Page 51 - JSOM Fall 2020

To ease learning, development of several knowledge products and not for immediate use need not have any tourniquet un-
may offer students or instructors choices to use in developing wrapped. Another efficiency point was how many uses may be
conversion skills. The Ranger medics published in 2007 their needed for a caregiver to learn the task of conversion. The in-
algorithm for conversion of a hasty tourniquet to a deliber- vestigator had a learning curve in a classic power law of prac-
ate tourniquet to exchange a field tourniquet placed “high tice as when someone is learning a skill. A moderate amount
21
and tight” on the limb for another 2–3 in. above the wound. of speed gained from 15 tests was unsurprising because this
This type of conversion aims to limit the volume of ischemic way of manikin use and this set of steps were new. The task
tissue. But emergency department providers or paramedics in took 17 minutes in ideal laboratory conditions. It may take a
the field may seek a method of tourniquet-dressing conver- while in the wild.
sion to limit both the duration and volume of ischemic tissue.
Novice healthcare providers, as end-users of conversion, may In the duration of manual compression of hemostatic gauzes,
22
focus on the rules and objective traits, like the order of steps the investigator felt the full 3 minutes were important. In his
to perform. Novices may look for stepwise how-to guidance war experiences, bleeding assessments often took that long,
and may need to be nudged to focus on their form to expend and the acts of control and its assessment were done efficiently
their effort efficiently. Advanced beginners may be con- by being done concurrently. Even in the Baghdad emergency
23
cerned about managing their time and their conversion skills department, providers of all types had challenges in assess-
while needing guidance and assistance with accuracy, trouble- ing whether bleeding was controlled. The problem was that
shooting, and aiding other end-users. Competent caregivers caregivers were busy, multitasking, and impatient. Actually, in
22
in conversion may have an unrealistic idea of what they can marginal cases, assessments sometime took 10 minutes. No-
actually handle, and they may consider working on various body missed a gusher, but if a tourniquet was on a fresh wound
types of conversion, their conversion speed, and mentoring and there was wet blood dripping slowly, then many thought
end-users individually. Proficient caregivers may see the whole the wound was bleeding. However, the tourniquet was placed
situation in context and work on their ability to adapt their on the limb where compression often closed the blood ves-
conversion skills to a variety of conditions and circumstances. sels to essentially stop their distal flow, yet these distal vessels
Proficient converters may train or organize caregiving teams would simply drain their distal contents by gravity. The blood
in conversion. Conversion experts have a rich experiential in the distal veins and arteries often drained out of the wound
22
background and focus intuitively on situational solutions to surface briefly after effective tourniquet use had begun. This
meet patient needs while developing mastery of conversion external blood was visible, but the tourniquet may have still
skills among care, teaching, research, or executive functions. been working properly. This situation was common in war,
but insight to its meaning was not. A visual check was made
Being new to conversion in 2006, Baghdad caregivers asked for approximately 4–6 seconds. If control was unclear to the
the investigator for a conversion guide. The caregivers were investigator in the check, rechecks followed at 1 minute and,
mixed in wanting a list of how-to steps, an algorithm, a de- if needed, at 3, 5, and 10 minutes. If, at any recheck, visible
cision tree, or a clinical practice guideline. The investigator blood flow accelerated or pooled more, then the tourniquet
balked because he felt that the thing to do was what was indi- needed troubleshooting because bleeding was uncontrolled.
vidually best for each patient, which he was then practicing in
care. However, he could not find a way to guide others except The initial check was a foundational skill for bleeding assess-
as apprentices. The caregivers did not want that. The develop- ment, and rechecking was important when there was uncer-
ment of conversion guides is overdue. Simulation may provide tainty. Baghdad providers initially showed confidence in their
a way forward to develop such knowledge products. ability with initial checks, but in war, that feeling did not last
long. Those who saw results of checks often enough learned
To introduce conversion simply, we use analogy. When blood to dial back their level of confidence, whereas some learned
is drawn routinely from an arm, a phlebotomist uses a venous to self-calibrate their confidence to their competence by using
tourniquet. In a nutshell, one inserts a needle into a vein, takes feedback from accrued experiences in assessment. The recheck
blood, removes the tourniquet and needle, and manually com- skill was valued for its clinical usefulness. The investigator ex-
presses a dressing onto the insertion site to control bleeding. plained and showed these check-recheck skills to a caregiver
Explaining it in this way may be familiar to a learner and can of a war casualty at the removal of a dressing when bloody
demystify the label of conversion. The stepwise progression in streams looked like gushing vessels. However, the streams
the task of converting a phlebotomist’s tourniquet to a dressing were not liquid but actually stringy clots. The gelling clots had
is analogous to the task of emergency tourniquet-dressing con- adhered to the cotton gauze when it was pulled gently off the
version. This short analogy primes a learner to the conversion wound surface. The few string arcs hanging from and teth-
idea, to its language, to its task structure, and to a common ered between wound and gauze were parabolic and concave
operating framework that fosters caregiving, teaching, and upward, like cables hanging from and tethered between ad-
management among individuals, groups, and organizations. jacent towers on a suspension bridge. However, true streams
The explanation hints at multiple conversion types, multiple of gushers were known to have flow that was parabolic and
ways to do its steps, and that learning starts with one way. concave downward as blood falls freely toward the ground.
The strings arced from the wound surface to the gauze, and
Regarding efficiency, unwrapping a tourniquet from its plastic the strings lengthening matched the widening gauze-wound
wrapper took time at an expense of patient bleeding. Routine gap. In the act of pulling the gauze away, strings appeared
24
consideration of having an emergency tourniquet readied by to be concurrently extracted more from the wound. Strings
unwrapping it ahead of time is now common in the US mili- pulled out of the wound almost concurrently. String lengths
tary. The need to unwrap tourniquets for this readiness reason matched the tourniquet-wound distances from wherever the
may be limited, such as to only one tourniquet per emergency strings emerged from the wound surface. The wounds were
kit in clinical service. Kits for resupply or otherwise in reserve too messy to see blood vessel lumens directly, but the string

Tourniquet Conversion Method | 49