Context

Uncontrolled hemorrhage is a major cause of preventable death. Wound care and managing external hemorrhage are important skills for athletic trainers.

Objective

Describe a laboratory activity used to allow students to practice managing uncontrolled external hemorrhage and wound packing.

Background

The prevalence of active shooter and other mass casualty events has grown, and a trend to move military-based emergency skills into civilian casualty care has emerged. Athletic trainers are uniquely positioned to respond to catastrophic events at the time of injury. Controlling hemorrhage and rapidly applying a tourniquet or administering wound packing have a great effect in preventing death due to severe hemorrhage.

Description

An educational technique using a pork shoulder was implemented to provide students with experience in wound packing.

Students describe this activity as a beneficial way to gain experience on an important skill not often seen in the clinical education setting.

Conclusion(s)

Faculty may consider implementing wound packing using a pork shoulder as a laboratory activity when teaching wound care and external hemorrhage management.

• Uncontrolled hemorrhage leads to death if left untreated. Wound packing can be used to manage external hemorrhage.

• Athletic trainers may be exposed to mass trauma events with external hemorrhage and must be prepared to treat patients with external hemorrhage.

• Using a pork shoulder with simulated blood provides students with a realistic activity to practice wound packing.

Over the last decade, a surge in mass casualty events has resulted in injury and severe hemorrhage, from bus crashes, bombings, and even active shooters. Uncontrolled hemorrhage is the most common cause of preventable deaths after trauma.1,2  An individual can die from blood loss within 3–5 minutes with severe hemorrhaging.3  Controlling hemorrhage as soon as possible after an injury through direct pressure, tourniquet use, wound packing, or hemostatic dressings improves outcomes and saves lives.4,5  While these instances are not common, it is important for athletic trainers to understand how to deal with traumatic wounds because although emergency medical services (EMS) respond quickly, athletic trainers are positioned to be the first on the scene in many of these cases.

Wound care is an important skill for athletic trainers. In the 2020 Commission on Accreditation of Athletic Training Education (CAATE) Standards for accreditation of professional athletic training programs,6  Standard 70 states:

Evaluate and manage patients with acute conditions including triaging conditions that are life threatening or otherwise emergent. These include (but are not limited to): Internal and External Hemorrhage (including use of tourniquet and hemostatic agents) and Wounds (including care and closure).6(p13)

Athletic trainers need to demonstrate competence in managing external hemorrhage even though extreme external hemorrhage is not something seen daily in athletic training. The American College of Surgeons Committee on Trauma strongly recommend tourniquets to control significant hemorrhaging if direct pressure is ineffective or impractical.1,7,8  Tourniquets are commonly used as an early option to control external hemorrhage and have a great deal of evidence to support their use. However, tourniquets cannot be used in junctional areas such as the neck, groin, or axilla; therefore, other options, such as wound packing and hemostatic dressing, are necessary.9

Wound packing is the process of using cloth or dressing, such as sterile packing gauze, to fill a soft tissue wound to compress the bleeding vessel enough to control hemorrhage.10  Hemostatic dressings are gauzelike dressings containing an agent to enhance the natural clotting cascade and are used to supplement traditional wound packing materials to promote clot formation while providing direct pressure.11,12  There are 3 primary types of hemostatic dressings: factor concentrators, mucoadhesive agents, and procoagulant supplementers. Factor concentrators absorb fluid content in the blood while simultaneously promoting clot formation; examples of these include QuikClot (Z-Medica, Newington, CT) and TraumaDex (MedaFor Inc, Minneapolis, MN). Mucoadhesive dressings, such as Hemcon (Tricol Biomedical, Inc, OR) or WoundStat (TraumaCure, Inc, Bethesda, MD), react with blood to physically adhere to tissue and seal the bleeding wound. Procoagulant supplementers enhance coagulation by delivering procoagulant factors such as thrombin, fibrinogen, and calcium to the wound to stimulate the intrinsic coagulation cascade.11,13  QuikClot Combat Gauze (Z-Medica, Newington, CT) is an example of a procoagulant. Hemostatic dressings can stop bleeding within 2 minutes, do not require any mixing or other preparation, are simple to apply, and are inexpensive.12

