Document resource
Introduction Since the start of the full-scale invasion of Ukraine by Russian forces in 2022, the war has been characterized by high attrition rates on both sides with hundreds of thousands killed and wounded. 1 2 Haemorrhage is the most common cause of shock in trauma patients, estimated to be responsible for half of preventable deaths.3 4 To reduce the haemorrhage-related mortality, proper training is vital. To this end, the Tactical Combat Casualty Care curriculum advocates for the use of advanced medical simulators, task-trainers and manikins.5 Recent publications classify Live Tissue Training (LTT) as a highly valued high-fidelity simulator.6 The frequent use of heavy weapon systems, such as massed large-calibre artillery, has resulted in an increasing number of casualties displaying wound patterns caused by fragmentation from exploding ordinance.1 8 Casualties presenting with catastrophic haemorrhages with multiple points of bleeding have increased in frequency.1 8 9 Due to their size and anatomical location, the preferred treatment of these wounds is packing with gauze or haemostatic dressings. Today, no high-fidelity simulator comparable to live tissue exists for training wound-packing techniques in wounds with multiple points of bleeding.To improve training in the management of massive haemorrhages, the main aim of this project was to develop and validate a repeatable high-fidelity simulator used for skill-training in haemorrhage control using wound packing techniques in a wound with multiple bleeding points.Methods The study was conducted during medical training courses at the Center for Disaster Medicine and Traumatology. All animal experiments were approved by the Regional Ethical Review Board (ID 16652–2020) and were performed in accordance with the guidelines established by the Medical Faculty at Linköping University, Sweden, and the European Convention on Animal Care. The study population consisted of attendees in LTT training (n = 51), divided into two groups based on their skill level (experts vs novices). The new simulator, Repeatable Exsanguination Simulator Using Live Tissue (RESULT), is an artificial artery constructed using readily available materials and implanted into anesthetized animal models. By using external blood (or other fluid) to create bleedings, training with RESULT has no impact on circulatory volume. RESULT was compared against two existing simulators, TrueClot and LTT with real bleedings on anesthetized animals. Parameters measured included evaluating participant performance (time to bleeding control), and validity and fidelity between the different simulators using questionnaires (1–7 Likert scales). Results were compared using two-way analysis of variance coupled with Šídák’s multiple comparisons tests. Numbers are reported as mean ± standard deviation. A p value < than 0.05 was considered statistically significant.Results Expert participants achieved bleeding control significantly faster in RESULT compared to novices (137±85 vs 207±119 seconds, p < 0.01; figure 1A). There were no significant differences between expert and novices using TrueClot or LTT. RESULT was considered more realistic (6.27±0.8 vs 3.76±1.1, p < 0.0001; figure 1B), more challenging (5.45±1.1 vs 3.43±1.3, p < 0.0001; figure 1C) and gave a more valuable training experience (6.64±0.7 vs 4.80±1.5, p < 0.0001; figure 1D) compared to TrueClot. RESULT was considered equally realistic (6.27±0.8 vs 6.65±0.81, p > 0.05; fig 1B) and challenging (5.45±1.1 vs 5.26±1.3, p > 0.05; fig 1C) as LTT. The value of the training experience with RESULT rated equal to LTT (6.64±0.7 vs 6.73±0.79, p > 0.05; figure 1D).Abstract A15 Figure 1Graphs summarizing measured parameters. A: Time to achieved bleeding control comparing experts and novices using the three different simulators. B: Perceived realism of the different simulators.1–7 C: Perceived challenge of stopping simulated bleeding.1–7 D: Value of training using the three simulators.1–7* equals p < 0.05, **** equals p < 0.0001Conclusions The present study validates RESULT as a reusable high-fidelity simulator for skill training on wound packing techniques in wounds with multiple bleeding points. As revealed by comparing performance in experts and novices, a higher degree of medical experience results in significantly faster bleeding control (70 seconds difference on average), further illustrating the validity of the simulator.References Quinn J, Panasenko Si, Leshchenko Y, Gumeniuk K, Onderková A, Stewart D, et al. Prehospital lessons from the war in ukraine: damage control resuscitation and surgery experiences from point of injury to role 2. Mil Med [Internet]. 2024 Jan 23 [cited 2025 Jul 26];189(1–2). Available from: https://pubmed.ncbi.nlm.nih.gov/37647607/Institute for the Study of War [Internet]. [cited 2025 Jul 26]. Institute for the Study of War. Available from: http://dev-isw.bivings.com/ACS Store [Internet]. [cited 2025 Jul 26]. ATLS ® Student Course Manual, 10th Edition. Available from: https://store.facs.org/atls-student-course-manual-10th-editionEastridge Bj, Holcomb Jb, Shackelford S. Outcomes of traumatic hemorrhagic shock and the epidemiology of preventable death from injury. Transfusion (Paris) [Internet]. 2019 Apr [cited 2025 Jul 26];59(S2). Available from: https://pubmed.ncbi.nlm.nih.gov/30980749/TCCC Combat Lifesaver [Internet]. [cited 2025 Jul 26]. Available from: https://www.naemt.org/education/trauma-education/naemt-tccc/tccc-cls-guidelines-and-curriculumSwain Cs, Cohen Hml, Helgesson G, Rickard Rf, Karlgren K. A Systematic review of live animal use as a simulation modality (‘live tissue training’) in the emergency management of trauma. J Surg Educ [Internet]. 2023 Sep [cited 2025 Jul 26];80(9). Available from: https://pubmed.ncbi.nlm.nih.gov/37516576/Mahoney A, Reade Mc, Moffat M. Experiences of medical practitioners in the Australian Defence Force on live tissue trauma training. BMJ Mil Health [Internet]. 2023 Apr [cited 2025 Jul 26];169(2). Available from: https://pubmed.ncbi.nlm.nih.gov/33087539/Epstein A, Lim R, Johannigman J, Fox Cj, Inaba K, Vercruysse Ga, et al. Putting medical boots on the ground: lessons from the war in ukraine and applications for future conflict with near-peer adversaries. J Am Coll Surg [Internet]. 2023 Aug 1 [cited 2025 Jul 26];237(2). Available from: https://pubmed.ncbi.nlm.nih.gov/37459197/Onderková A, Quinn J, Meoli M, Taylor D, Nesterenko S, Schramm Jm, et al. Enhancing prehospital care during the conflict in Ukraine: NATO’s role in global health engagement. Mil Med [Internet]. 2025 Feb 27 [cited 2025 Jul 26];190(3–4). Available from: https://pubmed.ncbi.nlm.nih.gov/39163204/