People love to use mnemonics to learn new information and prioritise actions. By chunking information in such a way, they can more easily automate it. And that is necessary, working in a time constraint high threat environment. In such circumstances it is a must, not just to perfect the skills, but more importantly to free up the working memory for decision making and situational awareness under stress. The desired skills need to be developed and stress tested to ensure performance to ensure probability of performance in real world. 

When there is enough time to think, analyse and decide, we prefer to make use of any form of external memory like a notebook and take it with us everywhere we go. 

An important goal is to use the time that we have for learning and training, to automate the skills we need when there is no time to use our conscious mind. 

So for those who are interested we collected some acronyms, mnemonics and sentences people use in Tactical Medicine. In some cases the order of the letters is essential, in others not. 

Not every mnemonic works for us, we has to admit. Keep in mind that a mnemonic or acronym is just a memory aid. "as long as the heuristics/mnemonics/acronyms stay in the prefrontal cortex, they are by definition difficult to use in high stress environments. 

If you know some other memory aids not mentioned here, please let us know! We are interested too in the background of mnemonics (when did it saw the daylight and what was it for?)

You can respond here on Linkedin! We will add your Mnemonics and share the result with you.

Please share, so we can collect all kind of (tactical) medical mnemonics, which can help individuals to improve their skills. 

Mnemonic: a system such as a pattern of letters, ideas, or associations which assists in remembering something.

Acronym: an abbreviation consisting of the first letters of each word in the name of something, pronounced as a word.

A mnemonic used to check if team members are fit to perform!

See: https://www.reanimatieraad.nl/nieuws/nieuwe-leidraad-de-choreografie-van-de-reanimatie/

Think FAST

COOL was used in a startle surprise intervention training for pilots to remember the four elements of the training: (1)Stress management/Relaxation (2)Enhancing situational awareness (3) Sensemaking and (Re)framing (4)Decision making

Training was to help pilots to:

1. Recognise and deal with the effect of the startle response ("de-startle")

2. Become aware of own control inputs and aircraft response

3. Prevent tunnel vision and/or confirmation bias

4. (re)gaining situational awareness

5. Start trouble shooting and/or follow designed procedures

 

See: Landman A. Managing Startle and Surprise in the Cockpit

Source: University of South Queensland

Source: NL Aerospacecentre

There are lots of ways people describe the steps between stimuli and reaction. I love the OODA by John Boyd:Observe Orient Decide,Act, in a loop because all action change the Observation. It is an ever going proces how humans deal with their environment. Simple and intuitive easy to understand. 

An immediate objective for caregivers working in a direct threat/hot zone is to "get of the X". The X is the area where a provider is currently standing, sitting, walking, or working that might be a target for the threat (e.g. in a sniper's line of fire or within the blast zone of an undetonated device) For TECC getting off the X means mitigating the cause of the direct threat or moving the patient and caregivers to a safer area. (from TECC manual) As they state: first responders can be challenged by an X that keep moving! Now you ar in the cold zone and a moment later it has turned into a hotline and vice versa. 

Shoot-Move-Tourniquet-Rescue

<C>ABCD or cABCD

A variant I noticed is:

Because safety is a dynamic thing and you can unexpectedly end up in an unsafe situation, it is important to stay aware of any possible threats! Nice invention.

Some made an extension of CABCD until H! CABCDEFGH

Give Comfort measures/Get documentation/ Glucose/

Opgedoken ergens rond 1984:

Invented by British SOF Medics to incorporate the 1996 TCCC guidelines in their protocols around 1998. Nowadays it is the acronym used by TCCC and TECC and PHTLS in Austere environments.

Hypothermia/ Head(injury)

Variants on MARCH are: 

• MARCH-E (Everything else) popular with Canadiens (Eric Savage 2011)

• MARCH-H (Head injuries)

• MARCH-HE (Head Injuries and Everything Else)

• MARCH-E (Eye injuries)

• S-MARCH-RV (Security, Recovery position, Vital signs)

• MARCH-PAWS-B (Pain Control, Antibiotics, Wound dressings, Splinting, Burn Treatment) used in prolonged field care and there als is:

• MARCH-PAWS-RAVINE (Resuscitate with whole blood and reduce tourniquets as soon as possible, Airway and Crick care package, Ventilate and oxygenate using PEEP/lung protective strategies, Initiate telemedicine consult and early evacuation, Nursing care, Environmental considerations (pad pressure points of the litter, earplugs for flight, medication for motion sickness).