Wound packing has historically been used in the military setting and is now becoming more prevalent in tactical EMS and civilian EMS teams.9  The American College of Surgeons Committee on Trauma has recommended that prehospital personnel are trained in hemostatic agents, proper wound packing, and pressure application techniques to enhance patient outcomes.1  Additionally, the Stop the Bleed campaign14  teaches lay responders how to apply direct pressure, pack wounds, and apply tourniquets. Due to the rising prevalence of life-threatening bleeding and serious disasters to which athletic trainers may be exposed, it is important for athletic training programs to include these skills in the curriculum and find effective ways to teach these skills. One approach to provide students with a realistic experience for wound packing is to create a wound packing simulator using a pork shoulder with simulated blood and allowing students to practice packing a wound to stop external hemorrhage. The purpose of this paper is to describe an educational technique using wound packing for athletic training students. In accordance with the Common Rule and federal definition of research, the university institutional review board did not require review of this educational strategy because it was an educational technique that was completed as a part of educational practice and was not considered research.

This laboratory activity was integrated into an emergency care for the athletic trainer course as a part of a larger section dedicated to wounds and emergency wound care. This course occurs in the students' first semester in the athletic training program. Before the wound care section, students learned about recognizing and treating shock; therefore, they had knowledge of hemorrhagic shock and the importance of managing hemorrhage. For this lab, students had stations in which they performed various wound care tasks, such as wound irrigation, wound debridement, basic wound closure using wound closure strips, and wound packing. The focus of the wound packing station was to provide students with experience in controlling acute hemorrhage and packing a wound for stabilization (Figure 1). Before beginning the lab, the wound packing activity was thoroughly described to students, and students were aware the wound they were packing was a pork shoulder. Students were safe to opt out of packing the wound for any reason, such as religious or ethical reasons. Students who opted out could use a hemorrhage control trauma trainer (eg, Simulaids,15  NAR Wound management simulator16 ) to gain experience packing wounds (Figure 2).

### Materials Needed

While students need to learn and practice packing a wound, educators cannot inflict injuries on students to make a realistic learning experience. Using a pork shoulder is a good replacement, as pork shoulders are easily found in the meat section of a local grocery store, ranging from $9 to$12 depending on size, approximately 1.13–1.36 kg (2.5–3 pounds). A bone-in pork shoulder with the skin on 1 side makes the model appear more realistic. If institutions are unable to procure pork shoulders or the Institutional Animal Care and Use Committee determine the use of pork models is not permitted, other options can be used. For example, Simulaids (Z-Medica)15  and North American Rescue16  have each developed hemorrhage control trauma trainers for approximately $350 that can be used for wound packing. However, often, commercial wound packing simulators do not have active bleeding. Therefore, these wound simulators do not create the stressful or time sensitive environment as options with higher fidelity. A budget friendly option to replicate a wound is to use a pool noodle with a dowel rod in the middle to simulate soft tissue surrounding the bone. A small foam roller could also be used. Educators can even use simulated skin (eg, rubber shelf liner, rubberized replacement skin from Simulaids, elastic resistance band) to make the limb more realistic (Figure 2). Additionally, an intravenous (IV) bag with simulated blood can still be placed inside the pool noodle to increase fidelity. Simulated blood is another item needed for this laboratory activity. We used Simulaid Simulation Blood Packet, which costs approximately$15–\$20 for a packet that makes approximately 3.79 L (1 gallon).17  We have found that 1 pack of blood is sufficient for 1 lab because we typically use a little over 1.89 L (0.5 gallon) of simulated blood with 2 pork shoulder stations with 25 students. Blood is made using the blood packet and hot and cold water. The blood is then placed in IV bags with the tubing clamped shut. Simulated blood can also be prepared using items found in the local grocery store, such as corn syrup, food coloring, and cocoa mix or dissolved gelatin for thicker blood. Additional items for this activity are outlined in Table 1 and Figure 3.

### Lab Preparation

#### Environment

This activity can be very messy because of the simulated blood, so the lab space should be prepared by lining the table or floor with plastic tablecloths or trash bags.

