Page 43 - JSOM Summer 2019

Ease of Use of Emergency Tourniquets
on Simulated Limbs of Infants

Deliberate Practice

1
1
John F. Kragh Jr, MD *; Brittnay Wright-Aldossari ;
2
James K. Aden 3rd, PhD ; Michael A. Dubick, PhD 3

You have chosen the hard road. As a Tactical
Medical Professional, simply doing your job means
that the chips are down. Your patients deserve ABSTRACT
the best! It takes an elite Operator to think under Background: To investigate questions about application of Introduction
pressure and perform in extreme environments. emergency tourniquets in very young children, we investigated
practices of Combat Application Tourniquet (C-A-T) use on a How a tourniquet fits a limb affects how effective it is in its
1
simulated infant-sized limb to develop ways to improve read- control of bleeding and how a patient feels its compression.
1,2
Be prepared to apply what you know. iness for caregiving. Methods: This study was conducted as If a tourniquet pinches skin, it can hurt and blister the skin.
Large limb circumferences may exceed tourniquet lengths, and
investigations of C-A-Ts used by two individuals in deliberate
practice. The practice setup simulating a limb of infants aged no fit may be possible. The shortest working length of a tour-
3−5 months included a handrail (circumference, 5.25 in.). This niquet may exceed the circumference of a small limb. If a user
setup needed a specific modification to the instructions for use deforms a tourniquet to make it fit a large or small limb, then
to adhere the band between the clips. Each user performed uneven compression of soft tissues and blood vessels may risk
100 practices. Results: With accrual of experience, application ineffectiveness. However plain these comments, little experi-
ence of clinical use has yet informed how tourniquet fit maps
Your initial training was only the first step. time was shorter for each user, on average in a power law of to limb size. 2–5
Now it is time to augment your ability practice, and more ease was associated when less time was
taken to apply the tourniquet. The ease of use was associated
to confidently apply your knowledge of with accrued experience through deliberate practice of a tour- The ease of tourniquet use in treating children is an open ques-
tion. In the Stop The Bleed classes, the basic bleeding-control
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unconventional medicine when needed. The niquet user while under coached learning. A check of tourni- course has a presentation slide (no. 55 [of 61], entitled “Bleed-
Journal of Special Operations Medicine quet fit on a 4.25-in. limb also entailed the modification used ing control in children”) that states: “In all but the extremely
in the 5.25-in. limb. However, an additional modification of
(JSOM) is the only academic, peer-reviewed wrapping the band in a figure-8 pattern around the rod was young child, the same tourniquet used for adults can be used
medical journal in the world dedicated to the needed because the rod and clip could not meet. The fit on a in children. For the infant or very small child (tourniquet too
big), direct pressure on the wound as described previously will
unique working environment of the Tactical 3.25-in. limb was impracticable for a workaround. Tourniquet work in virtually all cases.” Scripted notes, in part, add: “As
use was harder for smaller limbs (i.e., 4.25 in. and 3.25 in.). A
Medical Professional. Take your training to map of tourniquet fit was sketched of which sized limbs were long as they can be properly applied, the same tourniquet can
the next level with current, relevant updates too big, too small, within the fit zone, or at its borders. Con- be used in an adult or a child. If the child is too small for the
tourniquet to be applied properly, direct pressure on the bleed-
– as they happen. clusion: C-A-Ts mechanically fit the simulated limbs of infants ing wound will almost always work to control the bleeding.”
aged 3−5 months, and C-A-T use was practicably easy enough
to allow experienced users to fit tourniquets to limbs well us-
ing a specific modification of the routine technique. The find- To clearly delimit for instructors and learners the phrase “ex-
ings and knowledge generated in this study are available to tremely young” in the slide, we investigated tourniquet fit. In
inform researches and developments in best preparation prac- the current study, we investigated practices of Combat Ap-
Show your team tices for instructing first aid. plication Tourniquet (C-A-T; C-A-T Resources Inc., http://
how much you care. combattourniquet.com/) use on a simulated infant-sized limb
to develop ways to improve readiness for caregiving.
Keywords: Combat Application Tourniquet; limb tourniquet;
Subscribe to the JSOM and Stop The Bleed; medical device; combat injury first aid; use Methods
inform your thinking. instruction; resuscitation; emergency
This study was conducted within protocol guidelines at the US
Army Institute of Surgical Research in late 2018. The design
*Correspondence to 3698 Chambers Pass, Joint Base San Antonio Fort Sam Houston, TX; or john.f.kragh.civ@mail.mil
1 Dr Kragh and Ms Wright-Aldossari are researchers of bleeding control at the Institute of Surgical Research (ISR), Fort Sam Houston, TX. Dr
Kragh is an associate professor in the Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD. Dr Aden is a
2
statistician at the Brooke Army Medical Center, Fort Sam Houston, TX. Dr Dubick is researcher and chair, Department of Hemorrhage Control
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and Resuscitation at the ISR.
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