Page 32 - Journal of Special Operations Medicine - Fall 2015

Junctional Tourniquet Training Experience

John F. Kragh Jr, MD; James J. Geracci, MD; Donald L. Parsons;
John B. Robinson; Kimberlie A. Biever; Erling B. Rein MD; Elon Glassberg MD;
Geir Strandenes MD; Jacob Chen MD; Avi Benov MD; David Marcozzi MD;
Stacy Shackelford MD; Kevin M. Cox; Elizabeth A. Mann-Salinas PhD

ABSTRACT

Since 2009, out-of-hospital care of junctional hemor- local military units, if they choose, pay for their own
rhage bleeding from the trunk–appendage junctions has tourniquets and provide their own training.
changed, in part, due to the newly available junctional
tourniquets (JTs) that have been cleared by the US Food Since the topic of JT use is so new, the depth of the ex-
and Drug Administration. Given four new models of JT perience of such training and trainers is currently shal-
available in 2014, several military services have begun low, but the collective experience is broad. This may be
to acquire, train, or even use such JTs in care. The abil- valuable for audiences consisting of those people who
ity of users to be trained in JT use has been observed wish to train with JTs in the future, for those who wish
by multiple instructors. The experience of such instruc- to train others, or for those who need to make decisions
tors has been broad as a group, but their experience as about training. However, currently, there is no docu-
individuals has been neither long nor deep. A gathering mented record of such experiences.
into one source of the collective experience of trainers
of JT users could permit a collation of useful informa- Experiences such as lessons learned, principles of use,
tion to include lessons learned, tips in skill performance, tips to emphasize, and pitfalls to avoid would be useful
identification of pitfalls of use to avoid, and strategies as a guide to future lesson plans, to training programs,
to optimize user learning. The purpose of the present and, ultimately, to best care. The purpose of this review
review is to record the experiences of several medical is to record the experiences of medical personnel in train-
personnel in their JT training of users to provide a guide ing of JT users, to provide a guide for future trainers.
for future trainers.
Models of JTs in 2014
Keywords: hemorrhage, resuscitation, medical device, edu-
cation, skill development, emergency medical services Currently, four models of JTs that have been cleared by
the US Food and Drug Administration (FDA) are avail-
able for use. Since FDA clearance, labeling of three mod-
els has changed (Table 1), and one company changed its
Introduction
model’s name.
Junctional hemorrhage—bleeding from wounds at the
junction of the torso and its appendages—is common Combat Ready Clamp
in the current wars in Afghanistan and Iraq, and, if un- The Combat Ready Clamp (CRoC ) (Combat Medi-
™
controlled, it can be lethal. Although labeled in 2009 cal Systems; combatmedicalsystems.com) is a vascular
1–3
by Tai and Dickson, junctional bleeding is ancient; the clamp that was the first FDA-cleared JT (Figure 1). The
4
8
recent focus is on controlling it better. 4–7 CRoC was first cleared for groin use and subsequently
cleared for axilla use. A letter to the FDA was accepted
10
To control junctional bleeding, multiple junctional tour- that allowed periumbilical use of the CRoC for difficult
niquets (JTs) are now available in the marketplace, and inguinal bleeding. By labeling, use of the CRoC is cur-
each model has at least some evidence of both safety and rently confined to the battlefield. Evidence supportive
effectiveness. 8–11 Users of JTs have been trained in their of CRoC use includes a case report, a normal volunteer
application, and the novelty of the training with these study, a manikin study, and animal and cadaver stud-
recently fielded devices has led to varied experiences for ies. 10,12–18 Furthermore, the instructions for use and the
both users and trainers. Furthermore, issue to those in way the CRoC was packaged were changed to full as-
the field has been limited and informal, as no doctrinal sembly in a ready-to-use configuration and not in the
enactment decision has been executed service-wide, so prior unassembled state.

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