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models to Norway, and Major Erling “Earl” Rein, and different steps in applying the tourniquet were mea-
CAPT Geir Strandenes organized the assessment. The sured. Moreover, it was emphasized that even though
testing included SOF Medics of the four Nordic coun- tourniquet application is infrequently used, it is a vi-
tries of Norway, Denmark, Sweden, and Finland. The tal skill to master, and manikin training systems read-
Medics found that the SJT was best, reporting it was ily facilitate both teaching and learning of these skills.
effective, fastest, and most preferred. The Medics found Furthermore, development of a junctional-hemorrhage
that the distributors’ shipping configuration of each de- training manikin system has been made by a company
vice should be modified in preparation for device use; in Wales for the United Kingdom’s armed forces, but
based on this feedback, some makers reconfigured their preliminary communications are unclear whether this
device packaging. manikin is focused on surgical wound packing or pre-
hospital care.
Israeli Military Experiences With JT Training:
2013–2014 Experiences in the Management of the
A test of user preference was made by Israeli Defense Joint Trauma System in 2014
Forces SOF Medics. The USAISR sent the devices and The Joint Trauma System’s Combat Medic Conference
the test plan to Israel, and Colonel Elon Glassberg, and (renamed Battlefield Medicine Conference), a periodic
Major Gilad Twig organized the assessment. The test- teleconference by and for Medics in the theater of op-
ing included 14 Medics. Each tester was to use each of erations, focused on JTs as a topic of discussion at the
the four tourniquet models twice on each side of the September 2014 telemeeting. After a talk by an expert,
groin (a total of four applications, left and right side, there was a lengthy question-and-answer period during
per model per subject). Effectiveness was defined as which a number of issues were raised. The issue of col-
stopping the distal pulse by manual physical examina- lateral blood flow was raised in a question concerning
tion by a physician. In the five assessment categories, a training surrogate for effectiveness (i.e., hemorrhage
multiple models of tourniquet performed similarly well; control). For both extremity tourniquets and JTs, med-
SJT and AAJT performed best in four categories, JETT ics were being taught that distal pulse stoppage was a
was best in three, and CRoC was best in two. The Med- good surrogate for hemorrhage control. In this discus-
ics reported that all the tourniquets needed preparation sion, confusion ensued because speakers sometimes did
before packing in gear. Fourteen users were divided into not specify a tourniquet as a JT or “limb” tourniquet.
two groups: nine users (trained first), and five users who Occasionally, some speakers used the term “extrem-
were subsequently trained separately. Of the 14 users, ity tourniquets.” This confusion also raised the issue
only one of the first nine had 100% effectiveness for of usage. Extremity classically means that the shoulder
every test irrespective of model, but four of the last five and pelvic girdle are included in their respective upper
users had 100% effectiveness of every test irrespective and lower extremities. In 2006, we clarified this usage
of model. This comparison of effectiveness implied a point, using the term limb for portions of the extrem-
minor, unexpected finding that generated a hypothesis: ity to which a tourniquet could be applied; in 2008,
training quality may affect trainee performance, since we used the term “major limb trauma” in the context
trainers became more experienced and may have better of tourniquet use. The term extremity was then also in
trained the second group. wide use, but as time went by, the need for differen-
tiation between limb and junctional became increas-
The Training Manikin Situation in 2014 ingly important. Therefore, at this time, we suggested
Few manikin models were available for training with using limb, as in limb tourniquets, for those portions
JTs before 2014, but the situation is improving now of the extremities that are amenable to circumferential
as the number of models increases. The first manikin tourniquets in the established way. Extremity includes
available, a CRoC Trainer Manikin, was by Operative the junctional areas of the extremities, and so the term
Experience, Inc. (operativeexperience.com). Operative extremity tourniquet necessarily includes both JTs and
Experience, which has had a lasting relationship in limb tourniquets. Junctional refers to the body areas at
training with US SOF, now has a new axilla manikin for the junction of the torso and its appendages, and so JT
JT use. Further development of manikins for junctional includes the axilla area, the groin–buttock area, and the
hemorrhage control training has been made through neck; however, to date, there is no FDA-cleared JT for a
small business innovation research (SBIR), and Charles neck indication. In the conference, clear use of the terms
River Analytics (www.cra.com) has entered phase II in limb, extremity, and junctional removed the confusion
their SBIR to make a junctional hemorrhage manikin. from the conversation.
In a preliminary report, the company indicated that
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training systems that teach and refresh skills of JT use In that same conference, however, the pulse stoppage
have not been adequately developed. To address these concern as a surrogate for hemorrhage control was
needs, a sensor-enabled manikin was designed, and the not so easily resolved. Pulse stoppage in JT use is more

26 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015