TCCC Skills, Training and Education

#### TCCC SKILLS, TRAINING & EDUCATION

Surgery. 2019 Apr;165(4):795-801

# Building community resilience: A scalable model for hemorrhage-control training at a mass gathering site, using the RE-AIM framework.

Chaudhary M, McCarty J, Shah S, Hashmi Z, Caterson E, Goldberg S, Goolsby C, Haider A, Goralnick E

BACKGROUND: In a decade, the US military reduced deaths from uncontrolled bleeding on the battlefield by 67%. This success, coupled with an increased incidence of mass shootings in the US, has led to multiple initiatives intent on translating hemorrhage-control readiness to the civilian sector. However, the best method to achieve widespread population-level hemorrhage-control readiness for civilians has not yet been elucidated. This study evaluates the implementation of American College of Surgeons Bleeding Control training at a National Football League stadium as a prospective model for general mass gathering site implementation.

METHODS: The American College of Surgeons' Bleeding Control Basic layperson hemorrhage-control training was implemented at Gillette Stadium in Massachusetts. The five domains are as follows: reach (demographics of study participants), effectiveness (correct tourniquet application after intervention), adoption (investigator, leadership, and participant efforts for sustainability of intervention), implementation (course details), and maintenance (correct tourniquet application at retention testing at 3 to 9 months).

RESULTS: A total of 562 employees were included in the study. Of those included employees, 58.7% reported having taken first-aid training and 17.3% reported having taken hemorrhage-control training. There was an increased mean likelihood to help (4.39 vs 4.09, P < .01) and comfort level to control hemorrhage (4.26 vs 3.60, P < .01) after training compared with before training, on a Likert scale (1-5). The stadium operations team located hemorrhage control kits with automatic external defibrillators, integrated layperson immediate-response awareness into its Web site, and developed a public safety announcement. The training, performed by physicians, nurses, and emergency medical technicians, consisted of a 30-minute lecture and a 30-minute hands-on skills-training course, with a class size of 24. The total number of sessions was 24.

CONCLUSION: Achieving initial hemorrhage-control readiness and maintenance at a mass gathering site through American College of Surgeons Bleeding Control training is feasible but requires significant commitment from training staff, site leadership, and financial resources.

J Trauma Acute Care Surg. 2019 Jan 8 Epub ahead of print

# Life Saving Interventions in Blackout Conditions Using Night Vision Technology: Come to the Dark Side.

Derickson M, Kuckelman J, Phillips C, Barron M, Marko S, Eckert M, Martin M, Cuadrado D

INTRODUCTION: During military combat operations and civilian night-time aeromedical transport, medical providers are frequently required to perform life-saving interventions (LSIs) in low-light environments. Because definitive surgical care is often delayed until a white light environment is permissible, we sought to determine if night optical device (NOD) technology could enable surgical capabilities in blackout conditions.

METHODS: Using a cross-over design, 6 surgeons performed 11 different procedures on 6 swine, 3 in normal light conditions (LC) and 3 in blackout conditions (BC) using two-chamber NODs after familiarization with the procedures in both conditions on manikins. Successful completion and procedural times were compared between groups.

RESULTS: Blackout conditions were confirmed with ambient light reading of 0.2llux during BC vs 3962.9lux for LC (p<0.001). There were no significant differences in success rates for any procedure. There were no differences in operative times between BC and LC for extremity tourniquet placement, femoral artery cut-down and clamping, resuscitative thoracotomy, or percutaneous REBOA placement. The following procedures took significantly longer in BC vs LC: FAST exam (98s vs 62s), peripheral IV placement (140s vs 35s), intraosseous access (51s vs 26s), jugular vein cut-down and access (237s vs 104s), laparotomy and packing (71s vs 51s), stapled splenectomy (137s vs 74s), REBOA placement via cutdown (1,008s vs 338s), and cricothyroidotomy (177s vs 109s) (all p<0.05).

