Accuracy of Needle Chest Decompression Site Selection in Simulated High Stress Environments Among Air Force...

Tension pneumothorax (tPTX) is a life-threatening but treatable condition in combat environments, where survivability depends on rapid and accurate needle chest decompression (NCD). However, prior research shows a notable gap between clinical knowledge and hands-on procedural skills, with NCD site selection accuracy as low as 26.1% among military medics. This study's purpose was to evaluate the overall accuracy of NCD site selection among active duty military medical professionals in a novel, simulated high-stress combat environment. This study aimed to determine if environmental stressors affect procedural accuracy and to identify potential training deficiencies.

This prospective, randomized controlled trial (RCT) was approved by the Naval Medical Center San Diego (NMCSD) Institutional Review Board (IRB). We randomized 75 military medical professionals into a control group (well-lit, quiet room) and a high-stress group (darkened room with red light and auditory distractions). Participants were tasked with marking the 4 designated NCD sites (second intercostal space, midclavicular line and fifth intercostal space, anterior axillary line, bilaterally) on 6 live male models. We defined accuracy as a mark falling entirely within a predetermined 6 cm by 2 cm zone. We used Welch's 2-sample t-tests and linear regression to analyze accuracy data, and a Wilcoxon Signed-Rank test to compare the perceived ease of site selection.

The study found no statistically significant difference in overall NCD site selection accuracy between the high-stress and control groups (P = .7), with both groups achieving a low average accuracy of 31%. However, a significant difference was observed between the 2 anatomical sites, with accuracy at the 2ICS being substantially higher (41%) than at the 5ICS (21%) (P < .001). Participants reported no significant difference in the perceived ease of locating the 2 sites (P = .105), revealing a gap between self-perception and actual performance. We also found that real-life NCD experience was a significant predictor of overall accuracy (P = .044), though this finding is limited by the small number of participants with this experience (n = 2).

A simulated high-stress environment did not affect NCD site selection accuracy in this population. The significant difference in accuracy between the 2 sites, combined with the lack of difference in perceived ease, suggests that current Tactical Combat Casualty Care (TCCC) training may be inadequate, particularly for the 5ICS site. Our study's strengths include its randomized design and the use of live models, but it is limited by its single-center recruitment and the small sample size for real-life experience. These results underscore a critical need for improved hands-on training methods, such as cadaver-based learning, to ensure military medical professionals can competently perform NCD under all conditions. Future studies should explore the impact of different training methods and the influence of body habitus on site selection accuracy.