The first priority in the circulation phase of MARCH-PAWS is stopping any untreated massive bleeding.

During the circulation phase of MARCH-PAWS, what should be ensured first?

• A. That the casualty is repositioned for comfort
• B. No untreated sources of massive bleeding are present
• C. All bystanders are evacuated from the area
• D. That the casualty is aware of their surroundings

Answer: (B)

During the circulation phase of MARCH-PAWS, ensuring that no untreated sources of massive bleeding are present is the top priority. This phase focuses on the critical assessment and management of the casualty's circulation, particularly because uncontrolled bleeding is a leading cause of preventable death in traumatic injuries. Identifying and managing sources of significant hemorrhage is essential to stabilize the casualty and prevent further deterioration. Effective hemorrhage control techniques may include applying direct pressure, utilizing tourniquets, or packing wounds with hemostatic dressings. Addressing massive bleeding promptly is vital in the tactical environment, where every second counts, and rapid interventions can significantly impact survival rates. While considerations like ensuring the casualty's comfort, evacuating bystanders, and maintaining their awareness are important for overall care and situational safety, they are secondary to the immediate threat of life-threatening bleeding that needs to be addressed first in the circulation phase.

Outline to guide the read

• Why the circulation phase tops the list: stopping life-threatening bleeding is the first priority.

• What “no untreated sources of massive bleeding” looks like in practice.

• The core tools of hemorrhage control: direct pressure, tourniquets, hemostatic dressings.

• When to move beyond limb bleeding to look for hidden sources.

• Keeping the bigger picture in mind: comfort, bystander safety, and situational awareness come after the bleed is checked.

• Real-world rhythms: how a medic or responder might move through the steps in a chaotic environment.

• Quick reminders and common pitfalls to avoid.

Now, let’s dive in.

Bleeding first, everything else second

In the MARCH-PAWS sequence, the circulation phase is all about life-saving priority. Think of it this way: if the bleeding isn’t stopped, other concerns—no matter how important they seem—won’t matter as much. Massive hemorrhage is a leading cause of preventable death in traumatic injuries, and the moment you confirm that there are no untreated sources of massive bleeding, you’ve cleared the most deadly hurdle. It’s not dramatic flair; it’s plain physics: if blood keeps pouring out, the body can’t keep itself perfused, and the situation degrades in minutes.

What “no untreated sources of massive bleeding” means in plain terms

If you’re assessing a casualty, your first mental checkbox is simple: is there any uncontrolled blood loss that could kill them now? Untreated bleeds aren’t just “a little oozing” or “a small graze.” They’re wounds where blood is actively escaping and you don’t yet have a firm control on it. In the field, you’ll see it as spurting or pooling blood, or a wound that continues to saturate dressings despite pressure. It’s the kind of bleeding that makes a casualty lose consciousness or go into shock faster than you can blink.

The practical toolkit for hemorrhage control

There are three main approaches you’ll rely on, often in combination. Each has a different role, and knowing when to apply them is what separates effective care from missed opportunities.

• Direct pressure: the simplest and often the most effective first move. If a wound is on a limb, you press with your gloved hand or a clean pad, maintaining steady pressure until the bleeding eases. It’s a basic skill, but one that buys critical seconds and buys you time to apply more advanced controls if needed.

• Tourniquets: when direct pressure isn’t enough, a tourniquet placed high (proximal) on a limb can abruptly halt blood loss from a deep or heavy bleed. Modern field tourniquets are designed for quick application, even under stress. They’re not a sign of failure; they’re a signal that you’re doing everything possible to stop the bleed now.

• Hemostatic dressings and wound packing: for areas where direct pressure or a tourniquet isn’t practical—torso wounds, groin injuries, cut chest wounds—you can use hemostatic dressings or pack the wound with gauze soaked with hemostatic agents. This helps blood to clot more efficiently and slows the bleed when direct methods aren’t enough on their own.

A quick mental model: three layers of control

• Primary control: stop the bleed as quickly as you can with direct pressure or a tourniquet.