CONCLUSION: LSIs can be safely and effectively performed in blackout conditions using NODS, although increased difficulty with select procedure types were identified. Focused training and technological improvements to currently available devices are needed.

Aerosp Med Hum Perform. 2018 Dec 1;89(12):1076-1079

# Simulation Training for In-Flight Medical Emergencies Improves Provider Knowledge and Confidence.

Padaki A, Redha W, Clark T, Nichols T, Jacoby L, Slivka R, Ranniger C, Lehnhardt K

INTRODUCTION: In-flight medical emergencies require healthcare providers to operate in confined spaces with limited resources and delayed access to definitive care. These emergencies are common, with an estimated frequency of 1 per 100 to 1000 flights. Despite this, training for medical response in these environments is limited. We hypothesize that integrating such education into a pre-existing medical student elective course would improve knowledge and ability to respond appropriately to in-flight medical emergencies.

METHODS: The available literature surrounding in-flight medical emergencies was reviewed. Syncope, respiratory distress, allergic reaction, and cardiac arrest were identified as common and potentially life-threatening complaints. Simulation cases were designed for each of these complaints and a simulation room was modified to mimic an airplane cabin. These simulation cases and accompanying relevant didactic lectures were incorporated into an existing wilderness and extreme environmental medicine course, with multiple-choice tests completed by the students at the beginning and end of the 2-wk course.RESULTS: Participating in this study were 18 students. The pretest average was 76%, which improved to 87% on the posttest. Qualitative feedback regarding this type of training was overwhelmingly positive.

DISCUSSION: Simulation-based training for in-flight medical emergencies can significantly improve medical students' knowledge. This training was very well received by the students. Opportunities for training to manage in-flight medical emergencies remain limited; incorporating such training into existing curricula could provide a means by which to improve provider knowledge. Such a curriculum could be adapted for use by flight crews and other populations.

Mil Med. 2019 Mar 1;184(3-4):67-71

# "Stop the Bleed": A U.S. Military Installation's Model for Implementation of a Rapid Hemorrhage Control Program.

Chambers J, Seastedt K, Krell R, Caterson E, Levy M, Turner N

CONCLUSION: The STB initiative has the opportunity to save lives, not only in the public arena but on military installations worldwide. It is critical we educate, train, and prepare for mass casualty events to save lives in our current environment. We have launched our STB initiative here at JBA and hope our program serves as a potential model for other installations to proceed with developing their own in-garrison hemorrhage control program. Implementation at other military installations will likely require minor modifications given the needs and resources present at each individual facility. While, these needs can easily be met with affordable and customizable hemorrhage control kits requiring little maintenance as in our custom kits, cautionshould be exercised related to extensive modification of kits. The training is equally versatile, and can be targeted to health care professionals and the lay person at large focusing on hemorrhage control through trainings such as TCCC, B-Con, or SABC. Our goal is for every active duty and civilian member of our base be educated in effective hemorrhage control, with ready access to hemorrhage control kits throughout the base. We believe this should be a DoD-wide initiative, and it merits consideration for dedicated funding to support this public health program at other installations.

NASN Sch Nurse. 2019 Mar 28: Epub ahead of print

# School Nurses on the Front Lines of Medicine: The Approach to a Student With Severe Traumatic Bleeding.

Erdman M, Chardavoyne P, Olympia R

With the continued threat of mass casualty incidents in schools and surrounding communities, it is essential for school nurses to be knowledgeable regarding the recognition of hemorrhagic shock due to massive bleeding and the acute management of these victims. In the past decade, increased interest and research in acute bleeding control have led to published evidence-based guidelines to reduce morbidity and mortality for victims of violent acts. It is essential that healthcare providers, including nurses who are the first responders in schools, are aware of methods to assess and control massive bleeding. This article summarizes the most up-to-date recommendations for the management of children with traumatic bleeding.

