Page 48 - JSOM Summer 2019

plausibility (experience may improve one’s perceived ease of refocusing became easier over time in part because caregivers
use), temporality (two linked ideas changed simultaneously), learned that applying a tourniquet to a child was mechani-
strength (the magnitudes of the changes in speed and ease were cally easier than applying one to an adult. For ease of use,
large), scalability (changes in magnitudes were proportional the mechanical- emotional contradistinction was stark to the
throughout the range of accrued experience), consistency (as experienced but not to the uninitiated. The most experienced
in prior science, accrual of manual experience was associated caregivers found no pediatric modification was needed to
with improved motor performance), and coherence (the asso- the tourniquet IFU. Mechanical use was easier because pedi-
ciations were in line with known facts of motor learning) pre- atric limbs were lighter, smaller, and more compressible—as
liminarily outlined a theoretical cause-and-effect relationship were their blood vessels. Tourniquet tightening was faster
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between accrued experience and improved ease. If true, chang- and less effortful. The most common model of tourniquet,
ing the idea of such ease being materially based in a device’s the C-A-T, fits children’s simulated limbs at the mid-arm of
design, to allowing a user effect, may become disruptive to 3- to 5-month-old male infants, an almost unheard of empiric
customer evaluations and user preference studies if the con- need. Communities, schools, caregiving systems, and depart-
sumer reports currently imply ease of use of a television or ments of education may focus on supplying a single model of
ease in driving a car is only about the widget. tourniquet to fit their patients, to train their providers, and to
manage their preparedness. There appears to be no present
The third minor finding was about a second modification of need to complicate readiness efforts by dual-model fielding,
tourniquet technique from the IFU, and this figure-8 modifi- devising complex logistics, adding more training of tech-
cation may become a candidate skill for developing a way to nique modifications, or doubling up programs of instructor
use a common model of tourniquet on infant limbs. Awareness preparation.
of the technique outlined in the present study seems appro-
priate currently for consideration in the research community, The limitations of this study evolve from its design being
but cluttering the minds of Stop The Bleed learners and their based in an exploration of a new topic in first aid. Because
instructors with too much information is likely to be counter- the users operated the timer, they saw their time result be-
productive presently. fore recording their ease of use, thereby likely biasing ease
results; if another person operated the timer, such bias may be
Infants in need of tourniquets are rarely seen by caregivers, mitigated. Every aspect of the present work needs adequate
in part because the penetrating mechanism of trauma is un- assessments in research, development, testing, and evaluation
common. In a study identifying pediatric injury patterns by before consideration in application to teaching or caregiving.
year of age, using a large national database, Tracy et al. did The modifications from the current IFU are not yet cleared
not address tourniquets. Although blunt injury accounts by the US Food and Drug Administration (FDA) but are clin-
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for most pediatric injuries, Tracy et al. found a penetrating ically permissible within the scope of practice of caregivers,
mechanism of injury for 7.5% of children aged 0–18 years and because although the FDA regulates labeling of medical de-
12.7% of children aged 13–18 years. Tracy et al. also found vices, including their directions for use, it does not regulate
that the frequency of penetrating trauma was low for younger the scope of practice.
children but rose sharply after age 13 years, becoming a top-
five most common mechanism of injury. In fact, penetrating Future directions for scholarly activities include surveying the
trauma, not falls, was the second most frequent mechanism techniques and other tourniquet users for ease of use, ease of
of injury for adolescents aged 16–18 years. In the stacked learning such use, and mechanical effectiveness, such as on
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column charts of Tracy et al., the tiny layer of penetrating manikins. Understanding how the technique of wrapping the
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trauma for those younger than 1 year is so small it is hard band to secure the rod as a modification works mechanically,
to see and indicates its proportion is very low. The burden and validating on a manikin that the technique can be taught
of injury among children in need of a tourniquet that fits an and that a lesson plan can be developed for the public to use
infant appears to be hard to measure, partly because the fre- may be necessary. Other future directions are listed in Table 2.
quency is so low. Reeves et al. reported data from a war ca-
sualty registry showing that 1,318 patients were younger than
18 years, but only 19 (3%) were younger than 1 year, and of TABLE 2 Other Future Directions for Scholarly Activities
those 19, a tourniquet was used only on 1 (5%, or 0.08% of The instructions for use and Stop The Bleed information give
sound advice, but both may need attention on guidance in teaching
the total group). Among 727 patients cared for with 1,212 of how to best prepare learners to apply the tourniquet to infants.
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tourniquets at a Baghdad hospital, a 4-year-old Iraqi girl was Anthropometric data may be sought in an easier form to ana-
the youngest. 2,3,5 Her thigh’s girth was slightly more than that lyze than available currently in assessing the capacity to place a
of the wrist of one of the authors. Tourniquet use on this pa- tourniquet.
tient was mechanically routine except that her limb was small. The idea of blood volume being proportional to mammalian body
Use of a tourniquet on this patient was emotionally surprising, weight may need to be worked through for potential research and
anxiety provoking, and posed a potential regret of a prevent- educational usefulness. The idea that the wound volume may be
able death. We saw few children (3% [17/580] of casualties proportional to the average blood loss also may need to be sim-
ilarly worked.
with recorded ages <18 years), and caregivers accrued few ap-
plications of tourniquets to children but many on adults. Our A survey of data from a registry such as the National Trauma
Data base may permit a measurement of the burden of injury for
mental image of an incoming case became biased to match pediatric vascular lesions amenable to bleeding control interven-
our recall of previous cases, and so the uncommon child often tions like tourniquet use.
caught us off guard. The most experienced caregivers learned Manikins or other items like pool noodles may be useful in devel-
to acknowledge such emotions, let them drift to the periphery oping best readiness practices for caregiving to children.
of one’s awareness, refocused to get down to the business at Fit mapping may inform animal caregiving to pets or working
hand, and applied, assessed, or adjusted the tourniquet. This dogs.

46 | JSOM Volume 19, Edition 2 / Summer 2019