A Practical Approach to Care after SMARCH-E-PAWS-B: RAVINES

The RAVINES Mnemonic was created to help the medical provider on the ground in an austere environment with a very sick patient. Most medics will do a decent TCCC SMARCH survey and when they get to the end of that, get vital signs to begin trending and repeat the MARCH sequence while adding E-PAWS-B…

• E for Eyes
• P for Pain
• A for Antibiotics
• W for Wounds
• S for Splinting
• B for Burns round out the MARCH-E-PAWS-B mnemonic.

At some point the provider may run out of things to do or could get lost in the immensity of the work which needs done. This is a great place for a therapeutic pause to gather oneself and think of what could be done while moving on to a secondary or detailed exam from which to make a problem list and care plan. This will help keep the thought process moving in the right direction and in an appropriate order while serving as a reminder of some critical steps that we have identified such as reducing tourniquets to pressure dressings and making a telemedicine/evac call along with others that may be overlooked such as nursing care and environmental considerations. Mnemonics should be just cheesy enough but memorable in any situation so remember this; RAVINES or deep draws are places that a small unit would hide a patrol base while in enemy territory to rest and prepare for the next leg of the mission. Just as draws and RAVINES offer relative piece of mind in a dire situation, so too should this memory aid:

MARCHE your PAWS to the RAVINES…

• Resuscitation with appropriate fluids, Reduce Tourniquets as soon as possible (within 4 hours)

PFC WG Fluid Therapy Recommendations (December, 2014)

Emergency Whole Blood Protocol

PFC Fresh Whole Blood Transfusions FAQ

PFC WG Tourniquet Conversion recommendations (June, 14)

• Airway and Cric care package including Capnography, Sedation drip, Sterile suctioning, Heat moisture exchanger/Filter, Check cuff Pressure, Tube depth

PFC WG Airway recommendations (April, 14)

Post Cric Checklist

PFC WG analgesia and sedation comments (Feb, 14)

• Ventilate or oxygenate- Positive pressure with PEEP using a lung protective strategy

Why we need PEEP valves on BVMs

Scott Weingart’s Dominating the Ventilator Handout

• Initiate telemedicine and evacuation early

Telemed Script Cheat Sheet

Medical Planning Tool

• Nursing care including Monitoring and trending of vitals and ins and outs especially urine output, Positioning patient up, DVT Prophylaxis massage, turn patient 30 degrees to the sides, Passive ROM exercises, Oral Hygiene. This is where our nursing care checklist and the nursing mnemonic HITMAN can help remind you of nursing care priorities.
• Hydration
• Infection
• Tubes
• Medications
• Analgesia
• Nutrition

Also check out the awesome PFC Nursing Mnemonic SHEEP VOMIT made famous by our friends at the NATO SOCM Course.

Everything You Need to Know About Foley Catheters

• Environmental Considerations – Hypo/Hyperthermia, Ear plugs for flight, Sun screen and chapstick, Padding the litter and pressure points, Motion sickness prophylaxis
• Surgical Procedures – Cricothyroidotomy, Thoracostomy, Escharotomy, Fasciotomy, Lateral Canthotomy, Amputation, Debridement, Delayed Primary Closure, Shunting

“4 things You Should Do Before Packing an Aidbag,” Article By Next Generation Combat Medic Admin Max

Did you forget anything?

Did we?

SMARCH-E-PAWS-B-RAVINES

-Shoot back

• Primary weapon, Secondary weapon, Smoke Grenades, Tubular Nylon, Litters…

-Massive Bleeding

• Extremity Tourniquets, Wound Packing, Junctional Tourniquets, Pelvic Binders, Hemostats, Ace wrap, XStat, Suture kit, Stapler…

-Airway

• Recovery Position, Nasopharyngeal Airway, Cricothyroidotomy kit, IGel, Intubation kit, BVM, PEEP valve, Portable suction device…

-Respirations

• Occlusive Dressings, 10g Needle cath, Finger thoracostomy kit, Chest tube, Heimlich valve, Ioban…

-Circulation

• Interosseous starter Kit, IV starter kit, Eldon blood typing kit, Fresh whole blood transfusion kit, Portable blood cooler Freeze Dried Plasma, Plasmalyte, TXA, Calcium…

-Head Injury & Hypothermia

• Fowlers Positioning, Oxygenation/SpO2 above 95, Resuscitate with Plasma or fresh whole blood, 3% hypertonic saline, Keppra, Neuro exam card, GCS card…
• HPMK, Sleeping bag, Beanie cap

-Eye Injuries

• Lateral Canthotomy Kit, Fox Eye Shield, Erythromycin Ointment, Tetracaine Drops, Flourisceine paper, Cobalt lens light, Artificial tears…

-Pain Control and Sedation, Drugs

• Tylenol, Oral Transmucosal Fentanyl, Ketamine, Lidocaine, Midazolam, Fentanyl, Dilaudid, Morphine, RASS card, Zofran, Glycopyrrolate, Benadryl, Epinephrine, Solumedrol, Dexamethasone…
  

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This is usually a good point in which to pause get baseline vitals and complete a thorough secondary, head-to-toe exam and make a comprehensive problem list. From the problem list you can then start to make a prioritized care plan.

• Portable Ultrasound, Capnograph, Pulse Ox, Stethoscope, BP Cuff, Penlight, Foley Catheter, Otoscope Opthalmoscope, Thermometer, Blood Glucose Monitor, Head lamp, Watch, Timer, DD1380, PFC Flowchart, Sharpie, Grease Pencil, Trauma shears…
  

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-Antibiotics/Antimicrobials

• Ertapenam, Topical Vancomycin, Doxycycline, Amoxicillin, Ciprofloxacin, Metronidazole, Fluconazole Mebendazole, Artesunate, Praziquantel, Truvada, Tetanus Toxoid, Tetanus Immunoglobulin…

-Wounds

• Stapler, Suture kit, Dakins Solution irrigation kit, Gigli saw…

-Splints

• Sam splint, Traction splint, Sling and swath…

-Burns

• Silverlon Dressings, Plasma or Albumin, Ringers Lactate solution, Burn care flowchart…
  

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-Resuscitation and Reduce Tourniquets

• Cold Stored Fresh Whole Blood, Fluid Warmer, Fresh whole blood transfusion kits, Freeze dried plasma, Balanced Crystalloids for burn, crush or sepsis, Hypertonic Saline for TBI, Wound packing, Pneumatic tourniquet…

-Airway care

• Suction, Ballenger In-line Suction device, HME, Capnograph…

-Ventilations and Oxygenation

• BVM with PEEP, 6-8mL/kg lung protective vent setting,

-Initiate Early Telemedical Consult

• Call script, Cell Phone, Sat phone, Radio…

-Nursing Care

• HITMAN or SHEEP VOMIT

-Environmental Considerations

• Sunscreen, Chapstick, Mosquito netting, Clothing, Waterless soap,

-Surgical Procedures

• Scalpel, Hemostats, Metzenbaum Scissors, Tissue forceps, Gigli Saw, Chlorhexidine, Iodine, Drapes, Gowns, Hat, Surgical masks, Sterile gloves,