J Trauma Acute Care Surg. 2019; Epub ahead of print

# National Stop the Bleed Day: The impact of a social media campaign on the Stop the Bleed program.

Fisher A, Carius B, Lacroix J, Dodge P, Dodd J, Soderlund E, Thompson D, Loos P, Fannin J, Montgomery H, Gestring M

INTRODUCTION: National Stop-the-Bleed Day (NSTBD) was created to increase public awareness of the official Stop-the-Bleed® initiative and the Bleeding Control Basic course. The goal was to develop and employ an effective national social media strategy that would encourage and support efforts already in place to train the public in basic bleeding control techniques.

METHODS: March 31, 2018 was designated as NSTBD. Analysis focused on a two-week window centered on NSTBD. The number of courses offered, number of instructors registered and total number of students trained overall during this period was derived from the American College of Surgeons (ACS) website bleedingcontrol.org. Courses not registered with the ACS were not included. Data on overall website activity was also included for analysis.

RESULTS: 43 states and 18 countries participated in NSTBD. During the study period, there were 1884 courses registered on the bleedingcontrol.org (Figure 1). Comparatively, over a four-month period from August - November, 2017, the mean number of registered courses per month was 834. There were 34699 students trained during the two-week study period (Figure 2) as opposed to August - November 2017, the mean number of people trained per month was 9626. In addition, 576 new B-Con instructors were certified during this time window. Additionally, the international coordinators reported 1500 students were trained during the study period. During this time, the ACS reported a significant increase in website activity. This included 10,530 new visitors, 12772 visitors overall and 35342 page views recorded during the study period.

CONCLUSION: The NSTBD effort was successful in generating widespread interest for the Stop-the-Bleed® initiative. The use of a targeted social media campaign in this context was successful in driving people to available training opportunities while also increasing awareness of the overall effort. While only in its early stages, the NSTBD concept is a good one and should be developed further in coming years.

LEVEL OF EVIDENCE: Retrospective, Level V.

Mil Med. 2019 Mar 1;184(Suppl 1):342-346. doi: 10.1093/milmed/usy389.

# Comparison of a Novel Trainer to a Traditional Swine Model for Training Providers in Lateral Canthotomy and Cantholysis.

Herder P, Lu M, LaPorta A, Ross D, Calvano C, Enzenauer R

RESEARCH OBJECTIVE: Military personnel are at greater risks of head and facial traumas and permanent blindness from orbital compartment syndrome in modern warfare. Rapid treatment must be implemented with a low-risk surgical remedy: lateral canthotomy and cantholysis (LCC). Traditional training of LCC is primarily performed using an animal tissue trainer (ATT); however, limitations to these types of trainers exist. Therefore, our research objectives were focused on highlighting the effectiveness, benefits, and vision-saving potential of learning LCC on a synthetic trainer.

METHODS: Participants included 22 second-year medical students and 6 healthcare professionals. A pre-quiz assessed baseline knowledge. Next, an experienced ophthalmologist provided an overview and instruction. Subjects were randomized to either the synthetic trainer or the ATT and then switched to the other model for comparison. After performing LCC procedures on both models, a post-quiz and survey were administered.

RESULTS: Participants found the synthetic trainer easier to use than the ATT model (p < 0.01). There was no statistically significant preference (p = 0.23), or preference of practical eye anatomy (p = 0.26) between the trainers. Post-quiz results demonstrated an overall improvement from pre-quiz scores for participants (p < 0.001).

CONCLUSIONS: The synthetic trainer is comparable to the traditional swine model for training LCC procedures, and should be considered as a future training platform.

Trauma Surg Acute Care Open. 2019 Feb 18;4(1):e000263

# World trauma education: hemorrhage control training for healthcare providers in India.

Smith L, Caughey S, Liu S, Villegas C, Kilaru M, Gupta A, Winchell R, Narayan M

Background: Hemorrhage remains a major cause of death around the world. Eighty percent of trauma patients in India do not receive medical care within the first hour. The etiology of these poor outcomes is multifactorial. We describe findings from the first Stop the Bleed (StB) course recently offered to a group of medical providers in southern India.

