The L.A.S.T M.A.R.C.H
I wonder how many of you have spent hours listening to first aid lectures, drunk stale tea in damp church halls, eaten equally damp jammy dodgers, then tried to commit to memory the facts and figures required to pass the obligatory 3 yearly examination? Then forgetting what to do once faced with an incident!
This article is based on my thirty odd years experience of being involved in the Fire and Rescue Service as well as time spent as a mountaineer and member of a mountain rescue team.
It seems to me that too many organisations involved in the administration of adventure sports state that you must hold a Health & Safety Executive First Aid at Work Qualifications and as such you are prepared to cope with any ‘incident’! This in my experience is not the case. I hope the following will spark your imagination and as Napoleons Surgeon General said ‘I don't care who saves my life so long as somebody does’!!
An accident in a remote area is undoubtedly challenging for all those involved. It will not be a simple case of calling 999, staying there and all will be well. Preparing yourself by planning in general terms of what you can do, what you should carry and have a protocol of what to do will ensure that you take the right decisions and achieve the best possible outcome for the given incident.
The well rehearsed protocol of A,B,C, for dealing with a casualty is a good fall back position and has much merit, however it can limit what actions (and outcomes) you take. In itself the A,B,C, system does not consider quality. It merely asks you to ensure that the casualty has an Airway that they are Breathing and that you can detect Circulation. Indeed the latest guidance from the Resuscitation Council suggests that you no longer try to detect a pulse and that if bleeding continues having applied two pressure dressings to a wound, and then you should remove them and start again!!
When faced with a casualty in a remote setting you may well be faced with a considerable wait until further help arrives. You can use this time to ensure that you aim to bring quality to what you do so that not only do you check that say the casualty has an airway but that they have the best possible airway given the situation or that they have circulation but that the circulation is maintained at a life saving level etc.
So here goes!
The mnemonic the ‘LAST MARCH’ may help, the LAST part is the ‘incident plan’ the MARCH part is the ‘casualty care plan’
L.A.S.T
L = LOCATION
This asks you (or someone delegated by you) to carefully consider all aspects of your location. This would include a grid reference for the casualty’s location; although a map and compass should be your primary navigation tools a GPS removes a good deal of stress in an already stressful situation. It could include identifiable features, approach routes having considered hazards such as cliffs, cornices, rivers etc. It may give wind direction for the approach of helicopters or determine the easiest route to travel in for both you if you evacuate and for the approach of any rescue team. You could identify the location of sheltered areas for the remainder of the group, identifying a suitable landing spot for a helicopter etc and means of signalling your position, flares, torches, signalling etc. On more than one occasion people have reported themselves injured on one mountain when in fact they were on another!
A = ACCESS
You should consider safe and suitable access to the victim. It may be as simple as walking to them or could mean you have to abseil over a cornice or perhaps enter avalanche prone terrain. Your access plan should consider the best way to get the rescuers to the victim and get everyone back without endangering them or the team. In some cases where the continued threat to the victim is severe you may have to carry out a so called ‘snatch rescue’ where the minimum number of personnel take the minimum amount of time to access the casualty and remove swiftly to a place of safety.
S = STABILISE
One of the primary functions of any rescue plan should be how you immediately stop the situation getting worse. This part of the plan does not concern the final outcome of the incident but focuses on immediate actions. It could be that someone has fallen and may fall again so your stabilisation plan stops them and you falling further. This could include ropes or merely standing below someone in a braced position. Once this has happened you would then consider the ‘medical’ stabilisation (more to follow) but early consideration of how to protect the casualty from the cold is vital. Anyone injured will eventually suffer from hypothermia, once cooled it is virtually impossible to proactively rewarm a casualty in the pre-hospital environment especially in the mountains.
Remember also to look after the others in your team, while you are running around they may be getting cold sat around and don’t be tempted to give up so much of your own kit that you become cold. Everyone should carry enough for their own needs.
T = TRANSPORT
Many first aid courses consider how you might move a casualty. I have already suggested that you may have to move a casualty from ongoing risks, this sort of movement will generally only be over short distances. Improvised systems can work well for short distances but long carries can be dangerous for casualties and rescuers alike. Hypothermic victims do not respond well to rough carries and neither do those with head injuries. Knowing how to improvise safe and effective carrying systems will allow snatch rescues and the movement of a casualty a short distance to get into the lee of the wind. The larger picture of transporting the victim away from the scene will be down to the rescue team, however, if your early assessment of the situation indicates that the best option is the use of a helicopter then tell the rescue services as helicopters can take time to arrange and get to scene. Other issues regarding transport could include which paths to follow or tasking someone to identify the best route to carry the victim to say, a place of shelter.
M.A.R.C.H.
As already stated, A,B,C, is a good basic standard of assessing a casualty. But in some cases where say the casualty has been traumatically injured and they are in a remote location, then you may wish to consider a different approach. MARCH identifies, in priority order, an assessment protocol that considers quality. This protocol has been developed by Combat Medical Technicians and dealing with casualties in the mountains can be likened to combat medicine! You should quickly make a decision as to which protocol you first use. If there is considerable bleeding you may wish to use MARCH.
M =MAJOR, TORENTIAL, EXSANGUINATING, HAEMORHAGE!
Ok, sounds dramatic but what we are trying to say is that once a casualty has lost a considerable amount of blood there ain’t no way they are getting it back. The best airway in the world won’t keep them alive. In the remote environment preserving the re-circulating blood volume is paramount. You should quickly control open bleeding with direct pressure and pressure bandages. The first clot is the best clot, if the bleeding is considerable get that pressure directly on the bleed it’s the only chance they have. If bleeding comes through a dressing apply more, the dressing encourages the clot to form the pressure reduces the chance of the clot being ‘blown off’ the wound. Removing dressings only removes any clot that has formed.
