Page 35 - Journal of Special Operations Medicine - Fall 2017

Discussion offers new evidence that protection is important even within
3 months as opposed to a longer time, as previously estab-
The tourniquet users performed similarly in unwrapping a lished. 5,6,15 Evidence has established that first aid tourniquets
tourniquet from its wrapper with or without hands covered are best protected from sunlight, and keeping them in a first
with gloves; there were no statistically significant results. By aid kit or pouch is recommended. 5,6,16 One study of U.S. Ma-
studying nine glove groups, the statistical correction required rine Corps units mechanically loaded tourniquets after expo-
for repeated testing made reaching significance difficult. Care- sure during a deployment as stowed in a first aid kit, wrapped
givers routinely take standard precautions while rendering or not, and found that the kit protected the tourniquet both
first aid by using examination gloves to protect their own ways equally well. In the same study, however, tourniquets ex-
hands from blood to minimize risk of disease transmission. posed outside the kit, as attached to the outside of worn gear,
However, there are few data sets regarding caregiving perfor- mechanically failed more often than those stowed in kits. The
6
mance by types of gloves worn. 8–12 This study, being a first compilation of coherent evidence that tourniquets should be
look at glove effects, has provided a preliminary data set of stowed in kits is clear and consistent. When users noted that
information upon which to estimate sample sizes required for care for their gloves, their tourniquet, and its wrapper may
statistical power. Awareness of potential glove effects on care- be important to themselves and other persons in their mili-
giver performance may have applicability in either caregiving tary unit by helping the others understand how to best prepare
or teaching tourniquet use in first aid.
and stow the tourniquet, such help resonates with the fourth
stanza of the Ranger Creed which, in part, says: “My . . . care
Caregivers and instructors may use this knowledge to better un- of equipment shall set the example for others to follow.” 17
derstand the time required to unwrap a tourniquet. For users
such as Soldiers and law enforcement officers who may need The contradictory advice about whether to unwrap a tourni-
to provide care under fire, the added time to unwrap a tourni- quet had two premises, with one premise on each side of the
quet may prolong exposure to danger. For example, users in this argument. On the unwrap side, speed is a benefit, and exposure
study had a mean time to unwrap that was 64% of their mean is a risk. On the wrap side, protection is a benefit, and slowness
time to stop simulated bleeding (unpublished data). This added is a risk. Both premises are true, thus creating a paradox. How-
time, being 64% longer during care under fire, adds further to ever, this study resolved the paradox, because the protection
the preexisting risk of being shot for both the caregiver and the point is reduced to dirt and dust. The wrapper did not protect
casualty. Also, the delay due to unwrapping may allow the ca- the tourniquet from damage due to sunlight. Stowing an un-
sualty to bleed more; at an average of 17 seconds unwrapping wrapped tourniquet in its first aid kit is the practical solution.
time and a manikin bleeding rate of 625mL/min, the blood loss
may average 177mL, an important difference. Furthermore, The limitations of this study are rooted in its design. It was a
when there are multiple lifesaving interventions indicated for focused laboratory study of task deconstruction, not an as-
a casualty or there are multiple casualties in need of lifesaving sessment of caregiving in the wild. The laboratory setting was
interventions, such delay applies to any later lifesaving inter- ideal in that it was warm, quiet, and lighted, rather than war-
vention. The “unwrapping” beforehand can improve speed of like, with mud and blood, chafing and strafing, or night and
use by a relevant amount of time, in this case by an average of fright. Results may be worsened or complicated in actual care-
17 seconds. The new knowledge validated the existing practice giving conditions. The ability to detect statistically significant
of advisors who recommended unwrapping the tourniquet in differences can be improved by comparing more tests, more
their first aid kit when deploying to war in the military or when users, or fewer groups of gloves. This study does not offer a
working in law enforcement. We recommend this practice.
decision on whether to enact a policy of unwrapping tourni-
quets in a first aid kit, because it is only preliminary evidence
The environmental exposure led to rapid photodegradation of contributing to the discussion of such a decision. Also, this
the wrapper to the point that sun-exposed portions of the plas- study does not address whether it may be one or more tour-
tic wrapper were destroyed. The wrapping material, polyole- niquets that should be so unwrapped. Military doctrinaires,
fin, is vulnerable to photodegradation by sunlight, including logisticians, project managers, and investigators may want to
ultraviolet light and oxygen, including its ozone form; and ad- join in a conversation of how the bureaucracy wants to react
ditives and impurities of such polymers play roles in polymer to what currently appears to be an unstewarded decentraliza-
degradation. Conclusively, packaging the tourniquet in such tion of unwrapping practices. However, if no entity effectively
13
a wrapper did not protect it from exposure, and even sunlight stewards the conversation, our findings may be determined by
damaged it. Simply, the purpose of wrapping is to ease packing individuals to be locally actionable.
and transport; it is not about protection from environmental
exposure. The wrapping keeps commercial goods clean, helps Future directions for further scholarly work include several
packing be stacked neatly and densely to save space (Velcro- topics. An assessment of student end-users learning in a con-
brand fasteners do not inadvertently stick to others, making ventional educational setting may be more generalizable than
devices askew, disorganized, and disarrayed bulkily), and it that of the investigators in this study, who had experience with
keeps the stowage configuration right (routed in one-handed tourniquets. The tourniquets that are dual-packaged, a type of
way ready to go with paper instructions tucked inside).
repackaging, are a worthy topic of study regarding unwrap-
ping. Studies that include doffing and donning gloves might
The current understanding of how polymers such as plastics be useful to develop best caregiving practices. Other topics
are degraded by environmental exposure is evolving and it of interest among caregivers in the field include tourniquet
appears degradation may be less likely from a single type of performance over cold clothing, firefighting garments, and
exposure acting alone than it may be from interactions among manual performance while wearing specific types of work
different types of exposure, such as combinations among ul- gloves, such as firefighter gloves. Studying the step of remov-
traviolet light, heat, humidity, smog, or ozone. 14,15 This study
ing the tourniquet from the first aid kit may help develop ways

Unwrapping a Tourniquet | 33