#### Simulated Blood and IV Tubing

Simulated blood is prepared as instructed by the packet or recipe. The simulated blood is then placed in an IV bag with tubing and a clamp. The IV tubing will serve as the “vessel”; therefore, before threading the tubing through, make a 1.27-cm (0.5-inch) slit into the tube to allow students to feel the ruptured vessel. This should be done immediately before inserting the IV vessel into the pork shoulder so the blood does not leak out of the IV tube.

#### Pork Shoulder

Once the blood is prepared, the pork shoulder should be placed on the desired surface (eg, table or floor). To make cleanup easier, a disposable roasting pan is a good option to contain most of the blood; however, it decreases the fidelity.

The pork shoulder should be placed skin side up, and a scalpel is used to make deep lacerations (approximately 5–7.5 cm [2–3 inches] deep; approximately 7.5 cm [3 inches] long) into the tissue (Figure 4). Make an additional cut on the side of the pork shoulder and thread the IV tubing through the side cut through to the large laceration (Figure 5). This may require multiple cuts. The ruptured vessel of the IV tube will be placed under the laceration in the pork shoulder. This will provide students with the ability to feel the bleeding decrease when good direct pressure is applied, which increases realism. Once the IV tube is in the large laceration, unclamp the tubing and squeeze the IV bag to saturate the wound with blood. Once saturated, close the clamp on the IV tube until ready to use.

### Instruction and Teaching the Skill

As a part of the wound care section in this course, students learned how to manage hemorrhage and wounds. Before beginning this laboratory, the steps for managing hemorrhage were reviewed (Table 2). In pairs, students were instructed to go through the steps of managing hemorrhage on the pork shoulder (Figures 69).

Before students begin the wound packing station, the IV tube is unclamped, and IV bag is squeezed by the instructor to saturate the wound with fresh blood as students prepare to pack the wound. Throughout the activity, the instructor should continuously saturate the pork shoulder with blood until the students are able to find the bleeding vessel and apply compression directly to the vessel. Once the vessel is compressed, the instructor lightens the squeezing of the IV bag to simulate the decreased bleeding associated with quality direct pressure. This was evaluated based on the location and depth of the fingers. If students did not maintain good, focused pressure during wound packing, the instructor continued squeezing the IV bag, and bleeding continued. Focused pressure was evaluated by observing the students' perceived depth of the fingers and the ability to reduce the blood in the wound. If the students removed their fingers from the wound, the wound continued to bleed. Once the hemorrhage was controlled, the wound was packed and secured and the students' ability to complete the steps from Table 2 was checked by the instructor. Once checked, the students unpacked the wound, cleaned up all material, and placed materials in a biohazard bag. The instructor then prepared the station for the next group of students by squeezing fresh blood into the wound.

This activity can also be advanced by changing the environment because most patients will not have a wound contained on a treatment table in a well-lit area. Examples of changing environments to challenge students include changing the amount of light or noise, positioning the pork shoulder as if a patient was trapped under a table or another limited-access area, moving the activity outside, or positioning the pork shoulder next to a real patient and draping to simulate a patient with a deep wound (Figure 10). Figure 11 provides example scenarios that can be used with this activity.

One consideration for this activity is the use of hemostatic agents, which are recommended when packing a wound. Hemostatic agents can be used in this activity to provide students the opportunity to practice with these products; however, the hemostatic agents will not react with simulated blood and will not be as beneficial for demonstration purposes. If hemostatic agents are used during this activity, students should understand how these agents will react differently in an actual wound with real blood.

Overwhelmingly, students responded favorably to this laboratory activity. This course activity did not include any formal assessments; however, students commonly reported this laboratory activity was their favorite part of the course, and many students stated that they felt more prepared to manage external hemorrhage. After the activity, students were asked to provide informal feedback directly to the instructor. Students also provided formal feedback on their course evaluations. For direct quotes, students provided their consent to have their comments included in this article. Students commented on many benefits of this activity, such as helping them practice their wound packing skills, remembering various aspects of managing hemorrhage (eg, wearing gloves, compressing the bleeding vessel), and learning how to manage a stressful injury in a low-stress environment. One student stated:

The wound packing lab we completed in the emergency care class was extremely beneficial for me in that it provided me with a semirealistic scenario of packing a wound. The pork shoulder we used continuously bled until we could find the source of the bleeding and pack the wound with gauze. It demonstrated how it would physically feel to pack a wound as well as taught me how much pressure to use and how to quickly and efficiently pack a deep wound.