• Secondary control: add hemostatic dressings or packing for wounds that aren’t easy to seal with pressure alone.

• Tertiary considerations: once bleeding is under control, evaluate other threats to circulation, like chest injuries or abdominal bleeds that might need different interventions.

A few practical notes you’ll hear in the field

• Time matters. The faster you achieve effective hemorrhage control, the more likely the casualty survives the initial injury.

• Improvised options exist. If formal dressings aren’t available, clean cloths and padding can be used temporarily while you bring the situation under control. The goal is to reduce blood loss, not to win a fashion show.

• Training matters. The best outcomes come from practiced, muscle-memory actions. In the heat of the moment, you’ll rely on trained reflexes.

How to think about hidden sources of bleeding

Massive bleeding isn’t always obvious. It can hide inside the pelvic cavity, abdomen, or chest where you can’t see it from the outside. That’s why the circulation phase includes a careful assessment of potential non-visible bleeds, especially if the casualty continues to deteriorate after initial measures. In some scenarios, rapid transport to definitive care is the next critical step, but you don’t move on to transport while bleeding is still uncontrolled.

Keeping the big picture in sight: comfort, bystanders, and awareness

You’ll hear this echoed in the field: hemorrhage control comes first; comfort and safety follow. Sure, you want to keep the casualty comfortable to reduce shock and anxiety, and you’ll want to clear bystanders from the area for safety. And yes, you’ll check if the casualty is oriented and aware, because confusion can be a sign of worsening blood loss or head injury. But none of that can supersede stopping the bleed. It’s a careful balancing act, and with practice, your attention naturally orients toward the life-threatening problems first.

A moment for the tools and the team

In real life, the gear you trust—tourniquets like the modern, windproof designs, and hemostatic dressings that wick moisture and promote clotting—becomes an extension of your hands. The same goes for your teammates. Communicating clearly, sharing the load, and pacing your actions help you maintain control when the environment is loud, chaotic, or unpredictable.

Common missteps to avoid

• Spending too long on a single method when another is clearly needed. If a tourniquet isn’t stopping the bleed, move to packing, or reassess the wound location.

• Assuming bystanders are safe to stay nearby. In many tactical settings, bystander safety is critical, especially in unstable zones. Clear the area when needed, then refocus on the casualty.

• Overlooking non-visible bleeds. If the casualty isn’t improving, keep a high alert for internal sources of bleeding. That’s when rapid transport and escalation come into play.

Putting it all together: a disciplined sequence

Here’s a concise way to frame the flow, without losing flexibility for real-world variation:

• Step 1: assess and identify life-threatening bleeding. If found, initiate direct pressure and apply a tourniquet if needed.

• Step 2: move to hemostatic dressings or wound packing for wounds where pressure or a tourniquet isn’t adequate.

• Step 3: rapidly reassess for non-visible bleeds, monitor the casualty’s color, pulse, and level of consciousness, and prepare for transport if needed.

• Step 4: ensure the area remains safe for the casualty and responders, while maintaining situational awareness.

Why this matters for tactical medicine

The circulation phase is a clear reminder that survival in traumatic scenarios hinges on prioritizing life-threatening problems first. It’s not about heroics or bravado; it’s about disciplined, evidence-based care that buys time for the casualty and sets the stage for subsequent interventions. In high-stakes environments, the ability to identify, control, and reassess bleeding quickly makes the difference between a recoverable injury and a fatal outcome.

A few final reflections to wrap it up

• Bleeding control is a team effort. Your role matters, but so does the support you receive from teammates and the pace you keep.

• Training is the backbone of confidence. Repetition builds the calm you need when things get loud.

• Real care is dynamic. You adapt as the scene changes, always prioritizing life-threatening threats first.

In the end, the breath you hold before acting isn’t fear; it’s focus. You’ve trained your eyes to spot the bleed, your hands to apply the right pressure, and your mind to keep moving toward the next step. That sequence—the lifeblood of the circulation phase—translates to outcomes on the ground. And that’s what really matters: making every second count when the stakes are highest.