Page 47 - JSOM Fall 2019

Deliberate Practice in
Combat Application Tourniquet Placement by Loop Passage

John F. Kragh Jr, MD *; James K. Aden 3rd, PhD ; Michael A. Dubick, PhD 3
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ABSTRACT
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Background: We sought opportunities to develop learning bleeding. Skill acquisition and development through learn-
practices of individual first aid providers. In this study, we ing and practice so that performance is reliably safe and effec-
simulated deliberate practice in placing limb tourniquets. tive. In fact, technique affects performance, such as placing
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Methods: This study comprised tourniquet uses by two expe- a tourniquet 2–3 inches above a wound or by mechanically
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rienced persons. Their practice sessions focused on developing squeezing an underlying limb. The use of techniques with a
a motor skill with periodic coaching. The Combat Application focus on assessing selected metrics can measure the parame-
Tourniquet is 1.5-inches wide and was used in a technique of ters such as the extent of learning, degrees of expertise, decays
loop passage around the end of the limb to place it 2–3 inches of skill, or errors made. Indeed, gaining such knowledge will
above the wound. The simulated limb was a Z-Medica Hem- be instrumental to enlighten a first-aid provider about their
orrhage Control Trainer. Both users applied the tourniquet six shortcomings in areas for specific remediation by deliberate
times over 5 days to accrue 30 uses individually (N = 60 tour- practice. To this end, the procedure for choosing the topics
niquet applications for the study). Results: When represented for instruction or practice is crucial because selection of ar-
as summary parameters, differences were small. For example, eas spotlights the specific performances to look at, talk about,
average ease of use was the same for both users, but such pa- study, or rehearse. Such selection focuses attention of learn-
rameters only took a snapshot of performance, yielding a gen- ers and instructors, whereas lack of selection of topics would
eral assessment. However, for a learning curve by use number, leave any deficiencies of the learners unattended without any
a surrogate of experience accrual, application time revealed emphasis for improvement. The focused verbal communica-
spiral learning. The amount that users compressed a limb av- tion between the learners and instructor may suffice in gar-
eraged −15% compared with its unsqueezed state. Placement nering attention to acquire new knowledge. However, more
accuracy was classified relative to gap widths between the complicated topics may also require images, videos, demon-
tourniquet and the wound, and of 60 performances, 55 were strations, or hands-on practices. Of note, the topics wrongly
satisfactory and five were unsatisfactory (i.e., placement was assessed as uncomplicated may not be highlighted and thus
<2 inches from the wound). When a tourniquet only overlaid may be underemphasized, leading to suboptimal learning.
the 2-inch edge of the placement zone (i.e., tourniquet was
2–3.5 inches away from the wound), no error was made, but It is noteworthy that learners practice tourniquet use in com-
errors were made in crossing that 2-inch edge. These gauging mon first-aid classes associated with different programs such
errors led us to create a template for learners to see and to as “Stop The Bleed.” 8–10 An example is the Bleeding Control
demonstrate what the meaning of 2–3 inches is. Conclusion: basic course, which commonly uses a Combat Application
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Each metric had value in assessing first aid, but turning atten- Tourniquet (C-A-T Resources Inc., http://combattourniquet
tion to gauging wound–tourniquet gaps revealed placement er- .com/). When a C-A-T has its band loop passed around a limb
rors. Analysis of such errors uncovered what 2–3 inches meant during application, this method skips two steps—unrouting
in operation. Spiral learning may inform the development of and rerouting the band. The simplicity of loop passage makes
best readiness practices such as coaching deliberate-practice it an easy way to learn tourniquet application.
sessions.
In addition, we have found tourniquet placement and limb
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Keywords: Combat Application Tourniquet; tourniquet place- squeeze to be scientifically underdeveloped. On the basis of
ment; limb wound; Stop the Bleed; motor control and learn- these premises, we investigated deliberate practice in tourni-
ing; loop-passage technique quet placement on a simulated limb to improve the readiness
of individual first-aid caregivers.

Introduction Methods
The readiness of people to render first aid to injured persons This study was conducted within the protocol guidelines at
during emergencies depends on the abilities of the caregivers the Institute of Surgical Research in late 2018 and early 2019.
to perform skills such as tourniquet use to control limb-wound The design comprised 30 tourniquet uses each by two persons.
*Correspondence to 3698 Chambers Pass, Joint Base San Antonio Fort Sam Houston, TX; or john.f.kragh.civ@mail.mil
1 Dr Kragh is a researcher of bleeding control at the Institute of Surgical Research (ISR) and an associate professor in the Department of Surgery,
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Uniformed Services University of the Health Sciences, Bethesda, Maryland. Dr Aden is a statistician at the Brooke Army Medical Center, Fort
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Sam Houston, Texas. Dr Dubick is a resuscitation researcher and the chief of the Hemorrhage Control and Resuscitation Department at the ISR.
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