Another student commented:

The wound packing lab we did in our emergency care class allowed me to learn how to properly pack a wound while also having fun with it. I believe that having hands-on time in a lab is important in helping learn the skill, and the wound packing lab with the pork shoulder allowed for a good learning experience on how to pack a wound.

Another student stated:

This wound packing lab showed me just how much packing you need to do to stop a wound of this severity. This lab really displayed the intensity of these situations, and you quickly realize that, as you go along, you need to do more than you imagined to get the bleeding under control. As far as labs go, I couldn't think of a better way to simulate such an emergent situation.

Another student commented:

The wound packing lab was fun. I honestly thought it would be easy to find the “vessel” and stop the bleeding, but I was wrong. It was tough to find and stop the bleeding when you couldn't fully see what you were touching. I could only hope I was in the right area by looking for signs that the bleeding had minimized or stopped. Thanks for an awesome and informational lab!

While these are anecdotal outcomes, future research should further explore confidence levels before and after the activity with wound packing as well as further exploring perceptions of the activity.

This activity was used to develop skills in packing wounds; however, the steps and skills required could be assessed to ensure competence. Instructors could assess student learning of the skill by using a checklist (Table 2) to ensure students successfully complete each step of the activity. Additionally, a hybrid standardized patient experience could be used, which would require the student to complete the technical skill of packing the wound while also ensuring he or she is taking care of the patient holistically (eg, monitoring vitals). This could be done as a learning experience or as a practical examination.

This activity has been successfully implemented for both classes and conferences, and lessons have been learned along the way. This activity can be messy; therefore, adequate time (ie, 30–60 minutes) must be allotted before the activity to prepare the area, blood, and pork shoulder. During cleanup, triple bagging the pork shoulder before disposal helps keep the blood contained. We have found students are more successful with packing the wound when reviewing all the steps of wound packing before the activity. Additionally, it is necessary to have alternative activities, as described previously, for individuals who are uncomfortable or unable to use the pork shoulder. Ways to further enhance this activity include assessing the skill, developing interprofessional education experiences, and using a hybrid standardized patient experience.

Despite the importance of being able to manage severe external hemorrhage efficiently and effectively, students do not often engage in this type of wound management during clinical education experiences. Severe external hemorrhage is not limited to active shooter or mass casualty events and can occur as an isolated event during regular athletic activities, such as lacerations and incisions from ice skates, metal, or glass. Therefore, athletic training educators need to simulate this experience to ensure students can manage external hemorrhage if necessary. Using a pork shoulder with simulated blood can provide a valuable and worthwhile experience for students on a skill not often seen during clinical education. Faculty may consider using this educational technique to ensure CAATE standards6  are met related to this topic.

While this activity was done in an athletic training laboratory setting, there are ways to expand this activity through collaborations with emergency medical care students or nursing students. Some nursing programs have implemented the Stop the Bleed campaign14  into nursing curricula to teach emergency preparedness for mass casualty events.18  An interprofessional simulation experience in which athletic training students pack the wound and then nursing students act as emergency department nurses to treat the wound could be a valuable learning experience for both athletic training and nursing students. Athletic training faculty are encouraged to seek out additional ways in which this activity could be used interprofessionally.

Athletic training programs must prepare students to manage wounds and external hemorrhage.6  Athletic trainers are on the frontlines and may be perfectly poised to respond in a mass casualty and other life-threatening situations and therefore should be trained in hemostatic agents, proper wound packing, and pressure application techniques to enhance patient outcomes.1  Students perceived a wound packing laboratory activity as a valuable learning opportunity to provide experience with a vital skill that is not often seen in clinical education. This activity is a simple but effective way to enhance skills in managing external hemorrhage.

