Page 29 - Journal of Special Operations Medicine - Winter 2016

simultaneously effective, fast, safe, and bleed little), 2. Kragh JF Jr, Walters TJ, Baer DG, et al. Survival with emer-
then more uses may be required. gency tourniquet use to stop bleeding in major limb trauma.
Ann Surg. 2009;249:1–7.
3. Passos E, Dingley B, Smith A, et al. Tourniquet use for periph-
Limitations of this study are based in its design, which was eral vascular injuries in the civilian setting. Injury. 2014;45:
implemented for hypothesis generation, not hypothesis 573–577.
confirmation. Furthermore, it did not assess students and 4. Kragh JF Jr, O’Neill ML, Walters TJ, et al. The military emer-
was not generated from a conventional training program gency tourniquet program’s lessons learned with devices and
designs. Mil Med. 2011;176:1144–1152.
of instruction. Quantitative assessment of the procedural 5. Childers R, Tolentino JC, Leasiolagi J, et al. Tourniquets ex-
learning curve for tourniquet use remains challenging be- posed to the Afghanistan combat environment have decreased
cause selected metrics have different learning curves that efficacy and increased breakage compared to unexposed tour-
have not been assessed in a systematic manner. niquets. Mil Med 2011;176:1400–1403.
6. Kragh JF Jr, Burrows S, Wasner C, et al. Analysis of recovered
Further research may include assessment of students in tourniquets from casualties of Operation Enduring Freedom
and Operation New Dawn. Mil Med. 2013;178:799–805.
conventional training. Validation of metrics is indicated so 7. Kragh JF Jr, Littrel ML, Jones JA, et al. Battle casualty sur-
that their utility is made clear. Future learning curve inves- vival with emergency tourniquet use to stop limb bleeding. J
tigations may benefit from a standardized study design and Emerg Med. 2011;41:590–597.
assessment of several metrics. The competence– confidence 8. Kragh JF Jr, Nam JJ, Berry KA, et al. Transfusion for shock in
association may be explored in tourniquet users. Perhaps US military war casualties with and without tourniquet use.
Ann Emerg Med. 2015;65:290–296.
the learning curve for other first-aid interventions that are 9. Kragh JF Jr, Aden JK 3rd, Walters TJ, et al. In reply. Ann
analogous to tourniquet use, such as airway procedures, Emerg Med. 2015;66:340–341.
could benefit from learning curve analyses. 10. Lakstein D, Blumenfeld A, Sokolov T, et al. Tourniquets for
hemorrhage control on the battlefield: a 4-year accumulated
experience. J Trauma. 2003;54(5 suppl):S221–225.
Conclusion 11. Tarpey MJ. Tactical combat casualty care in Operation Iraqi
Freedom. Army Med Dept J. 2005:38–41.
Measures of learning readily available to tourniquet in- 12. Kragh JF Jr, Beebe DF, O’Neill ML, et al. Performance im-
structors include effectiveness, pulse cessation, time to provement in emergency tourniquet use during the Baghdad
effectiveness, windlass turn number, and pressure under surge. Am J Emerg Med. 2013;31:873–875.
the tourniquet. All of these are candidate measures for 13. Kragh JF Jr, Walters TJ, Baer DG, et al. Practical use of emer-
gency tourniquets to stop bleeding in major limb trauma.
potentially useful feedback to trainees. Plotting mea- J Trauma. 2008;64(2 suppl):S38–49.
sures by experience showed quantified learning of users 14. King DR, van der Wilden G, Kragh JF Jr, et al. Forward as-
and aided in generating hypotheses for future testing. sessment of 79 prehospital battlefield tourniquets used in the
current war. J Spec Oper Med. 2012; 12:33–38.
15. Kragh JF Jr, Walters TJ, Westmoreland T, et al. Tragedy into
Funding drama: an American history of tourniquet use in the current
war. J Spec Oper Med. 2013;13:5–25.
This study was supported via the US Army Medical Re- 16. Zhang L, Sankaranarayanan G, Arikatla VS, et al. Charac-
search and Materiel Command, the parent organization terizing the learning curve of the VBLaST-PT((c)) (Virtual
of the US Army Institute of Surgical Research. Basic Laparoscopic Skill Trainer). Surg Endosc. 2013;27:
3603–3615.
17. Tahmasbi Rad M, Wallwiener M, Rom J, et al. Learning
Disclaimers curve for laparoscopic staging of early and locally advanced
cervical and endometrial cancer. Arch Gynecol Obstet.
The opinions or assertions contained herein are the private 2013;288:635–642.
views of the authors and are not to be construed as official 18. Sclafani JA, Kim CW. Complications associated with the
initial learning curve of minimally invasive spine surgery: a
or reflecting the views of the Department of Defense or US systematic review. Clin Orthop Relat Res. 2014;472:1711–
Government. The authors are employees of the US Gov- 1717.
ernment. This work was prepared as part of their official 19. Savage E, Pannell D, Payne E, et al. Re-evaluating the field tour-
duties and, as such, there is no copyright to be transferred. niquet for the Canadian Forces. Mil Med. 2013;178:669–675.
20. Schreckengaust R, Littlejohn L, Zarow GJ. Effects of training
and simulated combat stress on leg tourniquet application ac-
Disclosures curacy, time, and effectiveness. Mil Med. 2014;179:114–120.
21. Clumpner BR, Polston RW, Kragh JF Jr, et al. Single versus
None declared. double routing of the band in the combat application tourni-
quet. J Spec Oper Med 2013;13:34–41.
22. Polston RW, Clumpner BR, Kragh JF Jr, et al. No slackers in
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Learning Curves of Emergency Tourniquet Use 13