021 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 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. Then you performed a respiratory assessment which revealed a suspected tension pneumothorax. 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 021).

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'm 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 Kiara Mitchell six minutes ago. You moved the patient to a more secure location, put gloves on, completed a blood sweep, performed a head-tilt-chin lift, identified a tension pneumothorax, and called for help (E T A 10 minutes). You are in the Tactical Field Care phase of TCCC, starting the ‘Circulation’ portion of the MARCH algorithm.
First, check the patient’s heart rate. 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 and their pulse (if not already weak) will weaken during this scenario (depending on how long you are in the scenario).
Next, we will assess the patient's skin temperature. What is the patient’s skin temperature?
If you said normal (or) 37 degrees Celsius, good job!
Next, 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 looking at you, not opening their eyes, or following commands.
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 (increasing), and their pulse strength is going from strong to weak.  
If you saw this patient in the field, getting them to somebody with more medical training as soon as possible would be critical. The tension pneumothorax is likely causing this patient’s shock. Getting a Medic to this patient as quickly as possible is vital. Use your radio to call and update the Medic now.
Radio Response: Tracking, thank you for telling us. This patient sounds very unstable! We will send somebody to you even faster now. E T A about 5 minutes (down from 10). We are on our way. Continue to work 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 022 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
  • Open fracture of the right thigh with visible bone
  • Tracheal shift to the left side
Pathologies
  • airway obstruction
  • pneumothorax, open, right
Scoring details
  • C-Check peripheral/central pulse
  • H-Assess Neuro & Response
  • Disposition
  • Radio Medic