The Hartford Consensus (2013) recommends that an integrated active shooter response should include the critical actions contained in the acronym THREAT.

RE rapid extrication to safety

For me this works as a very simple method to keep in mind the most important things to make the difference on a very basic level.

Or

Internal bleeding in thorax, abdomen, pelvis and femurs

Exsanguination can be the result of external or internal blood loss. This reminds me where to look for.

Source: UK SWAST primary survey 2007

Used as an extension of MARCH.

P Pain

A Antibiotics

W Wounds

S Splints

Erin Savage described this model used by Canadian Forces in 2011 in the J. Can. Chir. Vol 54, Suppl. S118-S123.

• Bleeding control
  
• Intravenous/intraosseous access
  
• Fluid resuscitation (HSD as a volume expander)
  
• Tourniquet assessment and removal
  

• Monitoring
  
• Pain
  
• Head to Toe
  
• Address all wounds
  
• Antibiotics
  
• Tactical Evacuation preparation
  
• Documentation of Care
  

A FIT ARSE is a useful mnemonic which prompts us how to continue care for extended periods of time. 

Hitman is a mnemonic used in Prolonged Field Care situations

H Head to toe exam

I Infections

T Tubes

M Medicines

A Administration

N Nursing Care mnemonic (SHEEP VOMIT)

S Skin protection (sun screen, insects)

H Hypo/Hyperthermia

E Elevate head

E Exercises (passive ROM)

P Pad stretcher and Pressure points

V Vital signs

O Oral hygiëne

M Massage (DVT profylaxis)

I Ins and outs (diet & fluids)

T Turn/cough/deep breath

PHASE airway

• ASA physical status 1-2
  
• Age > 12 years
  
• Cooperative
  
• BMI < 25kg/m2
  
• Height > 130cm < 200cm
  
• Weight > 30kg < 100 kg
  
• Airway management in hospital environment
  

• No prior history of airway management complications or problems
  
• No prior reconstructive surgery and/or radiation therapy to upper airway or neck
  
• No medical syndrome that is associated with airway management problems
  

• Mallampati 1-2 with mouth opening > 3cm
  
• No tooth teeth or buck teeth
  
• Good neck flexion and extension (>5cm movement from tip of chin to sternal notch)
  
• No large beard that makes face mask oxygenation problematic
  
• No short neck (thyromental distance > 4cm)
  
• No tumors or lumps in upper airway or neck region
  
• No active bleeding in the upper airway
  
• No inspiratory stridor
  

• Outside upper airway or neck region
  

• Saturation at start of procedure without supplemental oxygen > 95%
  
• Stable vital signs: systolic arterial pressure > 95mmHg; heartrate 40-140 beats/min; respiratory rate 14-20 breaths/min.

*Pregnant patients will most probably have BMI > 25 kg/m2 and ar often classified as advanced airways.

PHASE checklist: requirements for a classification of a basic airway. 

Huitink&Bouwman, Editorial  Anaesthesia 2015, 70, 241-257. 

It is part of a assessment plan for all patients presenting for airway management. 

This gives a summary of the chest examination of trauma victims

R Rate

I Injuries: search for all penetrating trauma

S Symmetry of chest wall movement

E Effort of breathing

N Neck Signs

F Feel: bone crepitus and surgical emphysema

A Assess resonance

L Listen to both sides of the chest

L Look at the patient’s back (if not already done!)

For me this one didn’t work so good. I keep in mind look, feel, listen and to ensure I don’t forget anything I use the patient as landmark and work top down. I look for respiratory rate and effort of breathing, neck signs, wounds, bruises or flail segments, symmetry of chest wall movement, then feel for bone crepitus, emphysema, thoracic movement and bilateral compression tenderness, I listen to breath sounds and if needed percuss both sides of the thorax. 

