7.2 Tactical Casualty Care: Phases of Care, M.A.R.C.H. & PACE
Key Takeaways
- POST Unit X.A requires 4 lecture hours on tactical casualty care, and its first performance outcome is recognizing the statutory duty to render medical aid under C.R.S. 18-1-707(2)(c).
- The three phases of care are direct threat or hot zone, indirect threat care or warm zone, and evacuation care or cold zone; the intervention set changes with the phase.
- M.A.R.C.H. sequences the rapid assessment: Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia and head injury.
- PACE sequences hemorrhage control: Primary tourniquet, Alternative direct pressure, Contingency wound packing, Emergency manual pressure until definitive care.
- Head tilt-chin lift and jaw thrust are not used in a tactical setting; the recovery position is the preferred tactical airway management technique.
Tactical Casualty Care: Phases of Care, M.A.R.C.H. & PACE
Unit X — Tactical/Operational Medicine (12 required hours) was added to the Colorado basic curriculum because officers are almost always the first responders present at a shooting, a stabbing, or a serious crash, and because Colorado now places a statutory duty on the officer to ensure aid is rendered. Sub-topic X.A, Tactical Casualty Care — Lecture (4 required hours), sets the doctrine; sub-topic X.B applies it in skills stations and scenarios.
The POST curriculum places an explicit boundary on this block: no advanced invasive interventions — needle decompression, cricothyroidotomy, surgical airway — are taught in the basic academy. Basic life support skills such as a nasopharyngeal airway may be taught only where the academy or agency understands and assumes the associated risk.
1. The Legal Predicate: C.R.S. 18-1-707(2)(c)
Colorado's use-of-force statute requires that when physical force is used, a peace officer shall "ensure that assistance and medical aid are rendered to any injured or affected persons as soon as practicable." That is a duty, not a courtesy, and it applies to the person the officer just used force against. Failure to render or summon aid is a use-of-force policy violation, a POST accountability issue, and a civil exposure under C.R.S. 13-21-131. The tactical medicine block exists in part to make that statutory duty executable.
2. Three Phases of Care
| Phase | Zone | Threat status | Care priorities |
|---|---|---|---|
| Direct threat | Hot zone | Active shooting or ongoing violence | Stop the threat; move the casualty or direct self-aid; life-threatening extremity hemorrhage only — tourniquet |
| Indirect threat | Warm zone | Threat suppressed or contained, not eliminated | Full M.A.R.C.H. assessment; airway, chest seals, wound packing, hypothermia prevention |
| Evacuation | Cold zone | Threat removed | Continued care, reassessment, packaging, handoff to EMS |
The single most important phase concept for a Colorado officer is that in the hot zone the best medicine is fire superiority. Care that stops the officer from ending the threat kills more people than it saves. Self-aid, casualty movement, and a tourniquet are what belong in the hot zone.
3. M.A.R.C.H. — The Rapid Assessment
M MASSIVE HEMORRHAGE → tourniquet high and tight; direct pressure
A AIRWAY → simple maneuvers; RECOVERY POSITION (tactical)
R RESPIRATIONS → sit up / chest seals for open chest wounds
C CIRCULATION → control non-life-threatening bleeding; check distal pulse
H HYPOTHERMIA / HEAD → prevent heat loss; protect from head injury deterioration
M.A.R.C.H. deliberately inverts the civilian ABC sequence. Penetrating trauma kills through exsanguination far faster than through airway compromise, so massive hemorrhage moves to the front.
4. PACE — The Hemorrhage Control Strategy
| Step | Method | When |
|---|---|---|
| P — Primary | Tourniquet | Life-threatening extremity bleeding; apply high and tight over clothing if needed |
| A — Alternative | Direct pressure | Bleeding that responds to pressure; junctional sites |
| C — Contingency | Wound packing with hemostatic or plain gauze | Junctional wounds (groin, axilla, neck) where a tourniquet cannot go |
| E — Emergency | Manual pressure maintained until definitive care | Everything else; someone's hands stay on the wound |
Tourniquet fundamentals. Apply high and tight above the wound, tighten until bleeding stops and the distal pulse is gone, mark the application time, and do not remove it in the field. Pain is expected and is not a reason to loosen. The POST curriculum requires instructors to insert unannounced tourniquet drills during the block in which students must "get off the X," find cover, and apply a tourniquet to themselves or another within 30 seconds — a standard worth practicing until it is automatic.
5. Airway, Chest and Shock
Airway in a tactical setting. The POST outcomes are explicit about what is and is not used:
| Technique | Tactical setting |
|---|---|
| Protecting your own airway | Always |
| Head tilt–chin lift | NOT in a tactical setting |
| Jaw thrust | NOT in a tactical setting |
| Recovery position | Best in a tactical setting |
The reasoning is practical: manual airway maneuvers require a dedicated rescuer kneeling over the casualty. The recovery position maintains a patent airway while freeing the officer to keep working.
Open chest wounds. A sucking chest wound presents with air movement through the wound, bubbling, and worsening respiratory distress. Apply a vented occlusive dressing or chest seal. Watch for tension pneumothorax — increasing distress, decreasing breath sounds on the injured side, distended neck veins, tracheal deviation as a late sign, and progressive hypotension. Basic-academy management is to burp the seal and expedite evacuation; needle decompression is expressly outside the basic curriculum.
Shock and hypothermia. The tactically relevant indicators POST teaches are a decreased level of consciousness and an abnormal distal pulse — weak or absent — with pale, cool, sweaty skin. Blood pressure cuffs are not part of the assessment. Prevent heat loss aggressively: get the casualty off the ground, remove wet clothing, and wrap. Hypothermia worsens coagulopathy, and a bleeding patient who gets cold bleeds more.
6. Movement and Remote Assessment
Drags and carries. Officers must know at least one drag they can perform alone (collar or webbing drag), one two-officer carry, and how to use a drag strap or improvised sled. The technique matters less than the decision: move the casualty when the movement is safer than staying, and move along a route that has been considered rather than the shortest line.
Remote medical assessment. POST requires officers to be able to assess a casualty they cannot reach — a downed subject in an open field of fire, or a person behind a barricade. Direct the casualty verbally to self-apply a tourniquet, assess consciousness and movement by observation, and prepare an approach plan with cover before committing anyone to the open. Talking a wounded person through their own care is often the only intervention available for the first several minutes, and it works.
Officers are still taking fire when a colleague is struck in the thigh with heavy bright red bleeding. Under the POST tactical casualty care phases of care, what is the correct action in the direct threat or hot zone?
A casualty has an open chest wound in a warm zone with progressive respiratory distress. Which action reflects the Colorado POST basic academy scope of practice?