This descriptive observational study of the implementation of an extremity bleeding control and tourniquet application workshop among inexperienced midshipmen of the JSE during navigation on high seas demonstrates the educational value of these training exercises as part of their activities. The highly ranked perception of usefulness (8.6) and content adequacy (8.7) of ET training during high sea navigation corroborate the convenience of incorporating these activities as a part of the academic program aboard training sail ships. Additionally, the high level of overall satisfaction (9.3) declared during the activity stimulates teamwork and partnership, two essential aspects of midshipmen training during distant journeys. However, when asked for the perception of the safety of tourniquet use onboard, the participants' response reveals concerns of causing ischemic damage to limbs with tourniquet use and apprehension regarding the safety of these devices in isolated maritime environments. These worries could be understandable considering the remote location and the limited availability for advanced surgical care. It is worth commenting that tourniquet application both in the field and in isolated scenarios is a temporary bleeding control measure that, as soon as possible, should be re-evaluated and possibly replaced with a hemostatic dressing or other methods of definitive bleeding control.
Even though there was no direct measure of the teaching success of the activity onboard the sailing ship, the authors consider that the educational value of performing hands-on supervised training with four different commercial tourniquets while navigation in high sea conditions is precious. The participants had no prior experience using ET during navigation, so it served as an initial pedagogic experience that should be enhanced in future training. Martinez et al. describe a useful performance score for ET training programs that includes a scale with four categories: effectiveness, total placement time, tourniquet pre-positioning, and tourniquet preparation . However, his score is described to measure the impact of a refresher course on deployed soldiers with prior ET training in a non-maritime environment. The conditions in which our study was developed made its application impracticable. Nonetheless, it does highlight the benefit of progressive learning and performing knowledge refreshing training sessions on newly deployed military personnel. These findings are similar to those reported by Kragh et al. advocating for basic training early during the soldiers' formation and later in-depth retraining with refresher training before any deployment . Our workshop attempted to issue basic training to the future naval officer without prior ET application experience during navigation, creating a foundation for future and progressive skill acquirement. This gradual learning of basic PHEM principles by future navy officers during the semester at sea activities should be reproduced by other naval sail ships.
Several countries have training sail ships in their Navy's (U.S Coast Guard the "USCG Eagle," German Navy the "Gorch Fock," Royal Australian Navy the "Young Endeavour," Italian Navy the "Americo Vespucci," Indian Navy the "INS Tarangini," Bolivarian Navy of Venezuela the" Simon Bolivar," Japanese Navy the "Kaiwo Maru," Peruvian Navy the "BAP Union," and Polish Navy the "Dar Młodzieży," Chilean Navy "Esmeralda"). However, this type of workshop has not been previously reported in any of them to our knowledge. Naval training sail ships offer future navy officers a realistic scenario for training maritime PHEC principles, and ET application workshops are an essential part of such training. This specific bleeding control training better prepares them for potential injuries during high sea navigation in an isolated maritime environment, considering that the oceans are the largest wilderness areas on earth. Even during non-hostile training tours, sailing with adverse weather can cause serious injuries resulting from broken sail lines under tension, leading to soft tissue lacerations and severe extremity hemorrhage . Future naval officers must also prepare themselves for potential maritime hostile activities exposing them to penetrating extremity trauma and blast injuries.
Training PHEC and ET applications while navigating high seas vary considerably with customary practice conditions of land troops. Constant and irregular vessel motion can unfavorably condition tourniquet application simplicity. Our study reported higher application ease for the windlass models in high sea conditions. There are few reports of extremity tourniquet application by naval units to which compare our results. Heldenberg et al. (2015) published their study evaluating three tourniquet types (CAT, Special Operations Force Tactical Tourniquet "SOFTT" and an improvised device) among 23 operators of the Israeli Naval Defense Forces . Their findings regarding application simplicity were similar to ours, with CAT and SOFTT, both windlass type tourniquets graded as higher for simplicity of application. However, their study compared windlass ETs with an improvised elastic model; participants were experienced navy special forces operators, and their study was not performed during high sea navigation, so direct comparison of both study results is not adequate. Our results show that even without prior training, the JSE midshipmen considered the two windlass type tourniquets (CAT and SAM-XT) easier to apply than the elastic model in navigating conditions. Concerning device preference, again, the results favor the windlass mechanism commercial tourniquets for self-application and buddy-application in a maritime environment. The constant ship movement during high sea states different from the land application, and the simple windlass tourniquet securing system may have influenced participants' choice.
Limitations of this study include the lack of participation of all the midshipmen aboard. The limited time dedicated to the hands-on practice and that the attendee's responses and preferences were based on personal perceptions. The lack of assessment of how different weather conditions and vessel movement affected the ease of tourniquet application. Furthermore, due to the study conditions, there was no direct measure of the teaching success. However, our workshop's participants' perceptions about its usefulness, content adequacy, overall satisfaction, and onboard tourniquet use safety suggest convenience. The workshop added valuable tourniquet application training in high sea conditions to future navy officers. Future research should be directed at developing maritime M-PHEC educational programs on other training sail ships and designing methods for evaluating such programs' teaching success. The researchers should also develop and test more tourniquet models and hemostatic agents specific to the unique maritime environment.