Page 46 - JSOM Winter 2023

The students in this study completed an eight-day progressive validate a Tourniquet Application Skills Assessment for our
simulation, ACME, during the summer of 2022. Throughout medical students. We began by reviewing the TCCC Tier 3
ACME, the students received three hours of skills training (Combat Medic/Corpsman [CMC]) Skills Assessment Check-
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(tourniquet training and two other skills) on the first day of list developed by the Joint Trauma System. We then adapted
the practicum that included one-on-one instruction. On each this checklist to include a critical actions checklist, a perfor-
subsequent day of ACME, each student received 45 minutes mance rating scale, and a record of the seconds taken to com-
purely of tourniquet training plus four hours of multi-skill/ plete the tourniquet application. After initial development,
scenario work as a five-person team (including tourniquets, using the modified Delphi method, each of the expert physi-
patient drag, assessment, tactics, and other medical interven- cians in our research team reviewed the skills assessment until
tions). During ACME, we used a low-fidelity wound packing reaching an agreement that it was a valid measurement of our
leg task trainer (silicone), which measured approximately students’ ability to correctly apply a tourniquet. 7
6-in × 12-in and was cylindrical and compressible upon tour-
niquet application. We also used high-fidelity mannequins, In our Tourniquet Application Skills Assessment, scores of 1
which were life-size and weight full body adult mannequins. or 2 indicated that a tourniquet was placed incorrectly or too
Each mannequin was fully clothed in combat uniform with slowly (Appendix A). This threshold was determined by critical
applied moulage blood and visually simulated injuries. fail points, including allowing too much time to elapse (thus
allowing a patient to lose too much blood volume), incorrect
Students received feedback during each aspect of the progres- placement (therefore not adequately controlling bleeding), or
sive training at ACME, including if each step was completed being inadequately secured (therefore unable to withstand
correctly, incorrectly, or omitted: 1) Removal from Joint First any patient movement). Two key differences separated a score
Aid Kit (JFAK) or carrying pouch; 2) Opening folded tourni- of 3 and 4: 1) the ability to apply a tourniquet in a smooth
quet; 3) Placing tourniquet around a limb; 4) Pulling the strap and controlled manner; 2) the ability to correctly complete all
as tight as possible; 5) Securing the hook-and-loop of the strap “noncritical” steps or those that still improve the quality of the
around the limb; 6) Twisting the windlass rod; 7) Placing the intervention but are not strictly necessary for the tourniquet
windlass rod in the windlass clip; 8) Placing the remaining to be effective. Ultimately, both scores of 3 and 4 resulted in a
limb-encircling strap in the windlass clip over the rod; 9) Plac- correctly placed tourniquet.
ing the windlass retention strap over the opening of the wind-
lass clip; and 10) Writing time on the windlass retention strap. Step 2. Faculty and Teaching Assistant Rater Training
Throughout ACME, any patient movement (including the To increase the interrater reliability of our results, our re-
transition to tactical field care, removal of clothing, and lifting/ search team conducted two separate assessment trainings for
rolling onto an extrication device) required a reassessment of both the faculty members and TAs who served as raters in our
tourniquets. Tourniquets that were no longer adequate were study. The faculty rater training, conducted for the military
readjusted or replaced at that time. physicians who served as expert faculty raters in our study,
included a detailed overview of the assessment rubric with
This study was conducted as a program evaluation of the Mil- specific illustrations and examples provided for each perfor-
itary Unique Curriculum at USUHS and was approved by the mance rating. The TA rater training was more intensive. First,
Institutional Review Board at the Uniformed Services Univer- the select group of TAs (USUHS medical students) completed
sity RB #22-14978. the eight-day progressive simulation in the student role so that
they could fully understand and teach the TCCC skills to their
Data Collection peers. Then, the TAs underwent a multi-day rater training,
We collected data in a series of three steps: 1) assessment de- which focused on how to use the tourniquet application as-
velopment, 2) rater training, and 3) pre/post testing (Figure 1). sessment to evaluate their peers.
ratings pre post symbols and lines
FIGURE 1 Pre- and post-test ratings. Step 3. Pre/Post Testing
We evaluated the students’ tourniquet application prior to the
start of the simulation and at the end of the simulation. On the
4 3 0 101 morning of the first day of the simulation, we paired the med-
ical students. One student acted as the patient, while the other
student acted as the provider. We read a standardized scenario
3 66 43 to the students in which the student in the provider role was
Rating instructed to “place this tourniquet high and tight on the pa-
tient’s right leg to control massive hemorrhage. Perform this
4
2
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task as quickly and effectively as you can, just as you would
in real life.” We repeated this process for each student at the
end of the last day of the simulation to conduct the post-tests
1 27 2 for our study.
pre-simulation post-simulation Data Analysis
We used SPSS Statistics for Windows, Version 28.0 (IBM,
https://www.ibm.com/products/spss-statistics) to analyze the
Step 1. Tourniquet Application Skills pre- and post-test data. We first conducted a Shaprio-Wilk
Assessment Development normality test and determined that the data was not nor-
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We assembled a research team of senior emergency medicine mally distributed (p<.001). As a result, we rejected the null
physicians and a PhD curriculum researcher to develop and that the data was normally distributed and used the Wilcoxon
44 | JSOM Volume 23, Edition 4 / Winter 2023