Methods: A cross-sectional survey of 101 participants who attended StB trainings in India was performed. Pre-training and post-training questionnaires were collected from each participant. In total, 88 healthcare providers' responses were analyzed. Three bleeding control skills were presented: wound compression, wound packing, and tourniquet application.

Results: Among participants, only 23.9% had received prior bleeding control training. Participants who reported feeling 'extremely confident' responding to an emergency medical situation rose from 68.2% prior to StB training to 94.3% post-training. Regarding hemorrhage control abilities, 37.5% felt extremely confident before the training, compared with 95.5% after the training. For wound packing and tourniquet application, 44.3% and 53.4%, respectively, felt extremely confident pre-training, followed by 97.7% for both skills post-training. Importantly, 90.9% of StB trainees felt comfortable teaching newly acquired hemorrhage control skills. A significant majority of participants said that confidence in their wound packing and tourniquet skills would improve with more realistic mannequins.

Conclusion: To our knowledge, this is the first StB training in India. Disparities in access to care, long transport times, and insufficient numbers of prehospital personnel contribute to its significant trauma burden. Dissemination of these critical life-saving skills into this region and the resulting civilian interventions will increase the number of trauma patients who survive long enough to reach a trauma center. Additionally, considerations should be given to translating the course into local languages to increase program reach.

Level of Evidence: Level IV.

J Spec Oper Med. Spring 2019;19(1):81-87.

# Low-Resource Tactical Combat Casualty Care Training for Peshmerga Units in Remote Areas of Kurdistan.

Taylor D, Murphy J, Stolley Z

The Peshmerga are the official military of the autonomous region of Kurdistan, Iraq. There remains a high level of variability across Peshmerga units in medical equipment and training. Presumably, Peshmerga soldiers are dying from preventable causes of death due to combat-related injuries, just as US troops did before the introduction of Tactical Combat Casualty Care (TCCC) training and supplies. This report outlines the efforts of a small US-based collective to provide TCCC training at the TCCC for all combatants skill level to Peshmerga forces and develop members of the Peshmerga as trainers.

Injury. 2019 Apr;50(4):864-868

# Practice makes perfect: The impact of Stop the Bleed training on hemorrhage control knowledge, wound packing, and tourniquet application in the workplace.

Zwislewski A, Nanassy A, Meyer L, Scantling D, Jankowski M, Blinstrub G, Grewal H

INTRODUCTION: The national Stop the Bleed (STB) campaign was implemented in 2015 to provide hemorrhage control education to non-medical providers to reduce the number of deaths due to uncontrolled hemorrhage. Hands on training limits the availability of this program, and its importance is not known amongst lay providers. This study aimed to evaluate the efficacy of STB training for laypersons on knowledge and skill-based abilities in the workplace setting. We hypothesized such hands on and in-person training would improve performance.

METHODS: Non-medical potential first responders (PFR; N = 298) participated in STB training comprised of a lecture and hands-on component. PFRs completed a bleeding control knowledge-based pre-and post-assessment. Following the lecture, participants were divided into experimental and control groups during which hands-on practice was manipulated to determine the impact of guided practice on wound packing and tourniquet application. Wound packing and tourniquet application assessments were performed and scores compared between the experimental and control groups.

RESULTS: PFRs scored higher on the bleeding control bleeding control knowledge-based post-test (M = 4.63, SD = 1.32) than on the pre-test (M = 3.21, SD = 1.14). Employees in the experimental group (M = 2.93, SD = .26) also scored significantly higher than the control group (M = 1.97, SD = .77) that attempted wound packing without any hands-on training. PFRs in the experimental group scored significantly higher (M = 7.41, SD = .91) than PFRs in the control group (M = 5.99, SD = 1.81) for tourniquet application.

