Page 57 - JSOM Winter 2019

or among interactions between groups of people. Finding when achieve interoperability. Although interoperability gaps are
stuff does not go right may indicate further assessment, re- usually not lethal (no one died as a result of fuel nozzles of
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mediation, or reallocation of resources. Note that in both stress- US armored vehicles not fitting Polish fuel tanks), first-aid
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ing and assessing performance, your metric matters. Choice gaps might not be so forgiving. Finding out that a caregiver
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matters because selecting a metric without understanding its cannot stop a bleed with an unfamiliar tourniquet may lead to
meaning (such as consequences of its sensitivity or threshold) a preventable death—a potential cost of poor interoperability.
may show just about anything we want if the “right” zone
(level) of performance is targeted. 18–21 More fundamentally, sci- The findings of this study have a readiness context: An indi-
ence has shown that how we evaluate performances affects how vidual is more ready in emergencies if they have their most-
performances are evaluated in that differences among ways we familiar tool at hand. A first aid provider’s equipment, such as
evaluate the same performances can show them differently. 18–21 a tourniquet, is to have common traits which aid its use among
In our study, a changed threshold of a time parameter changed people so that it is interoperable. For example, in transporting
the result from all passes to all failures. The passes could create an injured person from their point of injury to an emergency
the illusion of progress while risking production of confusion department at a hospital, there are handoffs from a first re-
after a team tested by actual caregiving realizes it is not as good sponder to an ambulance team and to the hospital team. Multi-
as it had thought. Assessors of performance are to learn the ple people may become involved with such a tourniquet. If the
meaning of this lesson on metric choice: Know a metric well to motorcycle patient, the caregiver, a caregiver’s spouse talking
scale stress by degrees of difficulty. on the phone, a San Diego dispatcher talking with the spouse,
etc. 24–26 have a basic, common understanding of the tourni-
The second minor finding was surprising because it dealt with quet, then they may be able to work together. However, if they
what’s fair. “Fair” and “equitable” are synonyms in that they name tourniquet parts oddly, for example, then conversations
have similar meanings, but they need not be interchangeable. may make little sense and people may have to slow down to
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These “adjectives mean showing no evidence of favoritism, repeat a point about troubleshooting. If the tourniquet design
self-interest, or the indulgence of one’s likes and dislikes. Fair, (a windlass of band and rod), size, length, packaging, stock-
which has the widest range, can imply any of the foregoing ing numbers, logistical ordering procedures, technique of use,
senses.” “Equitable also implies justice, but less from the method of configuration, removal procedure, and training re-
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standpoint of a rigid code of rules than from a sense of what is quirements are familiar to all, then it and the people may be-
in the best interest of all concerned in a given issue. It therefore come interoperable. If a doctrine of a dispatcher association is
may imply justice tempered by reason or compromise.” The to tell caregivers to remove tourniquets despite a community’s
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foregoing senses of favoritism and self-interest speak generally doctrine to use tourniquets, then people fail to be interopera-
about an individual, but equitable is generally about multiple ble until the doctrines are harmonized. Such attained interop-
people. The difference of meaning makes the fair–equitable erability could support caregiving efforts through aspects that
discrimination valuable. If an organization has a doctrine of are technical (including hardware of components), procedural
one model of tourniquet, then interoperable costs among its (including doctrines and procedures), and human (including
members are less than if it has many models to supply, learn, terminology and training). For example, NATO initiatives are
use, and manage. If by a code of rules a committee recom- to enhance interconnectedness and interoperability among
mends 10 models, then interoperable costs among organiza- Allied forces and partners. NATO holds that interoperable
tions rise compared with fewer models. What is in the best solutions can be achieved only through the effective employ-
interest of all concerned at state, local, and federal levels may ment of mechanisms in standardization, education, training,
be in fielding the fewest. If each of the 29 member states of exercises, lessons learned, demonstrations, tests, and trials. A
NATO were to buy a domestically made tourniquet model, programmed unity of effort may avoid duplication to improve
then that could be financially fair to each tourniquet’s inven- efficiency. The capability to work in a manner that requires
tor and that nation’s economy, but it would be inequitable to a tourniquet user to have sufficient knowledge of the unique
the Alliance. Workloads of NATO instructors might increase characteristics of unfamiliar models is problematic. A better
29-fold to maintain interoperability. A rule of interoperability approach is based on a standard interface that provides in-
would be violated by a modest proposal if each of the world’s teroperability among arrays of people. Caregiving problems
countries invented a model so instructors were to train the of interoperability discovered late may cause delays or cost
world’s 7 billion people to use 195 models of tourniquets. overruns or—worst of all—may contribute to deadly mistakes
Also, US interoperability costs may be scalable to the num- at critical times. Incidents with active shooters or mass casu-
ber of models fielded among 35,000 municipalities. A divided alties such as occurred at Columbine, Aurora, or Sandy Hook
doctrine can fractionize the time allocated to training among are situations when interoperability is needed in action. Lest
multiple models and cognitively burden learners. Caregivers we forget take-home messages of lessons learned, we are to
troubleshooting an unfamiliar tourniquet of another organi- prepare now (Table 3).
zation in a new situation may have their attention hijacked
by the tool. Caregivers using their most-familiar model have The limitations of this study evolve from its design as an inves-
more of their mental bandwidth available in which to multi- tigation of a new topic in first aid. If we included a pneumatic
task agilely as when talking to their patient during tourniquet design, then intermodel differences may been greater than at
placement. Caregiving organizations seeking interoperability present. If an improvised model was tested, then its interoper-
are to police themselves. For example, in 2018 the US Army ability costs would likely increase due to delays in gathering,
distributed a message for its units to verify as doctrinally assembling, and using untrustworthy components. For busy
correct a model of tourniquet for individuals to carry in all end-users and instructors already inundated with too many
medical sets, kits, and outfits. Although this Combat Appli- time pressures (including trying to keep their head above water
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cation Tourniquet was the only Army-approved model for this in a tsunami of science reports on tourniquets), asking them to
purpose, noncompliant kits needed logistical remediation to reform their tourniquet practices is like asking the drowning

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