019 ASM

Circulation Management Essentials in TCCC – Tier 1 – You are in a SAFE and SECURE location – The primary learning objective is to practice the Circulation phase of care in the M A R C H algorithm: evaluating the patient’s heart rate (basic vital sign) and assessing for evidence of shock. The estimated time to complete this scenario is 5 minutes. You first started taking care of Private Danny Rivers in Care Under Fire where you identified a LEFT LOWER EXTREMITY massive hemorrhage and placed a tourniquet on the left leg and then moved the patient to safety. Next you performed a blood sweep which was normal. You then identified an airway obstruction and implemented a head-tilt-chin lift. Then you performed a respiratory assessment which was unremarkable. You already have personal protective equipment (gloves) on. No other interventions have been performed. Initially, the casualty was near a drone explosion that occurred 9 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 MAR[C]H 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 019).

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: I don't have any numbness or weakness.
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 here to take care of you.
Response: The patient isn't able to speak, and has noisy breathing
Location: Head

Guided Steps

You started caring for Private Danny Rivers five minutes ago. You placed a tourniquet on his left leg, moved the patient to a more secure location, put on gloves, completed a blood sweep, performed a head-tilt-chin lift, and assessed respirations. You are now in the Tactical Field Care phase of TCCC, starting the ‘Circulation portion of the MARCH algorithm.
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 more 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.
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! 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?
The patient is unresponsive (not answering questions, not following commands, and not acting normally).  
A powerful indicator of shock can be the trend of the 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 likely in shock. Their heart rate is fast (and increasing), and their pulse strength is going from strong to weak. This can be hard to determine in the field. The most helpful thing usually is repeat assessments (looking for trends such as an increasing heart rate).
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 and blood loss from their amputation. 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! 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. In the meantime continuing working through the MARCH algorithm.
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 020 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
5-10 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
  • Abdominal internal bleeding
  • Amputated left leg at knee
  • Bruise behind right ear
  • Eye cornea trauma, left side
Pathologies
  • airway obstruction
  • external hemorrhage, left leg
  • internal hemorrhage, vena cava
Scoring details
  • C-Central/Peripheral Pulse
  • H-Assess LOC
  • Radio Medic
  • Disposition