Article

Skill decay or maintenance between tourniquet uses among first aid caregivers: Exploration in a manikin model

Correspondence / American Journal of Emergency Medicine 34 (2016) 18831910 1897

Fig. 2. forearm nerve blocks. Real-time ultrasound images of forearm nerve blocks using in-plane technique of needle (yellow arrows) visualization: median nerve block (A), radial nerve block (B), and ulnar nerve block (C).

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  • Skill decay or maintenance between tourniquet

    uses among first aid caregivers: Exploration in a manikin model?

    To the Editor,

    From 2013 to 2015, the number of civilian reports of emergency tourniquet use in the medical literature has increased [1-15]. Civilian law enforcement reports have also occurred during this time [16,17]. Al- though expert reviewers of first aid science note that tourniquet data are weak, first aid use of limb tourniquets has become a consensus inter- nationally as a skill recommended to be taught to everyone; such rec- ommenders are the leading authorities including the American Heart Association, the American Red Cross, the International Liaison Commit- tee on Resuscitation, and President Obama’s Administration (18, 19, https://www.whitehouse.gov/the-press-office/2015/10/06/fact-sheet- bystander-stop-bleed-broad-private-sector-support-effort-save, accessed Feb. 1, 2016; http://www.dhs.gov/stopthebleed, accessed Feb. 1, 2016). In 2014 and 2015, preliminary reports of tourniquet training started ad- dressing relevant issues, but much remains unknown or unclear, such as whether skill of tourniquet users may decay over time [18-21]. The purpose of the present study is to explore skill decay in tourniquet use in order to provide 1) initial information on a technique of measure- ment, and 2) preliminary guidance for instruction of users.

    We used a laboratory protocol of manikin (HapMed Thigh Tourni- quet Trainer; CHI Systems, Fort Washington, PA) use for measuring tourniquet user performance [22,23]. We retrospectively used existing data from three previous studies for an initial exploration; two such studies are in review and one study was published [24]. The studies had data collected in 2014 and 2015. One study of the three had one user and the others had two users. The types and models of tourniquet, number of uses, durations of data collection, and user skill level varied from study to study. The main measure of user skill was of a continuous variable indicating performance; we used two forms of this: speed (time to stop bleeding in seconds), and blood loss (volume in mL). Each time of use was recorded, and the interval between uses was

    ? The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

    1898 Correspondence / American Journal of Emergency Medicine 34 (2016) 18831910

    Table 1

    Results in associating tourniquet user skill level with inter-use time interval

    Parameter Slope of regression line Correlation coefficient, R2

    Time 0.0007 0.0053

    Time 0.0012 0.1467

    Time -0.004 0.0311

    Time -0.0005 0.0015

    Time 0.0211 0.0004

    Blood Loss -0.0751 0.0075

    Blood Loss -0.0121 0.0337

    Blood Loss -0.0108 0.1213

    Blood Loss 0.0007 0.0009

    Blood Loss

    0.0116

    0.0178

    Blood Loss

    7.3005

    0.1555

    calculated. The inter-use interval was plotted as the x-axis for each indi- vidual user; skill performance was plotted on the y-axis. Linear regres- sion (x-y) was used to explore the association to see if the slope was positive (skill decayed) as this was our best guess. The dataset’s R2 value was reported as an indicator of the association, a degree of corre- lation; a zero value indicates no association, and a value of 1 indicates perfect association. The linear regression equation (Microsoft Excel 2010, Redmond, WA) was y = Ax +B where x and y represented inter- val and skill level, respectively, and A was the slope of the line and B was the y-axis intercept. The slope was chosen as an indicator of skill level change; decay was positive, improvement was negative, and mainte- nance was neutral, e.g., zero. Intervals ranged from 1 minute to 28 days. Despite varied study purposes, tourniquets, and users, results were uniformly monotonous: skill levels remained virtually flat and the asso- ciation was weak between skill level and time interval (Table 1). In a representative plot, one user had a wide variety of intervals but still had virtually no change in skill (Fig. 1). This user had the opportunity and foreknowledge to deliberately vary intervals in order to spread out the data points so that only a subset of data points would be clus- tered of in a narrow range from 1 to 5 min. Data with more spread was expected to better allow exploration of skill decay, and in the other studies, which were done previously, most data were so clustered. Despite differences in spread of data, each study showed the same find- ing. Despite the varied intervals, the finding was the same: virtually flat

    skill level over time indicating neutral, near-zero change.

    This is a negative study: we specifically went looking for skill decay over time, but we found none. Surprisingly, we found skill maintenance. However, this is just a preliminary exploration and neither a definitive survey nor a clear answer. The report outlines a way of searching for skill level change among first aid caregivers, and it provides a first

    look at an implication that to date, refresher training (instruction aimed at skill maintenance) might not be needed in the short term like within 3 weeks of completion of initial training. The technique used required limited collection of data, little time from an investigator in use of a common software program, and an interpretation of analysis with linear regression. However, none of the studies was designed to answer the point at hand because they all addressed other hypotheses. Therefore, future prospective studies may specifically hypothesize skill decays over time. If more data show skill maintenance in intervals lon- ger than 3 weeks, then this skill perhaps may be like riding a bike; once learned, the skill may be undertook later without much preparation and without much decay in skill. However, the users in this study were liter- ally tourniquet investigators and did not represent routine students; wider sampling of varied users may develop knowledge of relevance to instructors.

