What exactly is the PACE methodology and how does it apply to tactical medicine? PACE is an acronym that stands for Primary, Alternate, Contingent and Emergent. This forms the basis for how we can solve problems we are faced with. The idea is that there are four routes we can take depending on how the problem presents itself, or in the event plan A fails, plan B fails, etc. PACE methodology can be paired with: 5 P’s - “prior planning prevents poor performance”, Murphy’s Law and two is one/one is none. This began as a method to evaluate communication options, but since it is task oriented it can be applied to other applications.
So how exactly does the PACE methodology apply? Let’s use hemorrhage control as an example.
So when faced with life threatening extremity hemorrhage, our primary method of hemorrhage control is a commercially made, military approved tourniquet. The research behind these tourniquets tells us that this is going to be the most successful long term solution to get from the point of injury to the surgeon. Also, relatively quick to apply, so it becomes my primary method of dealing with this problem. In airway management, while a surgical cric is the most definitive solution, it’s not the primary option (NPA) due to it’s complexity as a skill. The primary option is our “go-to” option when faced with a task. Research, training, product development, complexity of the solution may all affect why we have chosen this option as our primary route. If we look back 15 years ago, tourniquets were seen as a last ditch effort in hemorrhage control, and now they’re front line options.
My primary option is not always foolproof though...
So what do we do if there is an issue with the tourniquet? This could be from a number of reasons. The first dilemma we may come across is # of patients/injuries > # of tourniquets carried. Due to this problem, we need to have an alternative solution to hemorrhage control. In this scenario, it may be wound packing with a hemostatic dressing. While not as quick or definitive as our primary route, it’s a serious contender as solution #2. Many times the alternate option will have little to no delay or impact on the outcome, it’s just not the preferred method. It may be necessary to utilize the alternate option in conjunction with the primary option, but the primary option is applied first.
Murphy’s Law seems to kick in when we least want it to...
So what do we do if our primary and alternate methods have been exhausted? In recent Mass Violence events, our casualty count is going to vastly exceed our equipment and supplies. How do we address this? We utilize our contingent plan. This is something that’s an acceptable solution, but definitely not the preferred method. This shouldn’t be an improvised route, but it isn’t going to be as definitive as our primary or alternate method. With hemorrhage control this may be using a pressure bandage to stop hemorrhaging. It’s a good method, definitely not as successful as a tourniquet. If I’ve triaged patients and applied tourniquets to the worst hemorrhages, wound packed the set of next severe, and now I’m working on bandaging wounds, this is an acceptable option. We may sacrifice something once we’ve gotten to this method (increased complexity of the skill, increased time to apply, less successful in controlling severe hemorrhage) but we have less options to pick from and therefore have to be less picky.
The emergent plan is definitely not the route I want to take, but it may be all that I have available at that time. This is our SHTF or last ditch option. It may be a quick and expedient stop gap measure until we can apply our primary method, so this isn’t to be discounted completely as a waste of time. If I can visually identify a patient has a massive extremity hemorrhage as I approach, I may drop a knee down on a pressure point (groin, axilla) while I utilize my hands to pull a tourniquet out and apply it. It’s a stop gap measure in the sense that it buys me a few more seconds to put the tourniquet on, but if I’m out of tourniquets, hemostatics and bandages, I’m not going to stick around all day holding pressure on a patient. On that end, I may improvise bandages from cut clothing. Absolutely not a planned route as I’d prefer to have something with some research/backing behind it, but if the world is crashing around me and I have run out of all other options, something is better than nothing. Again, it can either be an expedient bridge to a primary option, or it’s an improvised last ditch effort.
In the end, the PACE methodology is probably utilized in medicine more often than we realize. When we talk about escalation of a difficult airway, we are talking about the PACE methodology to an extent. When we conduct mission preplanning and shake down equipment, we’ll have a primary light source and a backup. We might not realize it, but if we had to source two other light sources, they may present themselves if we look around… how many times have you seen someone use a cell phone light? This might become our emergent method in a pinch. We just have to open our minds to how we plan ahead.