Some remember Neck signs as TWELVE:

Some do TWELVE-FLAPS

For twelve see above and FLAPS is:

Source: SFTC 2000

This is an mnemonic for recognising life threatening chest injuries

BL blast lung

A Airway

T Tension Pneumothorax

O Open pneumothorax

M Massive Haemorrhage

F Flail Chest

C Cardiac Tamponade

Used for neurological assessment in a primary survey

Some add an 'A' : PERRLA

A more precise neurological assessment. Known as the Glasgow Coma Score (GCS)

This is a mnemonic of common causes of reduced GCS/Unresponsiveness

FAST test 

Test for recognising a stroke.

Use the letters in FAST to spot stroke signs and know when to call 911 (112)

for checking the limbs.

CPRO-BEAST is used for vital signs. The CPRO are the primary vital signs and can be found in seconds using a SPO2 monitor. The secondary vital signs take longer to assess or they use ore equipment to find. Read more on: https://linkedin.com/pulse/cpro-handover-tool-aebhric-okelly/ or go to carom.org, the website of The College of Remote and Offshore Medicine Foundation.

-

For the assessment of new borns (not regular in TacMed :)) APGAR

Abdominal Assessment DR GERMS

An mnemonic used during body examination

Used in Corom 

(S)AMPLE(R) history

Used for history taking:

Signs and Symptoms

OPQRST pain assessment

Provoking or Palliating factors

Region & Radiation

Time & Treatment

Used to question patients about pain in that order:

Another pain assessment tool

For Social history

Used for treatment of an ankle sprain

CRASH for crush syndrome

Head and neck = 9%

Legs (including feet) = 18% each

Posterior trunk = 18%

Anterior trunk = 18%

Arms (including the hand) = 9% each

Genitalia = 1% 

If burns are greater than 20% of TBSA (more than superficial), fluid resuscitation should be initiated as soon as IV/IO access is established. 

Initial IV/IO fluid rate is calculated as %TBSA x 10 ml/hr for adults weighing 40-80kg. For every 10 kg above 80kg, increase initial rate by 100ml/hr. 

Maintain an output over 30 ml per hour. 

4H's/4T's - reversible causes of a cardiac arrest

Unexploded devices are managed according to the 4C’s

C Confirm it is a suspect device

C Clear the area of people

C Command and Control

S Safety

C Communications

A Assessment

T Triage

T Treatment

T Transport

Source: MIMMS, BATLS UK

In the Care under Fire situation it can be useful to remember SAFE

S Send signal and shout for help

A Assess the situation

F Free the casualty from danger

E Evacuate (e.g. drag) the casualty to as safe area to undertake Care Under Fire

Information transmitting from the scene must be transmitted in a structured format to ensure no errors of omission and to optimize message handling by the recipient. The METHANE mnemonic from the MIMMS course has now been widely adopted by UK Defence Services:

M Military call sign, Major Incident Standby/ Major Incident Declared (multiple casualty incidents)

E Exact location (GPS grid reference)

T Type of incident

H Hazards, present & potential

A Access (including suggested Helicopter landing site or RV point: the operations room will assess reports of recent incidents to ensure no pattern is being set by using the suggested HLS/RVP

N Number and severity of casualties

E Emergency services, present & required

SIT report 

Method of a SIT report:

*if verbal communication is difficult, point to each injury and treatment and confirm acknowledgement.

Used by CitizenAid to communicate an incident report:

See the Citizen aid app.

AT MIST or MIST AT

Handover the patient and provide all the information needed for optimal care in the trauma chain is essential. It helps when sender and receiver make use of the same system. For me AT MIST or MIST AT as you wish works best.

The patient is handed over to the next level of care using the MIST mnemonic:

A Adult/Child

T Time

M Mechanism of Injury

I Injuries or illness found/ suspected

S Signs/ symptoms (P, BP, RR, SpO2), Temperature, EMV, AVPU

T Treatment given

SBAR is a Clinical Communications Format

S Situation (what is going on with the patient)

B Background: What is the patient’s pertinent history, clinical background, additional information?

