Page 67 - JSOM Winter 2017

meaningful situational components . . . which require prior all participants achieved a level of proficiency commensurate
experience in actual situations for recognition.” with advanced beginner status. Specifically, on training com-
pletion, all participants demonstrated some ability to perceive
Similarly, instructor guidance to servicemembers’ commanders situation-specific elements of skill performance. For example,
was to recruit participants at the novice level for all four skills. participants demonstrated, without prompting, an under-
The objective of the training was to achieve advanced begin- standing of how to check for proper tourniquet application by
ner level of proficiency for each participant across all four attempting to insert their fingers under the applied tourniquets
skills. After the initial didactic instructions for each session, as and checking for residual bleeding from injured limbs.
trainees practiced the skills for the first time before the lanes,
medic instructors assessed their baseline proficiency. At the All 28 participants completed the pretraining and posttraining
conclusion of each module following all skill practice on the survey. Participants reported significant improvements in self-
lanes, medic instructors assessed their postcurriculum profi- reported comfort levels for all four skills (Table 1). The largest
ciency. Two physicians (one board certified in emergency med- increase in median comfort level reported was for tourniquet
icine, the other in general surgery and surgical critical care), application: median comfort level score before training was 4
by mutual agreement, made a post hoc determination based (IQR, 0–6.25) versus 9.5 (9–10) after training. Before training,
on medic instructor feedback as to whether each participant eight participants (28.6%) reported a score of 0 for comfort
achieved advanced beginner-level proficiency for each skill. level with tourniquet application.

Additional outcome measures included self-reported trainee Table 1 Median pretraining and posttraining self-reported skill
comfort level with each of the four medical skills. We operated comfort levels on a 0–10 scale
under the assumption underlying previous battlefield medi- Median Survey Score (IQR)
cine training curricula: that higher battlefield first-responder Skill Pretraining Posttraining p Value a
comfort levels would lead to increased preparedness to use Scene safety assessment 4 (0–7) 9 (8.25–10) <.001
interventions under combat conditions. We measured com- Tourniquet application 4 (0–6.75) 9.5 (9–10) <.001
17
fort level using a 0–10 Likert scale. Before the start of train- Wound bandaging 5 (2–7.75) 10 (9–10) <.001
ing, we relied on translators to communicate to participants
that 0 reflected “no comfort in performing the procedure.” Patient transportation 5.5 (0–8) 10 (8.25–10) <.001
(litter carry)
Conversely, 10 reflected “complete comfort in performing the IQR, interquartile range.
procedure.” We instructed each participant to circle one score a Wilcoxon signed-rank test.
before training. After training, we repeated the instructions
and scale description via translator and had the participants Discussion
circle a posttraining score on a new form.
Training foreign militaries is a vital mission of the NATO-led
Data Analysis advise-and-assist operations. Medical personnel of all levels
We double entered all data into an SPSS database, version 21 play a key role in this mission by contributing medical skills
(IBM, https://www.ibm.com). We used this program for all training. We present our experience designing a simple curric-
statistical analyses. We used medians and interquartile ranges ulum with a target audience of non–English-speaking service-
(IQRs) to describe all ordinal self-reported comfort levels. We members without any prior specialized medical training. We
compared pretraining with posttraining self-reported comfort delivered this training to Turkish, Azerbaijani, and Albanian
levels, using a Wilcoxon signed-rank test. We used a Bonfer- soldiers based on HKIA in Kabul, Afghanistan. The training
roni correction in interpreting statistical significance given our resulted in significant improvements in instructor-assessed
performance of inferential statistical testing for each of the participant skill levels and participants’ self-reported comfort
four medical skills; based on this correction, we interpreted levels with each of the four medical skills we taught.
p < .0125 as statistically significant.
The largest self-reported improvements were in comfort with
tourniquet application, which correlates with the leading cause
Results
10
of death on the battlefield: hemorrhage. Before the training,
We delivered five 2-hour training sessions biweekly over 3 more than one-fourth of participants reported no comfort
weeks to 187 foreign nonmedic servicemembers. This co- whatsoever with the use of tourniquets. These data indicate
hort consisted of 175 (93.6%) Turkish servicemembers, eight that although tourniquet research and training have become
(4.3%) Azerbaijani servicemembers, and four (2.1%) Albanian essentially ubiquitous within the US military, 18–20 foreign ser-
servicemembers. We delivered the final session to 28 trainees. vicemembers may have significantly less prior training or expo-
All servicemembers participating in the curriculum completed sure to these life-saving interventions. Therefore, hemorrhage
the training. Instructors performed before and after lane as- control appears to be a particularly high-yield skill to focus on
sessments of each participant’s proficiency in each of the four during medical training missions.
medical skills. We administered the pretraining and posttraining
survey instrument to participants in this final training session. Our outcome measures are an important limitation of our
project. Two physicians with board certifications in emer-
On completion of all study procedures, the two physicians gency medicine or surgical critical care provided assessments
involved in the curriculum development and execution, in of each participant’s proficiency with each skill, in accordance
consultation with the medic instructors, assessed the skill level with the Dreyfus model of skill acquisition in a post hoc fash-
8,9
of all participants. As expected, all participants exhibited a ion. Although both physicians participated in the training
novice level of proficiency with each of the four skills before and observed each participant, they relied heavily on medic
the lane exercises. By mutual agreement of the instructors, instructor feedback as well to make these determinations of

Medical Skills Course for Partner Forces | 65