Purpose[edit | edit source]
Our module will allow paramedics in Guatemala to become confident and competent in performing hemorrhage control techniques (wound pressure, wound packing, tourniquet application, foley catheter inflation) as part of initial trauma triage performed in the pre-hospital environment.
Problem[edit | edit source]
Hemorrhage is the leading cause of preventable death after trauma, in itself the cause of up to 40% of deaths in traumatically injured patients. It only takes minutes for a patient to bleed to death. Decisions on hemorrhage control must be made within seconds.
In HICs, first-responders (paramedics, police officers, firefighters) are trained in hemorrhage control techniques but this is not the current reality in Guatemala, which lacks a formalized EMS system. Emergency prehospital care for the entire country of Guatemala is provided by three separate firefighting companies. In total, these three companies are made up of about 8500 firefighters, at least half of whom are volunteers. The firefighters of Guatemala attend to every type of emergency, from childbirth to shootings to natural disasters. The medical training to attend these emergencies is basic, with only one of the three companies providing the option of a formal EMT course which is not mandated. Furthermore, many traumas occur in rural areas where there are no trauma centers, blood banking capability is scarce, and hospital transport times vary dramatically and can be extensive.
Inadequate or incomplete training leads to poor hemorrhage control techniques and, ultimately, ongoing bleeding and preventable death. Practice in hemorrhage control has been shown to be effective, especially for advanced maneuvers which include tourniquet application. Untrained personnel were found to have unacceptably high rates of tourniquet failure when given tourniquets to deploy without any additional training aside from package instructions. These findings confirm that formalized training and hands-on practice is essential.
If we succeed in designing a transposable, low-cost simulator and assessment tool for hemorrhage control techniques, we will markedly improve the efficacy of care in one of most effective interventions in initial trauma management. We have created a novel training model for teaching bleeding control techniques that will have broad implications in reducing prehospital morbidity and mortality from traumatic hemorrhage.
Prehospital providers will learn four related psychomotor skills as a suite of hemorrhage control techniques:
- Application of external pressure to a bleeding superficial wound;
- Application of packing into a deep wound;
- Appropriate application of a tourniquet to a bleeding extremity; and
- Appropriate insertion and deployment of a foley catheter to a profusely bleeding wound or a wound in an anatomic junction (base of neck, axilla, groin).
Our simulation technology includes (1) a physical model of an extremity, complete with low-cost technology and tubing with pumps to simulate blood flow and (2) a smartphone application that includes didactic material and video-instruction to learn techniques and a virtual simulator to practice these techniques prior to physical model-based practice.
Simulation[edit | edit source]
Effective hemorrhage control requires prompt, decisive action and forceful application of pressure or a tourniquet. Using our program, the user will learn how to externally compress a wound, apply a tourniquet, and deploy foley catheters to arrest hemorrhage.
We chose to specifically address a suite of hemorrhage control techniques in our simulation, as these skills are often taught by direct observation, without appropriate feedback on application of appropriate pressure. Successful use of tourniquets, for example, often require higher-than expected amounts of pressure. Baruch et al noted a "confidence-competence mismatch" when observing non-medical users applying tourniquets and investigating reasons for failure. They report that a common reason for tourniquet failure in this group of users is retention of too much slack in the straps and too few turns of the windlass, as a result of inadequate assessment of the amount of pressure required to successfully deploy the tourniquet. In our model, we will use pump-based active fluid technology to generate visual feedback of the adequacy of compression. Our system will provide visual feedback based on arresting the 'hemorrhage' of the fluid. The use of a dynamic model that actively simulates bleeding, and provides visual feedback for the trainee, addresses the shortcomings of a standard training model for hands-on tourniquet application and may result in fewer tourniquet failures due to inadequate compression.
