Page 50 - JSOM Fall 2019

FIGURE 4 User results in squeezing or compressing a limb with a FIGURE 5 Results in user accuracy in placing a tourniquet 2–3
tourniquet. inches from a wound.

By use number, an indicator of experience accrued by the user, was
mapped by the squeeze (i.e., the amount of change in the volume of
the limb directly under the tourniquet) to see if users tended to have
recognizable patterns of performance. The mean of pooled data of
both users was −15%.
The linear gap between the wound and tourniquet is laid horizontally
on the x-axis, representing the typical view of the reader as a tourni-
TABLE 2 Guide to Assessing Placement of a Tourniquet Relative to quet user with a supine patient with the limb lying horizontally on the
a Wound ground, litter, or gurney during training or caregiving. The wound can
Tourniquet Tourniquet be imagined at the origin or 0 point at the left of the horizontal axis
Near Edge Far Edge and the tourniquet would be at a distance to the right of the origin.
Placement (inches) (inches) Assessment Reason The wound–tourniquet gap is measured between the edges of wound
Too close <2 <3.5 Unsatisfactory <2 inches and tourniquet, and the minimum gap was sampled in each use.
Correct at 2 3.5 Satisfactory 2 is within FIGURE 6 Frequency of tourniquet placement by ordinal gap ranges.
low margin 2–3 inches
Correct at 3 4.5 Satisfactory 3 is within
high margin 2–3 inches
Too far >3 >4.5 Unsatisfactory >3 inches

the other hand, no miss occurred on the high side (to the right
or >3 inches). In fact, no use resulted in a gap ≥2.9 inches. The
skewness (–0.8) indicated an asymmetrical distribution with
a long thin tail to the left side. On the basis of our research,
teaching, and caregiving, we classified placement (Figure 8).

Discussion
The major finding of this study was a surprising number of
errors made by the users while placing a tourniquet. In this
context, it is noteworthy that the Stop the Bleed program’s
Bleeding Control basic course (version 1) has a presentation
in which slide 27 (of 61) addresses tourniquet placement. The distribution of gap widths between the edges of the wound and
11
In that slide, the third bulleted point instructs “Place 2 to 3 tourniquet were arrayed by use counts. Gap labels are ordinal catego-
inches above the bleeding wound (higher on the arm or leg).” ries. Pitfalls to avoid in this study were seen in the several (n = 5) misses
That bullet specifies the proper range of distance between the at the left, which were too close to the wound, and these were errors
(“don’ts”) that indicated inattention of users or poor targeting. Cor-
visibly external skin wound and the tourniquet’s edge closest rective remediation (“dos”) may be to improve user awareness of bias
to that wound. Although our practicing was general and did toward the nearside, which may improve attentiveness of individual us-
not prioritize one metric of performance, because all were pre- ers, or changing the targeted point to the center of the placement zone.
sumed to be of equal value to individual learning, the applica-
tions revealed that results were of unequal value to scientific placement “What is the meaning of 2–3 inches?” Among
discovery, with the unexpectedly high number of misses, that learners and instructors, the gauging of the wound–tourniquet
is, outside 2–3 inches from the wound. gap with their fingers, by using a template (Appendix 1), aided
active learning of the direction previously heard in their “Stop
The plan was to measure the accuracy of placement, because The Bleed” class.
the wound–tourniquet gap had been troublesome in our past
studies, but the underlying causes of that trouble remained The first minor finding was related to attention. We purposely
unclear. By actually measuring accuracy behavior, including practiced with minimal distractions so the learner’s attention
errors, our aim was to seek opportunities to improve our remained undistracted. However, the way a performance was
understanding and, in turn, potentially develop best learn- spotlighted mattered, because a choice of metric framed the
ing practices. The attention given to targeting placement re- attention of the assessor of the performances. The choice of
sulted in ideas of how to better teach learners of tourniquet metrics affected the way the coach assessed performances and,

48 | JSOM Volume 19, Edition 3 / Fall 2019