Page 57 - Journal of Special Operations Medicine - Spring 2016

Figure 4 Ranking results of users’ most preferred junctional individual casualty and had limited duration (30 seconds)
tourniquet model. of use, which summed to a brief time (7–8 minutes total).

A second minor finding was that although both training
groups had the same program of instruction with the
tourniquets, the trainers gained experience before the
second group was trained, and the trainer-medic ratio
was also better in the second group. Such improvements
in instruction were unplanned but appeared to be asso-
ciated with improved learning.

Our findings are coherent with a small but growing body
of knowledge regarding use of junctional tourniquets.
The findings are different than those found in similar
testing conducted in the US Army by Kragh at el. In
11
that study, CRoC and SJT were most effective (94% and
100%, respectively), whereas AAJT was least at only
The most preferred tourniquet models were the SJT, AAJT, and JETT; 11%. However, the US Army testing was in accordance
the least preferred statistically were the AAJT, JETT, and CRoC. In with the instructions for use (IFU) current at that time
pairwise comparisons of preference, only the SJT–CRoC difference (before the 6 December 2013 IFU, which specified ap-
was significant (p = .0472; p > .178 for all others). Lower numbers
equate to better results (most preferred, rank = 1, best). Top and bot- plication directly to the periumbilical area), whereas the
tom of each box represents 75th and 25th percentiles, respectively; present testing was with the later instructions. Applica-
whiskers represent the range, and the line in the box represents the me- tion to the umbilicus in the US Army testing was painful
dian value of the distribution. The JETT was so often ranked 3 that the
box collapsed there. The CRoC had only one medic ranking it as best. and often intolerable, whereas application to the groin
in the IDF testing was comfortable and tolerable. An-
model, whereas four of the final five users had 100% other difference in results was that in US Army testing.
effectiveness in such tests. The proportion of effective the CRoC and SJT were fastest to achieve effectiveness,
tests in the first group was 84% (103 of 126) compared whereas in the present study, SJT was fastest. In our
with 96% (58 of 60) in the second group. study, the Israelis assembled CRoC in each test, whereas
in US Army study, it was always preassembled. The du-
The medics were trained by those physicians who were ration of CRoC assembly explained the difference in
also the assessors of testing, and the two groups of med- mean times to effectiveness between the two reports.
ics were trained by the same people. In other words,
the trainers had experienced the training and assessing Limitations of the present testing are rooted in its de-
of the first group before gaining another round of such sign, which included few testers, few tests, and few
experience with the second group. The medic-trainer devices. Junctional tourniquet use was mismatched in
ratios for the two groups were 9:4 (4.5:1) for the first its setting in that use was not in combat casualty care
group and 5:4 (1.2:1) for the second group. but was indoors in a common training-like setting. The
limited number of devices available during testing due
to AAJT breakage resulted in loss of devices, tests, and
Discussion
data. Previous testing had used similar device numbers
The main finding of this testing is that of the five assess- but no breakage occurred; hence, such a high breakage
ment categories, multiple tourniquet models performed rate was unpredicted during planning of the present
similarly well; SJT and AAJT performed best in four study. Notably, despite breakage, AAJT showed prom-
categories, JETT was best in three, and CRoC was best ise, with 100% effectiveness and high rankings in the
in two. In the categories of safety, effectiveness, time to preferences of those medics who were able to actually
effectiveness, and two measures of user preference, no use it. Also, assessing the distal pulse by manual physi-
model performed solely best in all of the five categories. cal examination (as in combat casualty care) may be im-
Additionally, no model performed jointly best with any proved scientifically by using Doppler techniques. The
other model in all of the five categories. test plan only simulated groin bleeding and did not test
control of bleeding from other junctional areas, like the
A minor finding of this study is that all tests and models axilla. Axillary hemorrhage control by use of junctional
were safe. To understand safety better, longer-term studies tourniquets remains a knowledge gap and needs testing.
are needed, but the present brief testing may indicate that
training of medics is safe within similar limits. Our study Given our study findings within the context of current
had limited repetitions (14–16) of uses of tourniquets for an junctional tourniquet knowledge, future directions for

Junctional Tourniquet Testing for Groin Hemorrhage 41