August 11, 2025

This month's continuing education will cover Active Shooter/Hostile Event Response (ASHER) and is presented by University Hospitals Tactical Medicine Division. 

Part 2, Casualty Assessment  

Last week, we reviewed the strategies used to assess our casualties under force protection. The second casualty care benchmark we must review is assessment. Tactical Emergency Casualty Care (TECC) operational principles tell us we must have a dedicated casualty assessment methodology. Considered the standard in the military TCCC and civilian TECC/TEMS community is the mnemonic MARCH: Massive Hemorrhage, Airway, Respiration, Circulation, Head/Hypothermia. Using MARCH guides the medical provider with an order of operations to identify and address life-threatening conditions by priority. We will present an in-depth explanation of how MARCH should be applied during ASHER, as it is very nuanced.  

Bottom Line Up Front (BLUF):  

We utilize MARCH as our dedicated casualty assessment methodology. The full assessment is typically to be completed during evacuation or en route care. Under MASCAL doctrine we must do the most good for the most casualties. Initially, we perform First and Second Pass Actions, which consist of the M.A.R. of the MARCH assessment. These actions are performed on the “X,” at or near the point of wounding. They consist of a rapid blood sweep for compressible hemorrhage, maintaining a patent airway, ensuring effective respirations, and checking the torso for injuries. We find and treat immediate life-threatening conditions only and move on to the next casualty. Provided below is how to perform the M.A.R. sequence.  

Massive Hemorrhage 

• Check pelvis front/back, each leg, neck, each shoulder, armpit, and arm

Airway 

• Ensure patent airway  

Respirations 

• Check for effective respirations, equal chest rise and fall

• Check front and back of torso for injuries  

• Recognize potential non-compressible torso hemorrhage, and the immediate need for rapid evacuation to definitive care

MASCAL - First Pass Casualty Assessment  

At a MASCAL, there will be multiple casualties and limited organic assets. Our actions must differ to rapidly stabilize immediate life threats of all casualties with the limited resources available. MASCAL doctrine is providing the most good for the most casualties. We must recognize that we will not be able to save all casualties. We can only expect to perform limited actions when we are truly overwhelmed. Initial casualty assessment will be focused on identifying massive bleeding and ensuring effective breathing. We call these our First Pass Actions and they are performed on the “X.” 

Approach the casualty and observe potential injuries. Introduce yourself, ask the patient's name, and tell them you are there to help. This action is as much a spiritual mindset as it is clinical. The casualty’s answer will provide context for airway patency, mental status, potential TBI, and respiratory status. The key is to establish mental status and determine the casualty’s ability to follow commands.  

Initiate the blood sweep; expose and address injuries as found during the "M" sequence. Absent of any obvious massive hemorrhage or unknown source of bleeding we start at the casualty’s pelvis, addressing bleeding from the largest compressible areas to the smallest. The order of the blood sweep, absent of stimulus: pelvis front and back, leg upside and downside, next leg upside and downside, neck above and below collar bone, and then moving to each shoulder. Check first shoulder, armpit, then arm, and move to the other side, shoulder, armpit, and arm. If the provider is drawn to a stimulus of massive bleeding from a casualty, expose and address that injury, but do not become fixated on it. The provider must start the blood sweep sequence over, after if the injury has been addressed, to ensure no other injuries are missed. It is acceptable to jump around within the step, but do not jump steps. Airway compromise, massive facial trauma, and sucking chest wounds may be dramatic, but missing a massive hemorrhage will kill your casualty first. Note that this is a hands-on assessment. You will use your hands in a raking-like motion while performing the blood sweep and when checking the torso for injuries. The provider must look where they are feeling. Do not perform blind blood sweeps, meaning when checking the casualty’s downside you must lift their limb or roll them. Do not place hands under the casualty and solely feel for injuries. Perform the M.A.R. sequence:  

