An online survey of non-compressible torso hemorrhage: training is needed

Hua-yu Zhang, Yong Guo, Xiao-ying Huang, Yang Li, Lian-yang Zhang

Department of Trauma Surgery, War Trauma Medical Center, State Key Laboratory of Trauma, Burn and Combined Injury, Daping Hospital, Army Medical University, Chongqing 400042, China

Corresponding Author: Lian-yang Zhang, Email: dpzhangly@163.com

Hemorrhage is the leading cause of combat deaths, which is a primary lesson learned from modern warfare.If temporary hemostasis is not available, the mortality of non-compressible torso hemorrhage (NCTH), a potentially preventable death (PPD), is as high as 85.5%.

Anatomically, NCTH cannot be conventionally controlled by extremity tourniquets. An optimized “treatment en route” strategy may exert a better outcome in NCTH patients.Therefore, gradually shifting to the prehospital application of external hemorrhage control devices (EHCDs), such as abdominal aortic and junctional tourniquet (AAJT) and resuscitative endovascular balloon occlusion of the aorta (REBOA),should be the primary focus.

An important achievement of tactical combat casualty care is the widespread availability of limb tourniquets and the resulting sharp decline in extremity hemorrhage mortality.Inspired by this, training in NCTH concepts and hemostatic techniques may also positively impact on the reduction of PPD, especially deaths that occurred during the prehospital phase.

The current study aimed to reveal the cognitive level of NCTH among Chinese medical staff after online self-training and to collect comments on NCTH-related training. The data will serve as an important driving factor for subsequent improvements of NCTH training in China.

METHODS

Self-learning material, including the definition, diagnosis and treatment strategy of NCTH, was released to medical staff engaged in trauma, emergency medicine and other specialties correlated with NCTH via eight WeChat messaging app groups on July 12, 2021. Next, a descriptive online survey powered by Wenjuanxing (www.wjx.cn) was conducted between July 19 and August 2, 2021.

The entire questionnaire (supplementary file) was divided into five sections, including demographic information, cognition of NCTH, attitude toward NCTH treatment, clinical practice and training-related information. The cognition section consisted of 13 single-choice questions. A score of 7 points or more was considered good. The attitude section was composed of 2 items, and a 4-point Likert scale was adopted in the rating system. A score of 4 points was the minimum score for a positive attitude. The section of clinical practice aimed to investigate how many NCTH cases could be encountered in daily work and NCTH-related treatment methods mastered by the respondents. Opinions toward NCTH training were also evaluated.

SPSS 25.0 was used for statistical analysis. Student’s-test, one-way ANOVA, and Chi-square test were used. A-value＜ 0.05 was considered statistically significant.

RESULTS

A total of 180 questionnaires (response rate 30.9%) were received. All respondents were doctors. The demographic information of respondents is shown in Table 1.

Most participants (85.0%) showed good cognition of NCTH, with an overall average score of 8.6±2.0. Furthermore, the correct answer rate was more than 50.0% among 10 out of 13 items. Remarkably, more than 90.0% of respondents had an accurate understanding associated with the injury mechanism (92.8%) and the applicability of REBOA (90.6%) and pelvic stabilizers (92.2%) in NCTH emergency control. In contrast, only a minority were able to correctly identify the definition (20.0%) of NCTH as well as the organs (33.9%) and arteries (37.2%) involved despite the completion of the current online training.

Similarly, the majority (85.0%) met the criteria for a positive attitude. Meanwhile, 77.8% of respondents strongly agreed that NCTH control was a major challenge, and only 47.2% of doctors were confident in NCTH treatment.

Notably, highly educated respondents who had seniority and experiences scored better in the attitude section. Males, tertiary hospital personnel, and university affiliated hospital employees outperformed their peers in attitude scores and classified evaluation (Table 2).

Most respondents (82.8%) reported that they had treated NCTH cases during their careers. However, since 2021, 46 (25.6%) respondents informed that zero case has been treated. Seventy-five (41.7%) doctors managed 1-5 cases. Thirty-three (18.3%) respondents managed 6-10 cases. Only 6 (3.3%) people reported having treated 11-15 cases. The remaining 20 (11.1%) respondents managed ≥16 cases. Among the listed strategies, the number of people who mastered at least one to all five measures (EHCDs, REBOA, resuscitative thoracotomy, temporary tamponade hemostasis and definitive operation) showed a decreasing trend, which was 50, 46, 36, 26 and 12, respectively. Another ten doctors were incapable of NCTH treatment. The most commonly used methods were EHCDs (87.2%) and definitive operations (59.4%).