Foley catheter hemorrhage control will be used in two different scenarios. In the first, the patient has a deep, narrow wound in an extremity, such as that caused by a penetrating injury. Foley catheters provide a low-cost method of performing direct compression to the deep wound without additional ischemia of the extremity distal to the injury as is the case when a tourniquet is used. This is particularly useful given the extended transfer times from rural areas, as well as the long wait times for definitive surgery once the patient has arrived at a trauma center. In the second scenario, foley catheters can be used to control hemorrhage at anatomical junctions, such as the axilla or groin, in which tourniquets cannot be applied.
Effective application of pressure, packing, foleys or tourniquet in our system will directly translate into clinical effectiveness of these skills as we will measure pressure exerted in order to arrest hemorrhage.
The module users will learn these various hemorrhage control skills by two methods. The first is virtual knowledge acquisition using a mobile gamification app with interactive cases. This will provide all the educational and technical information required to place a tourniquet, foley, or perform pressure and packing in a real case. Gamification has proven to be a fun and novel approach to learning acquisition and has shown to lead to increased knowledge retention. The second methodology is simulation-based training in a realistic lower limb module that allows the users to place a tourniquet and assess the proper location with a checklist and timer. Continuous practice is the key to correct placement of a tourniquet, and the combination of the app and physical model provides a comprehensive teaching module to acquire these skills.
There is clear translation to clinical performance, as the firefighters who are the intended users of this training module will use these hemorrhage control techniques in their daily practice in rescuing and managing bleeding patients.
Innovation[edit | edit source]
There is currently no training in hemorrhage control techniques at all in Guatemala as well as in many other LMIC countries in Latin America for pre-hospital employees or volunteers. We provide a novel, low-cost model for hands-on training in tourniquet application with realtime sensor-based feedback. This physical model will work in concert with a virtual simulation application software that teaches the indications and steps for each hemorrhage control approach. The virtual simulation utilizes innovative gamification techniques that incentivize learning prior to transition to the physical model-based training.
To use this module the learner needs to go through the following links in order to achieve a complete pedagogical experience to understand the correct hemorrhage control techniques.
References[edit | edit source]
- Curry N, Hopewell S, Dorée C, Hyde C, Brohi K, Stanworth S. The acute management of trauma hemorrhage: a systematic review of randomized controlled trials. Crit Care. 2011;15(2):R92. doi:10.1186/cc10096
- Rhee P, Joseph B, Pandit V, et al. . Increasing trauma deaths in the United States. Ann Surg. 2014;260(1):13-21.
- Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P, White L, Salomone JP, Seifarth W, Betzner MJ, Johannigman J, McSwain N Jr. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163- 73. doi: 10.3109/10903127.2014.896962. PMID: 24641269.
- American College of Surgeons BleedingControl.org—about us. http://www.bleedingcontrol.org/about-bc.
- Baruch EN, Benov A, Shina A, Berg AL, Shlaifer A, Glassberg E, Aden JK 3rd, Bader T, Kragh JF Jr, Yitzhak A. Does practice make perfect? Prospectively comparing effects of 2 amounts of practice on tourniquet use performance. Am J Emerg Med. 2016 Dec;34(12):2356-2361. doi: 10.1016/j.ajem.2016.08.048. Epub 2016 Aug 27. PMID: 27614373.
- Dennis A, Bajani F, Schlanser V, Tatebe LC, Impens A, Ivkovic K, Li A, Pickett T, Butler C, Kaminsky M, Messer T, Starr F, Mis J, Bokhari F. Missing expectations: Windlass tourniquet use without formal training yields poor results. J Trauma Acute Care Surg. 2019 Nov;87(5):1096-1103. doi: 10.1097/TA.0000000000002431. PMID: 31274827.
- Baruch EN, Kragh JF Jr, Berg AL, Aden JK Rd, Benov A, Shina A, Shlaifer A, Ahimor A, Glassberg E, Yitzhak A. Confidence-Competence Mismatch and Reasons for Failure of Non Medical Tourniquet Users. Prehosp Emerg Care. 2017 Jan-Feb;21(1):39-45. doi: 10.1080/10903127.2016.1209261. Epub 2016 Aug 5. PMID: 27494564.