Systematic Review of Live Tissue Versus Simulation Education for Prehospital Trauma Providers.

BACKGROUND: Advanced simulation capabilities have provided medical educators novel approaches for learners. Simulation has successfully replaced many aspects of medical education that previously used animal live-tissue training (LTT) for physician education. However, prehospital trauma providers, such as combat medics, currently used LTT to prepare for patient care. This use of LTT has sparked a debate about the optimal educational modality for this unique learner population. At this time, there is no clear evidence-based recommendation available to recommend either LTT or simulation as a superior modality. METHODS: The authors performed a systematic review of observational studies and randomized control trials (RCTs) to examine the use of LTT versus simulation in the trauma education of prehospital providers. The authors judged studies for inclusion and data abstraction independently and in duplicate, while also assessing quality and risk of bias. Since the literature demonstrated a heterogeneous background, no meta-analysis was performed. RESULTS: 12 studies met inclusion criteria: seven RCTs, four prospective cohorts, one cross-sectional study. Two of seven RCTs were presented as abstracts only. Ten of 12 studies were performed in a military setting, whereas two occurred in a civilian setting. Four studies used swine, two used goats, one used swine and goats, one used canines, and four did not specify the animal type. The authors used the Cochrane Collaboration tool to assess RCTs and found a considerable risk of bias. They used the Newcastle-Ottawa score to assess prospective cohorts (mean score of 5.75 ± 0.5, range 1-9), and the cross-sectional study (score 4, range 1-9). CONCLUSION: The existing literature provides limited, low-to-moderate quality outcome data. Evidence does not exist at this time to recommend either LTT or simulation as a superior educational modality for prehospital trauma care providers.

Analysis of Layperson Tourniquet Application Using a Novel Color-Coded Device.

OBJECTIVE: To determine whether a color-coded tourniquet designed for public use increases successful tourniquet application by laypeople. METHODS: This was a randomized study conducted on April 25, 2015. The study occurred during the Maryland Day activity at the University of Maryland in College Park, Maryland. Investigators recruited participants with posters displayed at major crosswalks around a central testing area. A total of 157 volunteers aged 18 years or older and without prior military service or medical training were enrolled. A participant stood in front of a waist-down mannequin with an isolated leg injury while an investigator read aloud a mass causality scenario. The investigator then asked the participant to apply a tourniquet to the mannequin's leg. All participants received a 4-step illustrated just-in-time (JiT) instruction card designed to facilitate layperson tourniquet application. Test participants received a color-coded tourniquet designed for layperson use with instructions printed on the device. Control participants received a black Combat Application Tourniquet (C-A-T; Composite Resources, Rock Hill, SC). Participants were randomized in a 1:1 ratio in blocks of 50. The primary outcome was the proportion of successful tourniquet applications by those who received color-coded tourniquets compared to those who received black tourniquets. Secondary outcomes included validation of previous data analyzing layperson success with tourniquet application, time for successful placement, reasons for failed applications, and participant self-willingness and comfort using tourniquets. We also analyzed demographic data on the study population and inter-rater reliability regarding the assessment of successful tourniquet application. RESULTS: Participants supplied with color-coded tourniquets successfully placed the device 51.38% of the time, compared to 44.71% of the time for controls using a black tourniquet (risk ratio: 1.15; 95% confidence interval: 0.83-1.59; P=0.404). Participants' self-reported willingness to use a tourniquet rose from 40.8% before the study to 80.3% after the study (P<0.05). CONCLUSIONS: The color-coded device did not significantly increase laypeople's proportion of successful tourniquet applications when compared with a standard black device. However, this study reproduced pilot study data showing that laypeople can successfully apply tourniquets about half the time if provided JiT instructions. Age, sex, race, income, and highest level of education were not found to impact one's ability to properly apply a tourniquet. Laypeople's willingness to apply tourniquets doubled to 80% after brief exposure to the device. These results affirm the feasibility of engaging laypeople as immediate lifesavers of trauma victims and justify further efforts to boost rates of proper application.

Just-in-Time to Save Lives: A Pilot Study of Layperson Tourniquet Application.

OBJECTIVES: The objective was to determine whether just-in-time (JiT) instructions increase successful tourniquet application by laypersons. METHODS: This was a randomized pilot study conducted in August 2014. The study occurred at the Uniformed Services University campus in Bethesda, Maryland. A total of 194 volunteers without prior military service or medical training completed the study. The participant stood in front of a waist-down mannequin that had an exposed leg. An observer read a scenario card aloud that described a mass casualty event. The observer then asked the participant to apply a Combat Application Tourniquet (C-A-T) to the mannequin. Test participants received a 4 × 6-inch card, with JiT instructions, in addition to their C-A-T; controls received no instructions. Participants were randomized in a 3:1 ratio of instructions to no instructions. The study's primary outcome was the proportion of successfully applied tourniquets by participants receiving JiT instructions compared to participants not receiving instructions. Secondary outcomes included the time for successful tourniquet placement, reasons for failed tourniquet application, and participants' self-reported willingness and comfort using tourniquets in real-life settings. RESULTS: Just-in-time instructions more than doubled successful tourniquet placement. Participants supplied with JiT instructions placed a tourniquet successfully 44.14% of the time, compared to 20.41% of the time for controls without instructions (risk ratio = 2.16; 95% confidence interval = 1.21 to 3.87; p = 0.003). CONCLUSIONS: Just-in-time instructions increase laypeople's successful application of C-A-T. This pilot study provides evidence that JiT instructions may assist the lay public in providing effective point-of-injury hemorrhage control.