Page 14 - JSOM Winter 2021

TABLE 1 Five Levels of Clinical Competence
Five Levels of Clinical Competence
Skill Level Description Trauma-related Example
The novice has no experience in the environment in Administrator or technician who has never worked in a trauma
Novice
which they are expected to perform. center.
The advanced beginner demonstrates marginally Medic who has had didactic trauma training but no clinical
Advanced Beginner acceptable performance and has enough experience trauma experience.
to note recurrent meaningful situational components.
Competence is achieved when one begins to see one’s Board eligible/certified physician, newly trained nurse, but has
actions in terms of long-range goals or plans. This only rotated as a learner at a trauma center.
Competent
individual demonstrates efficiency, coordination, and
confidence in his/her actions.
The proficient individual perceives situations Board eligible/certified physician or newly assigned nurse with
Proficient holistically and possesses the experience to limited but recent prior exposure to trauma, starting their career
understand what to expect in a given situation. at a high volume and best quality Level I trauma center.
The expert has an intuitive and deep understanding Trauma nurse coordinator, board certified emergency physician
of the total situation and is able to deliver complex or fellowship trained trauma surgeon/intensivist with years of
Expert
medical care under highly stressful circumstances. experience at a high volume and best quality Level I trauma
center.
Sources: Adapted from Benner, 1982; Dreyfus, 1981; Dreyfus and Dreyfus, 1980.

TABLE 2 Military Literature on Prehospital Transfusion
Article Setting Inclusion Findings Comments
Shackelford SA, Del Junco Mostly 1. Traumatic limb Adjusted hazard ratio for mortality
DJ, Powell-Dunford N, et al. Military air amputation at or above associated with prehospital
Association of Prehospital Blood ambulance the knee or elbow or transfusion was 0.26 (95% CI,
Product Transfusion During evacuations 2. Shock defined as a 0.08 to 0.84, p=.02) over 24 hours
Medical Evacuation of Combat systolic blood pressure (3 deaths among 54 recipients vs
Casualties in Afghanistan With of less than 90mmHg or 67 deaths among 332 matched
Acute and 30-Day Survival. a heart rate greater than nonrecipients) and 0.39 (95% CI,
JAMA. 2017;318(16):1581–91. 120 beats per minute. 0.16 to 0.92, p=.03) over 30 days
(6 vs 76 deaths, respectively)
Malsby RF, 3rd, Quesada Military air Traumatic injury (chest/ Feasibility study showed:
J, Powell-Dunford N, et al. ambulance in abd and single or multiple • 15 patients given 19 units
Prehospital blood product Afghanistan amputations) with • no adverse reactions and no
transfusion by U.S. army 1. systolic blood pressure instances of blood product
MEDEVAC during combat (SBP) <90mmHg temperature outside of the
operations in Afghanistan: a 2. heart rate (HR) >120 bpm accepted range
process improvement initiative. 3. Oxygen saturation (SaO )
Mil Med. 2013;178(7):785–91. <90%. 2
O’Reilly DJ, Morrison JJ, Jansen Regional MERT Physician order based Matched cohort study of 1,592 Confounded
JO, et al. Prehospital blood Command upon injury severity and patients in Afghanistan transported by by different
transfusion in the en route South in AFG blood product availability a prehospital intensivist team found rates of invasive
management of severe combat by MERT mortality significantly lower in those procedures
trauma: a matched cohort study. patients who received prehospital
J Trauma Acute Care Surg. blood transfusions than those who did
2014;77 (3 Suppl 2):S114–20. not (8.2% vs 19.6%, p<0.001)

A matched cohort study of 1,592 patients in Afghanistan • Hemorrhage control with mechanical hemostatic adjuncts:
transported by a en route care intensivist team found mor- ■ Tourniquet/junctional tourniquet
tality to be significantly lower in those patients who received ■ Pressure dressings/thrombin and fibrin impregnated
prehospital blood transfusions than those who did not (8.2% gauze
vs 19.6%, p < 0.001). Several confounding variables make • Hemostatic Resuscitation
19
these data difficult to interpret (e.g., differing rates of prehos- ■ Whole blood (WB) is optimal
pital rapid sequence induction, administration of pharmaco- 1. FDA approved CS-LTOWB
logic adjuncts and varied transportation times). Nevertheless, 2. Low titer group O whole blood (LTOWB)
it is likely that an aggressive approach to prehospital critical 3. Type O-WB (nontitered)
care including blood transfusion was part of an overall strat- 4. Component therapy with plasma (dried, liquid,
egy of damage control resuscitation that improved survival in or, thawed), red blood cells (RBCs), and platelets
severely injured patients. in 1:1:1 ratio
• Avoid hypocalcemia/Calcium replacement
PREHOSPITAL PRINCIPLES OF ■ In prolonged evacuations, empiric calcium adminis-
RESUSCITATION AND TRANSFUSION tration for every 4-6 units of RBCs or WB
• Avoid crystalloid resuscitation
• Rapid recognition of life-threatening hemorrhagic shock • Tranexamic Acid administration if less than 3 hours
■ Point of care devices if available: international nor- from time of injury
malized ratio; lactate level may be of value. • Consider source of Freeze Dried Plasma if available
• Prevent hypothermia

12 | JSOM Volume 21, Edition 4 / Winter 2021