon or they could die.
For this scenario, a teammate completed the Massive Hemorrhage, Airway, and Respiratory phases of care before your arrival. The patient has no bleeding (external), airway, or respiratory injuries. You already have gloves on.
Informational Step: One of the most common signs (clues) of shock is a high heart rate (higher than 100) (called tachycardia). Some other potential signs (clues) of shock are pale or clammy (cold and damp) skin, confusion (not due to head trauma), weakness, decreased urine output, and prolonged capillary refill (skin blanches for greater than 3 seconds).
First, check the patient’s heart rate. Feel the patient’s radial pulse by putting your hand near the patient’s wrist and pay attention if it is ‘weak’ or ‘strong.’ A normal pulse rate is between 60 and 100. Is this patient’s heart rate fast (tachycardia), slow (bradycardia), or normal? Is the patient’s pulse weak or strong?
This patient’s heart rate is fast (greater than 100), which can be a sign (clue) of shock. Other things can cause a high heart rate, such as physical exertion, pain, and fear. This patient’s pulse (if not already weak) will weaken during this scenario (depending on how long you are in the scenario). A weak pulse is another sign (clue) of shock.
You can assess the pulse in several locations, check each of these now, the carotid pulse (neck), the femoral pulse (groin), the radial pulse (inner part of wrist about an inch up the arm on the side of the thumb), and the pedal pulses on top of the patient’s feet (need to remove clothes and shoes). While not available on this manikin, you can also check the brachial pulse (inner part of elbow) in real life.
Informational Step: In this simulator, the heart rate is presented when you check the patient’s pulse. However, in real life, you must determine the rate independently. To do this, count the pulse for 15 seconds and multiply by 4. A normal heart rate (in an adult) is between 60 and 100 beats per minute.
Next, we will assess the patient's skin temperature. While in real life, this could be evaluated on any area of ‘unexposed skin’ in this simulator, it is assessed at the pulse locations. Check any pulse location now and pay attention to the patient’s skin temperature. What is the patient’s skin temperature?
If you said ‘normal' or 37 degrees celsius good job!
Informational Step: Note, a patient could still be in shock with a normal skin temperature, as this can be a later-stage finding (and this patient was just injured recently). While skin temperature can be a ‘clue’ to shock, it is good to note that the environment's temperature (outside temperature) can also significantly impact this. So, while this is good to know, it is sometimes less predictive
Next, we will briefly assess the patient’s mental status (if they are talking, acting, responding normally). Look to see if the patient is ‘alert.’ Are they looking at you? Next, ask the patient a question. Do you think this patient is acting normally, alert, oriented, following commands? Or are they confused?
If you said ‘confused’ (or) ‘not acting right’, good job! The patient started this scenario appearing responsive (looking around), but is now not looking around, answering questions, or following commands, which could all be because of shock. It is essential to note that a patient may not respond normally for several reasons; a common one in this setting could also be a ‘head injury.’
A powerful indicator of shock can be the trend of these signs (clues) we have assessed. Recheck the patient’s heart rate. It is likely higher now than when you started (pending how quickly you have completed this scenario).
Next, consider what you've seen in this patient. Is this patient in shock?
Yes, this patient is in shock. Their heart rate is fast (and increasing), their pulse is getting weaker, and they are not responding normally (not alert, not talking, not following commands).
Informational Step: Identifying that a patient is in shock can be hard in the field. The most helpful thing usually is repeat assessments (looking for trends such as an increasing heart rate). In this scenario, the patient's heart rate and mental status change quickly, so you can learn what to watch for.
If you saw this patient in the field, getting them to somebody with more medical training as soon as possible would be critical. This patient has bruising and tenderness to their abdomen. The patient’s shock is likely from internal bleeding. Ultimately, the patient needs blood and surgery. By identifying that the patient is in shock, you can help them get the care they need faster!
Next, open your tablet [X], select the disposition tab, and select Medical Evacuation to end this scenario. This concludes this training scenario on Circulation Management in Tactical Field Care. After reviewing the feedback panel, exit this simulation and select scenario 019.