The use of Tourniquets is much favoured for traumatic amputations and has merit but their use can be dangerous and proper training is required and out of the scope of this article.
A =AIRWAY
If you sat in a room of people with no distracting noise, you wouldn’t be able to hear them breathe, this is normal and best described as quiet, effortless, air entry and is what we are aiming for, for our casualty.
Placing the head in neutral alignment i.e. straight and upright serves to achieve this along with clearing the airway from obstructions such as blood, vomit, teeth, snow etc. Do not be afraid to move the head into neutral alignment. Move the head in a slow controlled manner but stop if pain or resistance is felt. A person flat on their back and unconscious may not be able to maintain their airway; the tongue relaxes and lolls to the back of the throat, causing a seal.
Additionally the stomach contents can regurgitate and enter the wind pipe again preventing air entry and damaging the lungs. The recovery position should be considered for unconscious casualties or any suitable position that keeps the airway clear. No unconscious casualty should be left alone and on their back.
R = RESPIRATION
Respiration looks at the whole process of the chest movement to allow maximum air entry and exit. Normal breathing should be in the range of 12 to 20 respirations per minute, anyone outside these limits whilst at rest has a problem. Not to get to technical but the windpipe (trachea) should be central, off to one side may indicate a problem with the lung on the other side (tension pneumothorax etc). Search the back as well as the front for penetrating wound that allow air to escape, if you find a wound cover it with a pad and stick the pad to the chest with tape on 3 sides forming a type of ‘valve’ that allows air out through the wound but not in.
Other indications of a serious chest injury would be damage to the ‘Adams Apple’ (laryngeal crepitus) the presence of air trapped under the skin (surgical emphacema) or bulging neck veins (the ‘Deidre Barlows’!).
There may not be much you can do but if you find any of the above it most likely indicates serious injury and allows you to make informed decisions.
C = CIRCULATION
We've already covered bleeding and the need to preserve re-circulating blood volume. When the Doctor tell you that your blood pressure is 120/80 then that’s a measure of the pressure your heart pumps blood out and the constant pressure within the system overall. Once the ‘pump’ (Systolic) pressure drops from say a norm of 120 to below 80 then the body is struggling to self maintain, a serious sign. If you can feel the casualties pulse at the wrist (Radial) then they have a chance of maintaining a sufficient circulation if you can feel it and later it goes then they are deteriorating, not good.
In addition you can carry out a capillary refill test, press on the casualties forehead, with your thumb for a count of 5 then remove it, if the casualty has a normal blood pressure then the forehead will return from white to pink in less than 2 seconds, any slower and they are shocked. Anyone with a pulse in excess of 130 beats per minute (difficult to count but ridiculously fast) should be considered as having a major bleed (internal or external).
Before moving anyone with suspect thigh/pelvic injuries should have a strap or bandage placed around the hips and the leg splinted to reduce movement and blood loss. A fractured pelvis can cause in excess of 4 litres of internal blood loss!
H = HEAD INJURY
The major cause of death in males between 18 and 24, however it isn’t the adventure sports surrounding the mountains but combat drinking and Nova rallying! There is little we can do concerning the consequences of the initial head injury but we can do something to prevent secondary brain injury. Slowing of the respiratory functions following head injury and loss of consciousness cause a downward spiral. If a casualty with a head injury has reduced respiratory function either through the direct result of brain injury or a compromised airway then carbon dioxide levels increase within the brain tissue causing acidosis and further injury. That further injury causes swelling which the brain eventually ceases to manage which causes further swelling and so on.
The rule for the head injury is to maintain a good airway with quality respiration and circulating blood volume. In short all we’ve talked about so far! There are some complicated ways of keeping a track on someone with a head injury but for our needs a simple method of telling us that someone is improving or deteriorating is all that is required.
A.V.P.U, where
A= Alert,
V = responds to Verbal commands,
P = responds to Painful stimuli (e.g. press the neck behind the ear lobe), and finally
U= Unresponsive (doesn't mean dead!)
A word of caution, someone with a head injury can become very aggressive and combatative, protect them and you. There is a condition where a serious head injury causes breathing to increase and decrease in rhythm (Cheyne Stokes breathing) this should not be confused with breathing rhythms associated with high altitude.
And finally!
“Equipment drives capability.” It isn’t necessary to carry the kitchen sink but a few carefully selected items makes all the difference. I consider two aspects, firstly the things that can ‘get you off the hill’.
These are items that allow you to carry on, things such as blister plasters, coverings for minor cuts and grazes, crepe bandages for twisted ankles, knees etc.
Then there are the things that save lives. I carry a couple of cheap medium sized wound dressing and one specialist major bleed dressing, the ubiquitous triangular bandage has a myriad of uses. A roll of zinc oxide adhesive strapping can be used to attach dressings or splint fractures. Other items include pain killers, latex gloves and some nappy pins. These can be used to pin a cuff to a shoulder therefore elevating a wounded arm or used to fasten a jacket when the zip breaks.
There are many other bits and bobs that you could add - I’ve seen bicycle inner tubes used as an arm sling for a fractured collar bone!
The secret is not to carry too much and what you do carry should be capable of carrying out a number of functions.
As I said these are my own observations and some of you may feel that they fly in the face of what you have been taught.
Go with what you’re confident with but remember that basic skills applied well will save lives. It’s been stated that around 50% of preventable pre-hospital deaths could have been avoided if someone had had the presence to open the casualty’s airway!!
Enjoy your skiing, and enjoy your long march!
author: Ian Johnston
publish date: March 2008
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