Massive Hemorrhage 

• Check front of the pelvis junctional area  

• Check back of the pelvis junctional area  

• Check each leg, one after the other 

• Check neck above collar bone and below 

• Check to shoulder girdle 

• Check first armpit and arm, repeat on other side 

Airway 

• Assess for airway compromise  

• Ensure patent airway  

Respirations 

• Check for effective respirations, equal chest rise and fall 

• Check front of torso for injuries  

• Check back if torso for injuries  

• Recognize if there is non-compressible torso hemorrhage and an immediate need for rapid evacuation to definitive care 

Sole Provider Assessment of Multiple Casualties  

Once the first casualty has had a blood sweep, move to the next casualty, and perform a blood sweep. We will continue the blood sweeps until massive bleeding for all casualties have been addressed. We will do the same for Airway of all casualties, and finally Respirations. The scope and application of this technique will be limited. It will be most beneficial in the immediate vicinity of the provider. 

MASCAL – Second Pass Casualty Assessment

During our second pass, we reassess lifesaving interventions performed earlier, using M.A.R. Second pass actions are also performed on the “X.” Next, we must prioritize patient movement to a casualty collection point (CCP) or dedicated treatment sector. Our actions must facilitate rapid evacuation to definitive care since we are still operating under MASCAL doctrine. We have limited resources and personnel. Prioritize patient movement off the scene versus treatment. In the event evacuation is delayed, full assessment and in-depth interventions may be performed. However, do not delay transport for any treatment on scene. 

The MARCH Assessment  

We must continuously reassess our casualties throughout all phases of care. MASCAL doctrine of first and second pass actions follow M.A.R. and are provided on the “X.” The entire MARCH assessment with in-depth medical interventions should be performed during evacuation or en route care. If you arrive at the scene of a MASCAL to transport a casualty, follow the sequence below. You will be reassessing the effectiveness of prior interventions, ensuring no other injuries were missed, and providing further treatment. When working through the circulation step, you will be utilizing full ALS capabilities (discussed next week). When assessing for head injuries we will be looking for battle signs, raccoon eyes, other signs of injury. Lastly, hypothermia is a part of our lethal triad or diamond. We must prevent hypothermia of casualties. Recent data has shown that if casualties arrive to the ED hypothermic (< 35°C), they have a x2 death rate. This data showed hypothermia on arrival was an independent predictor of death, not just a marker of critical illness or “metabolic failure” from shock. 

Follow the outline provided above for M.A.R. to complete the MARCH Assessment:  

Massive Hemorrhage 

Airway 

Respirations 

Circulation 

• Assess for signs of hemorrhagic shock.  

• Inability to follow commands with the presence of massive bleeding is the best indicator of hemorrhagic shock.  

Head/Hypothermia 

• Assess for head injuries and signs of severe TBI  

• Prevent and treat hypothermia 

Everything Else 

• Any other injury found during the blood sweep or assessment of torso may be noted and addressed after MARCH. 

Stay tuned for a hands-on lecture/demonstration of MARCH in the future. 

See you next week,

Shaun Kibler  

UH Tactical Medicine Division 

August 4, 2025 

This month's continuing education will cover Active Shooter/Hostile Event Response (ASHER) and is presented by University Hospitals Tactical Medicine Division. 

Casualty Care Benchmarks  

Violent mass casualty (MASCAL) incidents are dynamic, complex, and overwhelming. We must have divergent operational training and thinking when preparing our responders to take action at these critical incidents. Training teaches our responders how to think, not what to think. We must offload decision-making when providing casualty care. Once the threat has been mitigated or eliminated, our goal is to provide rapid stabilization at or near the point of wounding and rapid evacuation to definitive care. We can achieve that by training the end user tactics, techniques, and procedures to use during each casualty care benchmark: Access, Assessment, Stabilization, and Evacuation/Removal. These benchmarks provide us with an order of operations while providing care. They will be met no matter the operational context or characteristics. This week we will be reviewing Casualty Access. 