A Assessment: What do you think is going on with this patient?

R Recommendation(s): What do you think needs to be done?

Time critical/urgent patient pre-alert

mnemonic used to conduct an assessment of the region where you are deploying to:

See Corom 

The “Beat the stress, fool” mnemonic is a recall of the Performance Enhancing Psychological Skills (PEPS) people may use in high stress environments. The whimsical nature of the mnemonic may induce smiling, which helps to break the stress escalation cycle. 

See: https://www.annemergmed.com/article/S0196-0644(17)30314-1/pdf

Scan and Breathe as a trigger word (or trigger sentence :)) 

I use this after finishing each letter of the used trauma acronym. It helps me in a few ways:

• Don’t stay in a bubble for too long

• Keeping my arousal on an appropriate level for optimal prestation 

• Stay aware of my environment (danger, changes, team members) so that I can respond when necessary. 

• It helps me to optimise the team effort.

acronym used as framework in Imagery (mental representation of perceptual experiences and sensations, without having the actual experience.

A tool to assess personnel their fitness to operate. It's the Aeronautical Information Manual's recommended mnemonic for aircraft pilots to use to assess their fitness to fly.

Nice to formulate your goals and to make afspraken with others. I keep in mind that a goal is just an intention that most of the times need to be changed of aangepast during the way to reach that goal. To make sure your goals are clear and reachable, each one should be:

PURE is an extension on SMART

CLEAR is another extension on SMART

A mnemonic used in CBRN

M: Massive hemorrhage

A: Airway

    Antidotes

R: Respirations

C: Circulation

H: Hypothermia

     Headwounds (determine if altered mental status is due to agent or trauma)

E: Evacuate

Source: DeFeo DR and Givens ML. Integrating CBRN Protocol into TCCC. JSOM Volume 18, Edition 1/Spring 2018

L oyalty

D uty

R espect

S elfless Service

H onor

I ntegrity

P ersonal Courage

LEMON assessment for difficult intubation

L Look externally

E Evaluate the 3-2-2- rule

M Mallampati

O Obstruction

N Neck mobility

from Corom Fieldguide

Used as an intubation checklist

Prepare equipment (SPEEDBOMB checklist)

a drugs administration checklist used in Corom Fieldguide (www.corom.org)

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Altered mental status checklist

Alcohol and acidosis

Epilepsy, environment, electricity and electrolytes

Oxygen and overdose

Seizure and stroke

Types of Shock: CASH-N

Sepsis treatment: FLASHED

F.E.A.R Management Skills

Acronym used by the famous Tony Blair

Gebruikt door politie:

Zie: https://www.erikheinacademy.com/wp-content/uploads/2018/03/Fysiek-ingr.pdf

Erik Hein: "nadeel is het temporele karakter: in sommige situaties is het beter eerst naar de O (omgeving) bekijken en dan pas naar de handen (H)." HALO wordt ook wel een principe genoemd met als risico dat de technische vaardigheden dan niet meer serieus genomen worden. Een principe (=tactiek die meervoudig toepasbaar is) is echter leeg zonder techniek."

geldt zowel voor communicatie als in fysieke situaties. 

Gebruikt voor het opsporen van ernstige bloedingen in kritische gebieden. Het betreft gebieden waar de grote bloedvaten zich dicht onder het oppervlak bevinden. Nu hebben kogels en scherven daar niet een typische voorkeur voor, dus vergeet niet de rest van het lichaam af te zoeken. De TCCC gebruikt de "Bloodsweep". 

Ezelsbruggetje dat wordt gebruikt voor de handelingen die moeten worden verricht in het kader van de organisatie op en rond de plaats van het ongeval vóórdat daadwerkelijk eerstehulp kan worden verleend:

Ook bij CBR gebruikt zag ik. Daarbij is het markeren van plaats ongeval belangrijk. In de militaire setting spreekt de M van PAMAN mij voor de rest wat minder aan. 

Cover and Move