Page 66 - JSOM Winter 2017

acquisition. We hypothesized that after training, self-reported We taught scene safety assessment using the danger, respond,
comfort levels and instructor-assessed proficiency would be send-for-help framework commonly advocated in life-support
significantly higher for each of the four skills. algorithms in commonwealth nations. The first step is assess-
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ing the scene for possible danger to patients and rescuer. The
second step is to respond to any threats to achieve scene safety.
Methods
The third step is to send for help as needed to ensure scene
Setting safety and properly resuscitate the patient. We then instructed
We conducted our performance improvement project at the participants in basic methods of trauma assessment to include
Hamid Karzai International Airport (HKIA) in 2016. During evaluation of airway, breathing, circulation, and secondary
the project time period, this was a NATO Joint facility, with survey. Practical sessions required participants via translator
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Turkey serving as the framework nation. The facility included to verbalize these steps during low-fidelity simulations.
a hospital with Role 2E (previously Role 3) capabilities. 5–7
We taught tourniquet application using a Combat Application
Before conducting this project, we submitted the proposed Tourniquet (North American Rescue, http://www.narescue
®
design for a nonresearch determination by the US Central .com). During the practical sessions, we first required partici-
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Command and Medical Readiness and Material Command. pants to place tourniquets on colleagues acting as simulated
The review determined this study to be consistent with a per- casualties (buddy aid). Participants then applied tourniquets
formance improvement initiative not meeting the definition of to themselves with two and then only one hand (self-aid). We
research and, thus, not requiring institutional review board finished by examining tourniquet application after brief peri-
oversight (office log No. M-10582). ods of physical exertion (e.g., running, push-ups).

Design Wound bandaging focused on the application of various forms
We conducted a performance improvement project alongside of gauze and, particularly, the emergency bandage. During
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implementation of our basic medical skills training curricu- the practical sessions, we again required participants to first
lum using a before-and-after observational design. Instructors apply the bandage to colleagues and then to themselves, thus
made post hoc assessments of the proficiency of each par- practicing both buddy and self-aid.
ticipant before and after the training in accordance with the
model of skill acquisition formulated by Stuart Dreyfus and Patient transportation instruction taught several types of
adapted by Patricia Benner. We also administered surveys for manual carry as described in Field Manual 4-25.11. Taught
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8,9
training participants to report their self-assessed comfort level carries included the supporting carry, arms carry, pack-strap
with each of the four skills on which they received instruction carry, and the two-hand seat carry. Additional instruction
and practice as part of the training curriculum. We then com- taught trainees how to load and carry litters. Trainees prac-
pared the pretraining instructor assessments and self-reported ticed all skills with fellow participants.
comfort levels to the posttraining values to ascertain the im-
pact of the curriculum. HKIA Role 2 NATO Hospital US Army Medical and Nurs-
ing Corps Officers designed the curriculum. Medics from the
Participants Australian Defense Force and US Army acted as instructors
Participants were nonmedic members of the Turkish, Azer- and executed the training. The training comprised four mod-
baijani, and Albanian militaries assigned to HKIA. In col- ules, each of which was devoted to one of the four basic medi-
laboration with their commanders, we arranged for volunteer cal skills. Each module lasted approximately 30 minutes. The
enlisted members to undergo the training. The training con- first half of each module comprised verbal description of the
sisted of a single session lasting 2 hours. We coordinated skill with the assistance of Turkish, Azerbaijani, and Albanian
training times for two sessions per week, during which the servicemember translators. Next, the course instructors dem-
participating servicemembers were unlikely to have competing onstrated the skill for the trainees and allowed trainees an op-
duties. We delivered training to approximately 30 trainees at portunity to practice the skills at their own pace. The second
each session. Our guidance to the servicemembers’ command- half of each module entailed practical exercises comprising
ers was to select participants without any prior medical skills lanes administered by the instructors to the trainees.
training whose proficiency with the four skills was consistent
with a novice, per the Dreyfus model of skill acquisition. The Outcomes and Measurements
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servicemembers’ commanders were the final authority in de- Our outcome measures included post hoc instructor assess-
termining which individuals participated during each session. ments of student proficiency in each skill based on the Stu-
art Dreyfus model of skill acquisition as adapted by Patricia
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Intervention Benner. This model comprises five categories describing the
The project intervention was a 2-hour training curriculum. stages of skill acquisition ranging from novice (lowest level of
The curriculum focused on four battlefield first-responder proficiency) to expert (highest level of proficiency). For the
skills centered on evacuation and on hemorrhage control as purposes of our study, only the two categories representing the
the most common cause of preventable death on the battle- lowest levels of proficiency were applicable: novice and ad-
field. 10,11 Our intent was to design a curriculum that was simple vanced beginner. Novices “have no experience with the situa-
and concise, given the challenges of limited participant medi- tions in which they are expected to perform tasks. . . . They are
cal experience and language barriers. The four skills included taught about [these situations] in terms of objective attributes
(1) assessment of scene safety, (2) limb tourniquet application, . . . that can be recognized without situation experience.” In
(3) wound bandaging, and (4) patient transportation via litter. contrast, “the advanced beginner is one who can demonstrate
The basis for the specific techniques taught was Field Manual marginally acceptable performance. This person is one who
4-25.11 (First Aid), unless otherwise noted. 12 has coped with enough real situations to note the recurrent

64 | JSOM Volume 17, Edition 4/Winter 2017