    John F. Kragh Jr. COL, MC* Michael A. Dubick PhD

    U.S. Army Institute of Surgical Research, 3698 Chambers Pass Bldg 3611, Rm 222-4, JBSA Fort Sam, Houston, TX 78234-7767

    *Corresponding author. U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Bldg 3611, Rm 222-4 JBSA Fort Sam, Houston, TX 78234-7767

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2016.06.087

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      Figure 1. Skill level of a tourniquet user was maintained over time.

      Correspondence / American Journal of Emergency Medicine 34 (2016) 18831910

      Schroll R, Smith A, McSwain Jr NE, Myers J, Rocchi K, Inaba K, et al. A multi-

      1899

      Funda Sungur Biteker, MD

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      Predictors of mortality in severe sepsis

      To the Editor,

      We read with interest the article recently published by McCor- mack and colleagues [1]. The authors evaluated the prognostic role of The Mortality in Emergency Department Sepsis (MEDS) score in ED patients with severe sepsis. They found that patients in the mortality group had older age; higher lactate; lower albumin; and higher international normalized ratio, ED intubation, and intensive care unit admission.

      Despite the efficacy of modern treatment, severe sepsis is the leading cause of death due to infection [2]. Sepsis is a complex process with a high degree of variability, and current studies showed that myocardial dysfunction, which is characterized by transient biventricular impairment of intrinsic myocardial con- tractility, is a common complication in patients with sepsis and septic shock. cardiac troponins and Natriuretic peptides are bio- markers that were previously introduced for diagnosis and risk stratification in patients with acute coronary syndrome and con- gestive heart failure, respectively. However, the elevation of car- diac troponin natriuretic peptide levels in patients with sepsis, severe sepsis, or septic shock has been shown to indicate left ventricular dysfunction and a poor prognosis [3]. Therefore, we would be grateful if the authors have and would provide the data regarding troponin and natriuretic peptide levels on admis- sion and their relationship with the severity of the disease in pa- tients with sepsis.

      Mugla University, Faculty of Medicine, Department of Infectious Diseases

      and Clinical Microbiology

      Volkan Dogan, MD? Ozcan Basaran, MD Murat Biteker, MD

      Mugla University, Faculty of Medicine, Department of Cardiology

      ?Corresponding author. Mugla Sitki Kocman Universitesi Tip Fakultesi, Orhaniye Mah, Haluk Ozsoy Cad., 48000, Mugla

      Tel.: +90 252 214 13 26

      E-mail: addresses [email protected]

      [email protected]

      http://dx.doi.org/10.1016/j.ajem.2016.06.092

      References

      McCormack D, Ruderman A, Menges W, Kulkarni M, Murano T, Keller SE. Usefulness of the mortality in severe sepsis in the emergency department score in an urban tertiary care hospital. Am J Emerg Med 2016;34(6):1117-20.

    23. Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013;369(9):840-51.
    24. Klouche K, Pommet S, Amigues L, Bargnoux AS, Dupuy AM, Machado S, et al. plasma brain natriuretic peptide and troponin levels in severe sepsis and septic shock: relationships with systolic myocardial dysfunction and intensive care unit mortality.J Intensive Care Med 2014;29(4):229-37. http://dx.doi.org/10.1177/0885066612471621 [Epub 2013 Jan 1].

      elevated cardiac biomarkers are not associated

      with mortality in low-risk cardiac patients with severe sepsis?,??

      To the Editor,

      Previous research has shown that cardiac dysfunction in severe sepsis worsens outcomes and increases mortality [1]. Dogan et al. [2] in their correspondence point out that further evidence is still necessary to prove that elevated cardiac biomarkers, specifically Cardiac troponin I and brain natriuretic (BNP) levels, are associated with higher mortality for patients with severe sepsis. As requested, we conducted an analysis using the same study sample that was used to evaluate the Mortality in Severe Sepsis in the Emergency Department scoring method, which identified several clinical factors associated with higher in-hospital mortality [3]. For statistical analysis, the Student t test was used to determine an association between cardiac biomarkers, ejection fraction (EF%), and in-hospital mortality.

      Of 182 patients who presented to the emergency department with severe sepsis, 127 (70%) had an initial CTnI level (0.20 +- 0.06 ng/mL;

      95% confidence interval [CI], 0.07-0.33), and 44 (24%) had a second

      cTnI level (0.52 +- 0.16 ng/mL; 95% CI, 0.19-0.86). The Upper limit of normal for cTnI at our institution is 0.3 ng/mL indicating that the mean cTnI for the second cTnI was significantly higher than initial cTnI in our patient cohort (P = .03). Only 37 patients (20%) were found to have a reported BNP level (909.62 +- 338.39 pg/mL; 95% CI, 223.32-1595.93), and 45 patients (25%) had an EF% (53.22 +- 3.16;

      95% CI, 46.86-59.59) determined by echocardiogram during the hospital course. Our analysis did not find a significant association between survival and mortality for initial cTnI (0.24 +- 0.09 ng/mL vs 0.12 +- 0.05 ng/mL; P = .39), second cTnI (0.50 +- 0.21 ng/mL vs 0.55 +-

      0.27 ng/mL; P = .87), and BNP (767.16 +- 315.37 pg/mL vs 1294.20 +-

      946.84 pg/mL; P = .49). The EF% did not significantly differ between survival and mortality groups (53.52 vs 52.78; P = .91).

      ? Funding: None.

      ?? Presentations: None.

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