SMARCH - The acronym that saves lives: QMN036
Martial Mental Models: The Quartermaster, Thursday, 13 June
(Today’s report is a 6 minute read)
BLUF: SMARCH helps Green Berets save lives by listing in priority order the steps necessary for treating life threatening wounds in combat. It was introduced as part of a new methodology for treating and evacuating casualties called Tactical Combat Casualty Care (TCCC), and addressed not only the type of wounds soldiers were experiencing, but the environment in which they occurred.
Brady here. As many readers of The Quartermaster know, I spent my formative years within the confines of military schools. One thing that's common to all military schools is that they demand incoming freshmen memorize a long list of seeming useless knowledge - facts, phrases, doctrine, songs, quotes - to be recited on command at any time of day to an upperclassman. Thankfully one of those pieces of knowledge I had to memorize at 14 was The Four Lifesaving Steps. Clear the Airway, Stop the Bleeding, Control & Treat for Shock and Protect the Wound. These steps were to be taken when an individual came upon a wounded person - even an unconscious one - in order to improve the likelihood that the injured person would stay alive long enough to reach intensive medical care. They aren't exhaustive, detailed steps, but they can be retained and recalled by a teenager or soldier overloaded with information in a stressful situation. And for a non-medical-professional in the 1990s, that was about as good as it got.
The conflicts that followed 9/11 brought on many more opportunities to improve trauma medical skills. Direct firefights provided more gunshot wounds and roadside bombs - also known as improvised explosive devices (IEDs) - provided blast and shrapnel injuries not seen by US troops since they encountered enemy artillery strikes in Vietnam. A new methodology for treating these casualties and evacuating them was developed by US Forces called Tactical Combat Casualty Care (TCCC), and addressed not only the type of wounds we were experiencing, but the environment in which they occurred. And the Four Lifesaving Steps were revised and reprioritized - and became SMARCH.
SMARCH stands for Security, Massive hemorrhage, Airway, Respiration, Circulation, and Hypothermia. The steps here are in order of priority for a tactical trauma situation- meaning that each step is more critical for being quickly addressed than the next. I'll cover them here. (It's important to note that none of the below is medical advice- it's a high level explanation of a memorized process for treating casualties in combat):
Security: Many injuries in Iraq and Afghanistan were sustained in active combat where combatants could be approaching and engaging from any direction. In many cases direct fire was a factor in reaching and moving the casualty. Originally the acronym was just MARCH until repeatedly applied in combat, where the immediate area had to be secured, or the casualty had to be removed under fire.
Massive hemorrhage: Finding the source of bleeding and applying direct pressure is the first medical step in SMARCH. Serious loss of blood became a major factor in survivability of combat trauma (considered to be the leading cause of preventable battlefield deaths), and so immediate and effective application of tourniquets became even more important than before. Originally taught as a field-expedient method using a piece of cloth and a stick, soldiers began carrying purpose made tourniquets like the SOF-T or RATS that could often be used one-handed by the injured soldier himself if possible. Additionally, hemostatic bandages became more available and made clotting considerably faster.
Airway: Keeping the airway open is key - in many cases a casualty will be unconscious such that breathing has to be continuously monitored, but in most cases keeping the airway open is a matter of head and jaw placement. In some cases such as facial trauma trained medical personnel perform a cricothyrotomy or insert a Naso-Pharyngeal Airway(NPA). The idea is make sure the airway isn't blocked, and stays that way.
Respiration: It's been told to me that what causes most deaths from gunshot wounds to the abdomen are 2 things: the chest filling up with air from a sucking chest wound or filling up with blood from a massive internal hemorrhage. These are dangerous because pressure from both blood and air will collapse lungs and keep them from working. Finding chest wounds and sealing them, monitoring breathing and alertness, and then if needed having a trained professional relieve pressure with Needle Decompression or a chest tube are all the substeps that happen here.
Circulation: This step involves finding any other non-life-threatening bleeding, and evaluating the casualty's pulse and blood pressure. If the blood pressure falls below a certain level it's an indicator of shock - and this is where intravenous (IV) access is gained and blood, plasma or blood expanders are administered. Many medics anticipate this and gain an IV as soon as possible. Predecessor methodologies like Combat Lifesaver address this requirement and many soldiers have practiced giving IVs in field situations for decades. The IVs address any preexisting blood loss and keeps the casualty’s blood pressure where it needs to be.
Hypothermia: Often overlooked in trauma situations, hypothermia has accounted for enough battlefield deaths to be a concern. Keeping the casualty as warm as possible during treatment and evacuation is important - just as is checking for signs like shivering, slurred speech or mumbling, or slow, shallow breathing.
Key to making SMARCH an effective model for keeping injured people alive long enough to receive intensive medical care are two things: preparation and practice. Green Berets load, check and recheck aid bags and individual first aid kits (IFAK) to ensure they have all the tools ready and in working order. Situational training, led by team medical sergeants, is used often on a weekly basis to ensure everyone stays up to date on the latest practices and can take lifesaving steps by memory in bad situations. A discussion of IFAK contents can be covered in a future post. (BJM)
A good summary of TCCC can be found on Survivalblog.com - and for those who want to see the big picture results of the advances in trauma medicine that were made during the last couple decades, check out JAMA’s Original Investigation The Effect of a Golden Hour Policy on the Morbidity and Mortality of Combat Casualties from 2016.
MORE ON GREEN BERET MEDICAL MEDIA WITH CPP:
I like these two accounts because they’ve somehow, surprisingly, not been taken down by Instagram. These two account runners often post medical trauma videos and photos - not for the faint-of-heart. In just a few weeks, however, I’ve learned about Battle’s Sign, why having a trauma surgeon in the field can be so valuable especially for heavy trauma, how to improvise chest seals, how to be prepared to treat injuries for working dogs, and so on.
There are almost no instagram accounts that I can think of that provide more relevant, useful, and ‘real talk’ information about lifesaving skills for anyone who wants to be prepared for the violent reality of being ‘in the field’
And then of course there’s posts like this that remind me that there are just some things you can’t teach. (CPP)
THE SPY IN YOUR POCKET: LaLiga’s app listened in on fans to catch bars illegally streaming soccer (3 min) “Using a Shazam-like technology, the app would record audio to identify soccer games, and use the geolocation of the phone to locate which bars were streaming without licenses. El Diario reports that fans have downloaded that app more than 10 million times, essentially turning them into undercover narcs. The league claims that the app asks for permission to access the phone’s microphone and location, and that the data — which is received as a code, not audio — is only used to detect LaLiga streams. The app does explain in the terms of service that by giving the app permission, users are consenting to LaLiga using their phones to detect fraudulent behavior, like pirated soccer games.” (KSA)
Remarks Complete. Nothing Follows.
KS Anthony (KSA), Chris Papasadero (CPP) & Brady Moore (BJM)