Table 1. Demographics of the respondents (n=180)

Table 2. NCTH-related attitude of subgroups in demographic features

The vast majority (98.9%) respondents were satisfied with the current training and deemed it beneficial to improve NCTH management. In addition, all of the respondents were willing to share the handout, and 81.7% were motivated to engage in further study.

Although 99.4% of respondents were willing to participate in NCTH-related training, time commitment (47.8%), travel distance (26.1%), and lack of practical operations (20.6%) were the top 3 barriers to attendance. Because the improvement of specific treatment methods (93.3%) was the primary concern, respondents were more willing to participate in offline operation training (67.8%), which also accounted for why few people chose to recharge themselves through online theory selflearning (1.1%).

DISCUSSION

Non-compressible or compressible: not a question anymore

Nearly 90.0% of doctors reported that they were capable of using EHCDs during NCTH management, but no more than 40 respondents thought EHCDs could control NCTH. A superficial understanding of the word “non-compressible” may explain this phenomenon. Without a clear understanding of the definition, promoting specific treatments will be difficult. The resulting low efficacy of NCTH rescue may further solidify the incorrect notion that lethal hemorrhage is insoluble in the prehospital stage.

Continuous improvement of the definition, such as abdominal compartment syndrome, profoundly impacts clinical practice.Therefore, the standardization of the NCTH definition may also promote clinical efficacy. NCTH was originally named for the lack of hemostatic strategy and anatomical features, but with the progress of EHCDs and REBOA,the implication of “noncompressible” has been weakened. NCTH can be further divided into EHCDs compressible and non-compressible but endovascular controllable. In addition, selfexpanding foam and injectable nano-therapy also expand the NCTH treatment strategies.The continuous development of hemostatic methods is proof that noncompressible is not equal to untreatable.

Training and trainees: why and how

More than half of the respondents lacked confidence in NCTH treatment. Doctors became more prudent when answering relevant questions due to the high mortality of NCTH.Inadequate experience may lead to a conservative attitude, given that about 70% of respondents managed no more than 5 NCTH cases in 2021.

With regard to the situation that medical personnel from different specialties deployed to the front lines during the COVID-19 pandemic, medical staff engaged in trauma care are also presumed to be emergent hemostasis providers. Therefore, NCTH control training should be well designed. Different topics should be implemented through various modalities to strengthen the eff ectiveness of each training. Given existing barriers, an offline practice should play a leading role in handson training. In contrast, literature teaching, such as basic knowledge and academic progress, can be mainly carried out via internet resources. It may help to consolidate understanding through repeated learning beyond the limitations of time and space. Significantly, systematic establishment of NCTH cognition cannot rely on selflearning alone, according to the current study.

China trauma care training (CTCT): a Chinese approach

CTCT, the first standardized trauma care training program in China sponsored by the Chinese Medical Doctor Association, was launched in July 2016.CTCT provides individualized training according to personnel (team leaders, doctors, and nurses) to promote better training outcomes. Given the positive eff ect of CTCT,it is reasonable to believe that advanced concepts of emergent hemostasis will be popularized with the help of the NCTH-embedded CTCT platform, which is also significant to the improvement of trauma care capacity in China.

CONCLUSIONS

Efforts are needed to bridge the cognitive gap of NCTH among medical staff. A better understanding of the definition is essential for the high-quality application of relevant strategies, thus improving medical providers’ confidence. CTCT is a ready-made platform with flexible training modes, which should be fully utilized in NCTH training.

ACKNOWLEDGMENTS

The researchers appreciate all participants for their time and eff ort.

Funding: This study was supported by the Clinical Technology Innovation and Cultivation Project of Army Medical University (CX2019JS109) and the Innovative Project of Daping Hospital for Clinical Medicine (2019CXLCA002).

Ethical approval: The current study was approved by the Ethics Committee of Daping Hospital (Certificate number: 2019092). All procedures were strictly implemented following the.

Conflicts of interest: The authors declare that they have no competing interests.

Contributors: HYZ and LYZ proposed the main framework of the research. HYZ, YG and XYH collected and analyzed the data. HYZ drafted the manuscript. YL and LYZ revised the paper. All authors have read and approved the final version of the manuscript.

All the supplementary files in this paper are available at http://wjem.com.cn.