Page 35 - Journal of Special Operations Medicine - Fall 2015

training to individual users; the breadth (e.g., number of • Improved dexterity was necessary to master the man-
individuals trained, quantity of information conveyed) ual skills, so learners practiced for several times until
of the training is unknown, but the quality of training he or she became proficient.
experienced was high, as reported by trainees. • Periodic refresher training was thought to be of po-
tential importance and was recommended for future
Early support for JT use in theater came from a com- consideration.
mander of a Field Assistance & Technology (FAST)
medical team. LTC Raven Reitstetter was a medical The second study related to JT training, by Lunati et al.,
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laboratory officer who was both aggressively forward was an assessment of 30 users of three JT models. This
thinking and engaged by the AMEDDC&Ss Director- study looked at use metrics (e.g., effectiveness, time to stop
ate Combat Doctrine Development (DCDD). LTC Re- bleeding, blood volume lost) and it used similar methods
itstetter was deploying with his small team and was of training as the Mann-Salinas et al. study. The trainer
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prepared for JT reporting, and DCDD was attempting was the same person who performed this function in the
to fill a capability gap in junctional hemorrhage control. Mann-Salinas et al. study and so had gained more expe-
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FAST brought about 14 devices into theater and trained rience. The 30 users were a diverse set of medical person-
several people in JT use. Unfortunately, the FAST was nel and included 10 Combat Medics from the US Army.
defunded and the team redeployed abruptly. There were Training was stepwise by individual trainee.
several communications about the training; common
themes were that the users were unfamiliar with both Three common mistakes were made early in a user’s ex-
the device and the clinical problem, the number of in- perience: malpositioning of models, not removing enough
structors was low, the number of users to train was high, slack before tightening, and not providing counter-
and the quality of training was inadequate. These initial tension (Table 2). Malpositioning often involved placing
experiences were not unexpected to the Program, and belts too proximal, above the targeted point along the
redoubling of effort began. pressure point (also above the similarly leveled greater
trochanters). Slack removal was problematic for the
The Emergency Tourniquet Program conducted labora- three circumferential tourniquets that also needed coun-
tory and research studies that aided understanding of JT ter-tension so that the targeted compression was not in-
training. The first study, by Mann-Salinas et al., was an advertently pulled off the targeted point.
assessment of six JT users. This study was rooted in a
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DCDD question that was asked in a 2010 medical pre- The ratio of trainees to instructor was 1:1, and the in-
sentation given by a senior medical consultant in DCDD: structor was always present to emphasize key points and
could users be trained in application of the CRoC, the to give immediate feedback on technique, including in-
only FDA-cleared JT at the time? This question seemed structions on correct technique and avoidance of prob-
likely to be answerable as yes or no depending on the lems. Emphases in feedback included subtle features of
quality of training. The asker had a role of substantial
importance in enacting any possible doctrine about JTs, Table 2 Key Findings of Experience in Junctional Tourniquet
so the Program’s manager decided to conduct a study Training
that would answer the question. A manikin study was Rookie mistake was to put the devices on too high, above
performed that compared CRoC use among six users the level of the greater trochanters.
(two nurses, a surgeon, a physician, a research physi- Some parts are removable, may fall off, and can be
ologist, and a former SOF medic). All participants were separated or lost. SJT was noted for this.
trainable and could achieve 100% effectiveness within The more moving parts, the easier the parts were to tangle.
the scope of a laboratory study. These findings indicated This was experienced most with the JETT.
to the investigators that training was effective and that Some models had recurrent problems (e.g., AAJT bulb-tube
training of other users appeared plausible, feasible, and disconnections which were correctable).
practical. The training was formal and included watching CRoC pre-assembly is how SOF medics prepare it, as
a video of instruction, reading a hardcopy of instructions opposed to off-the-shelf packaging.
for use, handling the CRoC, and applying the CRoC to a
CRoC trainer manikin (Operative Experience; operative- The worse the execution of each step, the higher the risk
for ineffectiveness.
experience.com). The ratio of instructors to trainees was
high and the results indicated that the quality of instruc- Poor step execution mortgages the next step; further poor
execution compounds the problem.
tion was high. Lessons learned included:
The order of the steps is also the order of importance of
• Red, simulated blood promoted a sense of urgency, the steps.
which enhanced the training by creating a more realistic Apply tourniquet coarsely, palpate femoral pulse, and
emotional response compared with use of clear water. adjust targeting before final tightening.

Junctional Tourniquet Training Experience 23