Part 1

Casualty Access 

Bottom Line Up Front (BLUF): 

In the context of ASHER, we access casualties through coordination with our law enforcement partners under force protection. Based on operational context, Unified Command will determine a strategy to facilitate Fire/EMS personnel access to casualties:

• Escorted Warm Zone (Rescue Task Force) 

• Protected Islands & Corridors 

• Law Enforcement Rescue 

The mindset of these strategies may be distilled down to: bring us to them, let us in to work, or bring them to us. Strategies to address the three most likely scenarios that may emerge: 

• Suspect is neutralized/detained- “Visual Chain” Method 

• Suspect is barricaded/isolated by officers- “Visual Chain” Method w/ RTF Model 

• Suspect has fled- or whereabouts are unknown- RTF Model 

Introduction  

Casualty access is the first barrier to care a responder must problem solve in real time. We are presented with casualty access problems every day in the fire service: a call to service for a rollover motor vehicle crash (MVC) with entrapment, fire victims trapped, or a squad call. We frequently train different casualty access techniques such as vehicle extrication, search/Vent-Enter-Isolate-Search (VEIS), and forcible entry. In the context of ASHER, we access casualties through coordination with our law enforcement partners under force protection. Our actions are heavily context driven and based on the environment. At a scene of violence, three likely scenarios may emerge:

1. suspect is neutralized/detained

2. suspect is isolated/barricaded by officers

3. suspect has fled or whereabouts are unknown

Once security is established, Fire/EMS personnel may access casualties for the purposes of assessment, stabilization and evacuation/removal. Security is ultimately provided by escort or protected areas. All Fire/EMS personnel must understand the strategies used to provide security and access to casualties.

“Public Safety Personnel with good training and conditioning become pragmatic and adaptive with a different form of rationality and reason.” (van Stralen, et al 2017).  

Based on operational context, Unified Command will determine a strategy to facilitate Fire/EMS personnel access to casualties. Major limiting factors are the operational footprint, size of the building, and number of organic assets. The following tactics may be used in a combination, phased, or transitional approach. 

Escorted Warm Zone (Rescue Task Force) 

Once the threat has been isolated or eliminated, additional law enforcement will be assigned with Fire/EMS personnel to create a Rescue Task Force (RTF). Law enforcement personnel will escort Fire/EMS personnel into areas that have been cleared but not secure (Warm Zone). Law enforcement will provide security and move Fire/EMS to access, stabilize and evacuate/remove casualties to designated treatment sectors (i.e. Casualty Collection Points). These areas must be clearly defined and understood by all responders prior to deploying Fire/EMS personnel. 

This method can be a quick action to escort Fire/EMS to a specific area of need. As more RTFs are deployed, they must maintain a high level of team and situational awareness to prevent crossfire and congestion issues (i.e. leap frogging).  

Use consideration: Escort Fire/EMS personnel to specific geographical areas or used at large open terrain venues. Suspect has fled- or whereabouts are unknown. 

Protected Islands and Corridors (Visual Chain) 

Once the threat has been isolated or eliminated, additional law enforcement will ultimately converge on target, clear the area, and establish a foothold. They will dominate at hard points within the structure to maintain a warm zone and provide security. This security is established via a visual chain within the structure. These areas must be clearly defined and understood by all responders prior to deploying Fire/EMS personnel. 

This method allows Fire/EMS personnel to move freely in the specified areas. However, there must be enough law enforcement personnel to provide adequate security via the visual chain. Use consideration: Suspect is neutralized/detained.  

Law Enforcement Rescue 

Law enforcement personnel will extract casualties from Hot Zones to Fire/EMS personnel at designated points in either Warm or Cold Zones. Law enforcement may utilize lift, drag, carry techniques, patrol cars or obtain vehicles of opportunity to extract casualties to these areas.   

This method can be used when Fire/EMS is under operational (i.e. area denial) or personnel constraints. Law enforcement may utilize this method if their response is overwhelming the tactical need, allowing them to transition to rescue efforts. 

Closing 

All responders must understand the strategies discussed to allow rapid access to casualties at scenes of violence. Understanding and training these tactics will allow responders to get to the point of wounding faster to achieve our goal of rapid stabilization. Only then can we facilitate rapid evacuation to definitive care. Next week we will discuss using a dedicated casualty assessment methodology. 

Best,

Shaun Kibler  

UH Tactical Medicine Division