CONCLUSION: Knowledge related to hemorrhage control increased following the STB course. Participants who engaged in hands-on practice for tourniquet and wound packing were more proficient than those who only saw the lecture. We confirm that in person, hands on training is key to the success of lay STB training.

J Surg Res. 2019 Jul 20;244:516-520

# Advancing the Education of Stop the Bleed: Development of a Perfused Synthetic Cadaver Model.

Gupta A, Villegas C, Rosenberg J, Winchell R, Barie P, Narayan M

BACKGROUND: As active shootings and mass casualty incidents have become more prevalent, courses designed to teach basic hemorrhage control to laypersons have proliferated. Participants currently undergo Stop the Bleed (StB) training currently use a synthetic limb mannequin. In a prior survey of 88 participants, there was overwhelming sentiment that the mannequin was limited by its inability to demonstrate cessation of bleeding when hemorrhage control techniques were applied. We hypothesized that simulated bleeding that can be controlled by StB techniques would improve the mannequin and increase confidence of trainees in achieving bleeding control.

METHODS: The mannequin was redesigned to be a self-contained model mimicking bleeding, with fluid flowing from a reservoir into a latex tubing with a laceration mimicking an arterial wound. Fluid was pumped by a rubber bulb attached to the tubing and held in the instructor's hand. Twenty StB trainers conducted beta testing of the perfused mannequin. Forty participants underwent training with both old and new models and completed posttraining surveys.

RESULTS: Beta-testers reported positive feedback regarding both realism of the perfused mannequin and participants' ability to obtain bleeding control using StB techniques. Participants who trialed the mannequin reported increased awareness of the rate of blood flow out of a wound, which in turn increased their sense of urgency to achieve hemostasis.

CONCLUSIONS: In an effort to address shortcomings noted by participants in the current StB mannequin, we developed a novel perfused bleeding mannequin, which responds appropriately to various hemorrhage cessation techniques and is both high fidelity and low cost.

JAMA Surg. 2019 Jul 24;Epub ahead of print

# Effectiveness of the American College of Surgeons Bleeding Control Basic Training Among Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial.

McCarty J, Hashmi Z, Herrera-Escobar J, de Jager E, Chaudhary M, Lipsitz S, Jarman M, Caterson E, Goralnick E

Importance: More than 500 000 laypeople in the United States have been trained in hemorrhage control, including tourniquet application, under the Stop the Bleed campaign. However, it is unclear whether after hemorrhage control training participants become proficient in a specific type of tourniquet or can also use other tourniquets effectively.

Objective: To assess whether participants completing the American College of Surgeons Bleeding Control Basic (B-Con) training with Combat Application Tourniquets (CATs) can effectively apply bleeding control principles using other tourniquet types (commercial and improvised).

Design, Setting, and Participants: This nonblinded, crossover, sequential randomized clinical trial with internal control assessed a volunteer sample of laypeople who attended a B-Con course at Gillette Stadium and the Longwood Medical Area in Boston, Massachusetts, for correct application of each of 5 different tourniquet types immediately after B-Con training from April 4, 2018, to October 9, 2018. The order of application varied for each participant using randomly generated permutated blocks.

Interventions: Full B-Con course, including cognitive and skill sessions, that taught bleeding care, wound pressure and packing, and CAT application.

Main Outcomes and Measures: Correct tourniquet application (applied pressure of ≥250 mm Hg with a 2-minute time cap) in a simulated scenario for 3 commercial tourniquets (Special Operation Forces Tactical Tourniquet, Stretch-Wrap-and-Tuck Tourniquet, and Rapid Application Tourniquet System) and improvised tourniquet compared with correct CAT application as an internal control using 4 pairwise Bonferroni-corrected comparisons with the McNemar test.

