Patient Assessment and Packaging in Rescue Environments

Patient Assessment and Packaging in Rescue Environments

Rescue environments — crashed vehicles, confined spaces, collapsed structures — add layers of hazard that make patient assessment more demanding than a routine street call. Before you touch any victim, confirm scene safety, don appropriate PPE (at minimum nitrile gloves; add eye protection and helmet if debris or fluid exposure is possible), and ensure the mechanism that caused harm is controlled or stabilized. Never compromise your own safety: a second casualty helps no one.

The MARCH Framework

Military-derived and now widely adopted in civilian tactical and rescue medicine, MARCH organizes your primary assessment around the most rapidly lethal threats.

M — Massive Hemorrhage. Uncontrolled external bleeding kills faster than almost any other survivable injury. Expose the wound, identify whether it is extremity, junctional (groin, axilla, neck), or truncal, and act immediately. Extremity wounds get a commercial tourniquet; junctional wounds get wound packing with hemostatic gauze and direct pressure.

A — Airway. Is the airway open and unobstructed? A conscious patient who is speaking clearly has a patent airway. An unconscious patient may need a jaw-thrust (preferred when spinal injury is possible), an oropharyngeal airway (OPA), or suction. Never hyperextend the neck of a trauma patient before ruling out spinal injury.

R — Respiration. Count rate and assess depth and symmetry. Look for paradoxical chest movement (flail segment), tracheal deviation, or absent breath sounds, which may indicate tension pneumothorax. Provide supplemental oxygen per local protocol when available.

C — Circulation. Assess radial pulse rate and quality. Pale, cool, diaphoretic skin with a weak or absent radial pulse signals shock. Treat bleeding sources not addressed in the M step, keep the patient warm, and position to improve perfusion if spinal injury has been ruled out.

H — Hypothermia Prevention. Entrapped patients rapidly lose body heat, especially in metal vehicles or wet environments. After addressing hemorrhage, airway, and circulation, cover the patient with a space blanket or rescue blanket and minimize time on cold surfaces.

Tourniquet Application

A commercial windlass tourniquet (such as a CAT or SOFT-T Wide) is the standard of care for life-threatening extremity hemorrhage. Apply it 2–3 inches proximal to the wound over clothing or bare skin — never over a joint. Tighten the windlass until bleeding stops, lock it, and note the time of application on the device. Confirm arterial occlusion by reassessing distal bleeding and, if accessible, loss of distal pulse. Document application time and communicate it clearly during handoff.

Critical safety rule: Do not remove a tourniquet in the field once applied. Removal is a hospital decision.

Wound Packing with Hemostatic Gauze

Junctional wounds (groin, axilla, base of neck) cannot be controlled with a tourniquet. Pack the wound cavity completely by pushing hemostatic gauze deep into the wound void with a finger or two fingers, continuing to layer gauze until the void is filled, then applying firm direct pressure for the time specified on the product (commonly three minutes minimum). Hold pressure continuously — releasing early allows clot disruption. Communicate the product used and time of application during transfer.

Spinal Motion Restriction (SMR) in a Confined Space

SMR replaces the older concept of full spinal immobilization. The goal is to limit motion that could worsen an unstable spinal injury, while still allowing timely extrication. In a vehicle or confined-space scenario:

1. Assign roles before contact. One rescuer is dedicated head-holder throughout; a second is the packager.

2. Size and apply a cervical collar. Measure from the shoulder to the jaw to select the correct size. The collar limits flexion and extension but does not eliminate all motion — the head-holder's hands remain in place.

3. Seat the patient on the KED (Kendrick Extrication Device) or prepare the Sked. The KED is designed for sitting vehicle patients. Slide it behind the patient, position the head flaps, secure torso straps (middle, bottom, top), then leg straps, and finally head straps in that order. Do not release the head-holder until head flaps are secured.

4. Transfer to long backboard. Rotate the packaged patient as a unit, lower to the board, and apply straps. Maintain in-line alignment throughout — no one releases the head until the patient is secured.

5. Reassess after every move. Check airway, breathing, circulation, and extremity sensation/movement after packaging and again after transfer.

Handoff and Documentation

At transfer to EMS or receiving personnel, provide a concise verbal report: mechanism of injury, findings in MARCH order, interventions applied (tourniquet time, gauze product, SMR device), any changes in patient status, and your name and role. In a rescue environment, clear communication prevents interventions from being missed or duplicated.

Safety Reminders

• Don nitrile gloves before patient contact; upgrade PPE if there is risk of arterial spray or contaminated fluid.
• Stabilize the vehicle or prop before working inside it.
• Account for all gauze placed in a wound and document the count.
• Never leave a tourniquet patient unmonitored; check distal circulation distal to the device regularly.
• If working in a confined space, follow your department's confined-space entry protocol independently of patient care.