Page 42 - 2020 JSOM Winter

Effects of Donning and Wearing Personal Protective Equipment
on Tourniquet Use and Conversion

John F. Kragh Jr, MD *; Tuan D. Le, MD, DrPH ; Michael A. Dubick, PhD 3
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ABSTRACT
Background: We sought to gather data about the effects of laboratories, and emergency departments. PPE may include
personal protective equipment (PPE) use on tourniquet inter- clothing, gloves, goggles, face shields, or other equipment de-
ventions by preliminarily developing a way to simulate delay signed to protect the wearer from injury, illness, or spread of
effects, particularly on time and blood loss. Such knowledge infection. PPE recommendations vary by circumstance, as in
might aid readiness. Field calls to emergency departments may flu seasons, at accident scenes, or in medical procedures.
indicate donning of PPE before patient arrival. The purpose
of this study was to investigate (1) delay effects of donning This study occurred in a 2020 pandemic of COVID-19, a
the PPE studied on field-tourniquet control of hemorrhage human disease caused by the novel coronavirus 2019 (2019-
and (2) delay effects of wearing the PPE on application of a nCoV, now referred to as SARS-CoV-2). We sought to develop
field tourniquet and its conversion to a pneumatic tourniquet. caregiving concepts by simulating trauma during a pandemic.
Methods: The experiment simulated 30 tests of nonpneumatic For military healthcare providers, training includes an Emer-
field tourniquet use (http://www.combattourniquet.com/wp gency Preparedness Response Course for treating casualties
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-content). The research intervention was the use of PPE. Data during an all-hazards incident. The course content notes that
were grouped. The control group had no PPE (PPE0). PPE1 “performance of even routine tasks may be affected while
and PPE2 groups had mostly improvised and off-the-shelf wearing personal protective equipment” because “tasks are ac-
equipment, respectively. PPE1 included donning a coat, gog- complished more slowly” and “reaction and decision times are
gles, face covering, cap, booties, and gloves. PPE2 had analo- longer.” If emergencies arise unexpectedly or calls lack infor-
gous items. The group order was randomized. A test included mation, field medics may face whether to don PPE as someone
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paired trials: field tourniquet, followed by conversion. An in- bleeds. Delays can result from donning gloves ; unwrapping
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vestigator simulated the caregiver. A task trainer simulated a a packaged tourniquet ; searching, finding, and grasping
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thigh amputation. Donning delays were evaluated as differ- tourniquets from where they are kept ; additional routing of a
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ences in mean times to stop bleeding compared with PPE0. band through its buckle ; and calling emergency services such
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Blood loss results from donning PPE were calculated as the as 9-1-1. In two such simulations, 80% and 86% of the
delay multiplied by its bleeding rate, 500mL/min. Results: blood loss occurred before the tourniquet touched the patient.
PPE0 had no delay: its mean blood loss was 392mL. PPE1 had
805mL more blood loss than PPE0 did. PPE2 exceeded PPE0 Given little data of donning PPE for tourniquet application
by 1004mL. Donning time (blood loss) for PPE1 and PPE2 and conversion, we designed a way to simulate interventions
were 1.4 minutes (712mL) and 1.7 minutes (863mL), respec- to assess delay effects. The purpose of this study was to inves-
tively. The wearing of PPE did not slow down field tourniquet tigate (1) effects of donning the PPE studied upon control of
application or its conversion. Conclusions: How long it took bleeding and (2) effects of wearing the PPE on application of a
to don PPE delayed the time to stop bleeding and increased field tourniquet and its conversion to a pneumatic tourniquet.
blood loss, but wearing PPE slowed down neither field tourni-
quet application nor its conversion.
Methods
Keywords: bleeding control and prevention; precautions; This experiment was conducted on 20 April 2020. The ac-
emergency; simulation; readiness practices; device removal tions of interest were emergency-use of a field tourniquet and
conversion of that tourniquet to a pneumatic tourniquet. The
caregiver conditions were no PPE (PPE0), improvised PPE
(PPE1), and off-the-shelf PPE (PPE2). There were 10 blocks
Introduction of the three PPE conditions with condition order randomized
Since 2000, the use of tourniquets to control limb-wound by lot.
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bleeding has increased. A little-studied tourniquet topic is
its use in concert with wearing PPE. PPE is commonly used The first author (JFK), who is a clinician-scientist experienced
in caregiving settings such as physicians’ offices, clinical with tourniquet and conversion procedures, performed the

*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 health scientist of hemorrhage control in the Department of Tactical Combat Casualty Care at the US Army Institute of Surgical
Research (ISR), Fort Sam Houston, TX, and an associate professor in the Department of Surgery, Uniformed Services University of the Health
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Sciences, Bethesda, MD. Dr Le is a general health scientist at the ISR and an adjunct professor in the Department of Epidemiology and Biosta-
tistics, University of Texas Health Science Center at Tyler, TX. Dr Dubick is senior scientist, Combat Mortality Prevention Division, at the ISR.
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