The Windlass Tourniquet: Is It Taking the Wind Out of the "Stop the Bleed" Sails?

BACKGROUND: Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. MATERIALS AND METHODS: One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. RESULTS: 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33-60 sec), the time taken to read the instructions was shorter one month following STB (P <0.001), but there was no difference at 6 months (P = 0.1). Incorrect placement was noted for 19.4% and 23.5% of attempts at 1 and 6 months. Male participants were more successful in effective placement at one month (93.3% versus 31.3%, P = 0.004) and at six months (77.8% versus 43.8%, p = 0.04). CONCLUSIONS: Skills decay for tourniquet application was observed between 1 and 6 months following STB. Instruction review and STB produced the same hemorrhage control rates as reading enclosed instructions without prior training. Training efforts must continue; but an intuitive tourniquet relying less on mechanical advantage is needed.

Pediatric Firearm-Related Injuries: Taking Kids Out of Harm's Way Begins with Targeted Prevention.

BACKGROUND: Firearm-related injury is a public health crisis and remains the 3rd most common cause of death from ages 1 15 years. By evaluating events surrounding such injuries, evidence-based intervention strategies efforts may be targeted to maximize impact. MATERIAL AND METHODS: A retrospective chart review was performed for firearm-related injuries in patients 15 years-old and under at an urban Pediatric Level 1 Trauma Center between January 2016 and December 2020. Age, gender, race/ethnicity, injury severity score (ISS), reported cause of injury, timing of injury around school and curfew, and mortality were evaluated. Medical Examiner data identified other deaths that occurred within the hospital's catchment area. RESULTS: There were 195 injuries including 14 from the Medical Examiner. Overall, 82.6% were male with median age of 14 years (range 1-15; IQR 13-15), and median ISS of 5 (IQR 1-10). African-American children comprised 74.9% of the cohort while only representing 35.9% of local schools. Intentional interpersonal injuries comprised 65.6%; 17.4% were bystanders; 7.2% were negligent discharges; and 0.5% suicide. Median age for intentional interpersonal injuries was 14 years (IQR 13-15) compared to 11 years (IQR 8-14, P = 0.03) for negligent discharges. Regarding timing, 6.9% of injuries occurred during school hours; 56.4% after school or during non-school days; and 36.7% were after legal curfew. Mortality rate was 17.4%. CONCLUSIONS: Firearm safety education and community-based violence intervention should start in the pre-teen years. Pediatric firearm-related injury prevention strategies must be multifaceted addressing structural racism, truancy, curfew violation, extra-curricular activities, childcare options, firearm safety education, violence reduction, suicide prevention, and recidivism.

Heroes in crisis: Trauma centers should be screening for and intervening on posttraumatic stress in our emergency responders.

BACKGROUND: Emergency responders face a crisis of rising suicide rates, and many resist seeking help due to the stigma surrounding mental health. We sought to evaluate the feasibility of an urban trauma center to screen for posttraumatic stress (PTS) among emergency responders and to provide mental health services. METHODS: Paramedics, firefighters, law enforcement, and corrections officers involved with patients in the trauma unit were asked to complete the Post-Traumatic Growth Inventory (PTGI) and Post-Traumatic Checklist for Diagnostic and Statistical Manual-5 (PCL-5). Additional factors known to affect PTS were correlated: occupation, age, sex, years of service, marital status, children, and pets. Willingness and barriers to seeking interventions for PTS were evaluated. RESULTS: A total of 258 responded: 36.7% paramedics, 40.2% law enforcement officers, 18.4% corrections officers, 0.8% firefighters, and 3.5% with multiple positions. Responders had a mean of 14.5 years of service (SD, 9.9 years). Mean PTGI and PCL-5 scores were 52.1 (SD, 25.1) and 17.2 (SD, 16.5), respectively. Overall, 24.7% had diagnostic PTS disorder with no difference seen in rates between professions. Of these, 80.7% had not sought care. Barriers included that they were not concerned (46%), did not recognize symptoms (24%), and were worried about consequences (20%). Concern over career advancement or losing one's job was the greatest barrier cited for seeking care. Among law enforcement, 47.7% were concerned that they would lose their ability to carry a firearm if they sought care for PTS. The PTGI score, divorce, and 46 years to 50 years were the only factors examined that correlated with increased PCL-5 score. There were 82.5% that felt the trauma center was the right place to screen and intervene upon PTS. CONCLUSION: Trauma centers are an ideal and safe place to both screen for PTS and offer mental health assistance. Comprehensive trauma-informed care by hospital-based intervention programs must expand to include emergency responders. LEVEL OF EVIDENCE: Epidemiological study type, Level II.

The scales of recovery: Balancing posttraumatic stress with resilience in the violently injured.

BACKGROUND: Community violence remains a clinical concern for urban hospitals nationwide; however, research on resilience and posttraumatic growth (PTG) among survivors of violent injury is lacking. This study intends to assess survivors of violent injury for resilience and PTG to better inform mental health interventions. METHODS: Adults who presented with nonaccidental penetrating trauma to an urban level 1 trauma center and were at least 1 month, but no more than 12 months, from treatment were eligible. Participants completed the Connor-Davidson Resiliency Scale, Posttraumatic Growth Inventory (PTGI), Primary Care Posttraumatic Stress Disorder screen, and a community violence exposure screen. Additional demographic, injury, and treatment factors were collected from medical record. RESULTS: A total of 88 patients participated. The mean resiliency score was 83.2, with 71.1% scoring higher than the general population and 96.4% scoring higher than the reported scores of those seeking treatment for posttraumatic stress disorder (PTSD). Participants demonstrated a mean PTGI score of 78 (SD, 20.4) with 92.4% scoring above the significant growth threshold of 45. In addition, 60.5% of patients screened positive for significant PTSD symptoms, approximately eight times higher than general population. Exposure to other traumatic events was high; an overwhelming 94% of participants stated that they have had a family member or a close friend killed, and 42% had personally witnessed a homicide. Higher resilience scores correlated with PTGI scores (p < 0.001) and lower PTSD screen (p = 0.02). CONCLUSION: Victims of violent injury experience a myriad of traumatic events yet are highly resilient and exhibit traits of growth across multiple domains. Resiliency can coexist with posttraumatic stress symptoms. Practitioners should assess for resiliency and PTG in addition to PTSD. Further investigation is needed to clarify the relational balance between resilience and posttraumatic stress. LEVEL OF EVIDENCE: Epidemiological study type, Level II.