020 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 Luke Hensley in Care Under Fire, you moved the patient to safety, and then you identified massive bleeding from a groin wound and placed wound packing and a pressure bandage. Next, you identified an airway obstruction, which you helped resolve by sitting the patient up. 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 20).

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 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 Luke Hensley five minutes ago. You moved the patient to a more secure location, put on gloves, performed a blood sweep, managed bleeding from a groin wound, propped the patient upright, and assessed respirations. You are now in the Tactical Field Care phase of TCCC, starting the ‘Circulation’ portion of the MARCH algorithm.
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 is strong.
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!
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.
It is difficult to assess this patient’s mental status because the patient has an airway obstruction and is having a hard time talking. The patient’s eyes may or may not be open depending on their level of consciousness.
A powerful indicator of shock can be the trend of these signs (clues) we have assessed. Recheck the patient’s heart rate. It is relatively stable.
The patient's heart rate appears stable.
Next, consider what you've seen in this patient. Is this patient in shock?
No, this patient does not appear to be in shock. Their heart rate is fast (but relatively stable), and their pulse strength is strong (and stable). Overall, it can be hard to identify shock in the field. The most helpful thing usually is repeat assessments (looking for trends such as an increasing heart rate).
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 021 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
  • Facial burn
  • Groin junctional wound, left side
  • Left lower hand burn
Pathologies
  • airway obstruction
  • external hemorrhage, left kidney
Scoring details
  • C-Check peripheral/central pulse
  • C-Assess Neuro and Response
  • Disposition