Results: A total of 102 participants (50 [49.0%] male; median [interquartile range] age, 37.5 [27.0-53.0] years) were included in the study. Participants correctly applied the CAT at a significantly higher rate (92.2%) than all other commercial tourniquet types (Special Operation Forces Tactical Tourniquet, 68.6%; Stretch-Wrap-and-Tuck Tourniquet, 11.8%; Rapid Application Tourniquet System, 11.8%) and the improvised tourniquet (32.4%) (P < .001 for each pairwise comparison). When comparing tourniquets applied correctly, all tourniquet types had higher estimated blood loss, had longer application time, and applied less pressure than the CAT.

Conclusions and Relevance: The B-Con principles for correct CAT application are not fully translatable to other commercial or improvised tourniquet types. This study demonstrates a disconnect between the B-Con course and tourniquet designs available for bystander first aid, potentially stemming from the lack of consensus guidelines. These results suggest that current B-Con trainees may not be prepared to care for bleeding patients as tourniquet design evolves.

Trial Registration: ClinicalTrials.gov identifier:NCT03538379.

J Spec Oper Med. 2019 Fall;19(3):64-70.

# Airway Management for Army Reserve Combat Medics: An Interdisciplinary Workshop.

Miller BM, Kinder C, Smith-Steinert R.

BACKGROUND: An Army Reserve Combat Medic's training is focused on knowledge attainment, skill development, and building experience and training to prepare them to perform in austere conditions with limited resources like on the battlefield. Unfortunately, the exposure to skills they may be responsible for performing is limited. Research shows that greater than 90% of battlefield deaths occur in the prehospital setting, 24% of which are potentially survivable. Literature demonstrates that 91% of these deaths are related to hemorrhage; the remaining are related to other causes, including airway compromise. The skill and decision-making of this population are prime targets to optimize outcomes in the battlefield setting.

METHODS: Army Reserve combat medics were selected to voluntarily participate in an educational intervention provided by anesthesia providers focusing on airway management. Participants completed a preintervention assessment to evaluate baseline knowledge levels as well as comfort with airway skills. Medics then participated in a simulated difficult airway scenario. Next, airway management was reviewed, and navigation of the difficult airway algorithm was discussed. The presentation was followed by simulations at four hands-on stations, which focused on fundamental airway concepts such as bag-mask ventilation and placement of oral airways, tracheal intubation, placement of supraglottic airways, and cricothyrotomy. Pre/post knowledge assessments and performance evaluation tools were used to measure the effectiveness of the intervention.

RESULTS: Statistically significant results were found in self-reported confidence levels with airway skills (z = -2.803, p = .005), algorithm progression (z = -2.807, p = .005), and predicting difficulty with airway interventions based on the patient's features (z = -2.809, p = .005). Establishment of ventilation was completed faster after the intervention. More coherent and effective airway management was noted, new knowledge was gained, and implications from psychological research applied.

CONCLUSION: Supplementing the training of Army Reserve Combat Medics with the utilization of anesthesia providers is an effective platform. This exercise imparted confidence in this population of military providers. This is critical for decision-making capabilities, performance, and the prevention of potentially survivable mortality on the battlefield.

Anaesth Crit Care Pain Med. 2019 Oct 12;Epub ahead of print

# Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers.

Swiech A, de Rocquigny G, Martinez T, Loarer G, Vico S, Planchon J, Le Goff A, Bertho K, Derkenne C, Travers S, Malgras B, Martinaud C, Carfantan C, Gaudry S, Boutonnet M, Pasquier P

INTRODUCTION: The current terrorist threat challenges nations to train numerous non-trauma care providers with different backgrounds in damage control (DC) strategies. The purpose of this work was to propose a specific DC training program.

METHODS: A Task Force of 16 civilian and military physicians met for a 24-hour session, to propose the construction of a DC training program for non-specialised caregivers.

RESULTS: Existing DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned.

CONCLUSIONS: The DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.