1.
Bulger
EM,
Snyder
D,
Schoelles
K,
et al
An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma
.
Prehosp Emerg Care
.
2014
;
18
(2)
:
163
173
.
2.
Zwislewski
A,
Nanassy
Meyer
LK,
et al
Practice makes perfect: the impact of Stop the Bleed training on hemorrhage control knowledge, wound packing, and tourniquet application in the workplace
.
Int J Care Injured
.
2019
;
50
(4)
:
864
868
.
doi:10.1016/j.injury. 2019.03.025.
3.
Limper
L,
Lee
S.
Planning for injuries from an active shooter emergency—part 2
.
Board of Certification for the Athletic Trainer Web site
.
Published September 26, 2019. Accessed September 3, 2021.
4.
Holcomb
JB,
Butler
FK,
Rhee
P.
Hemorrhage control devices: tourniquets and hemostatic dressings
.
Bull Am Coll Surg
.
2015
;
100
(1 Suppl)
:
66
70
.
5.
Kheirbek
T,
Monaghan
SF,
Benoit
E,
Lueckel
SN,
CA
Jr.
Advances in the management of bleeding trauma patients
.
R I Med J
.
2019
;
102
(8)
:
30
33
.
6.
2020 standards for accreditation of professional athletic training programs
.
Commission on Accreditation of Athletic Training Education Web site
.
Published 2018. Accessed September 3, 2021.
7.
Brinsfield
KH,
Mitchell
E
Jr.
The Department of Homeland Security's role in enhancing and implementing the response to active shooter and intentional mass casualty events
.
Bull Am Coll Surg
.
2015
;
100
(1 Suppl)
:
24
26
.
8.
Jacobs
LM,
McSwain
N,
Rotondo
M,
et al
Improving survival from active shooter events: the Hartford Consensus
.
Bull Am Coll Surg
.
2015
;
100
(1 Suppl)
:
32
34
.
9.
Bolleter
S,
Heightman
AJ,
Taillac
PP.
Wound packing essentials for EMTs and paramedics
.
Updated April 1, 2017. Accessed date September 3, 2021.
10.
Drew
B,
Bennett
BL,
Littlejohn
L.
Application of current hemorrhage control techniques for backcountry care: part one, tourniquets and hemorrhage control adjuncts
.
Wilderness Environ Med
.
2015
;
26
(2)
:
236
245
.
doi:10.1016/j.wem. 2014.08.016.
11.
Granville-Chapman
J,
Jacobs
N,
Midwinter
MJ.
Pre-hospital hemostatic dressings: a systematic review
.
Injury
.
2011
;
42
(5)
:
447
459
.
doi:10.1016/j.injury. 2010.09.037.
12.
Payne
EK,
Berry
DC,
Seitz
SR.
Educating the educator: use of advanced bleeding control mechanisms in athletic training: a shift in the thought process of prehospital care—part 2: hemostatic agents
.
Athl Train Educ J
.
2014
;
9
(4)
:
193
201
.
13.
Littlejohn
L,
Bennett
BL,
Drew
B.
Application of current hemorrhage control techniques for backcountry care: part 2, hemostatic dressings and other adjuncts
.
Wilderness Environ Med
.
2015
;
26
(2)
:
246
254
.
14.
Stop the Bleed
.
U.S. Department of Defense, Defense Health Agency Web site
.
Accessed September 3,
2021
.
15.
Simulaids Z-Medica QuikClot Trauma Trainer
.
AED Superstore Web site
.
Accessed September 3,
2021
.
16.
NAR Wound Management Simulator
.
North American Rescue Web site
.
Accessed September 3,
2021
.
17.
Simulaid Simulation Blood Powder
.
School Health Web site
.
Accessed September 3,
2021
.
18.
Varanelli
V,
Basilio
M,
Breda
K.
Teaching nursing students to Stop the Bleed emergency preparedness education for mass casualty events
.
Teach Learn Nurs
.
2019
;
14
(4)
:
288
290
.
19.
Strapp
E.
Beyond direct pressure: evidence-based practice for shock and advanced wound care
.
Lecture presented at Mid-Atlantic Athletic Trainers' Association Annual Symposium
.
May 18,
2018
;
Ocean City, MD.