Out of unspeakable tragedy comes progress in bleeding control

In December 2012, the world witnessed the unspeakable—the fatal shooting of 20 children and six teachers and administrative staff at Sandy Hook Elementary School in Newtown, CT. The nation was shocked by this senseless act, but in many ways Sandy Hook was a tipping point. Several individuals and organizations began to consider ways to improve survival from these horrific situations.

Among those organizations was the American College of Surgeons (ACS), which has since launched a significant effort to improve survivability from mass casualty situations. This article summarizes the College’s role in this ongoing effort and provides an update on the initiative.

Background

Shortly after the Sandy Hook shooting, the ACS Board of Regents approved the establishment of the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events. The committee first met April 2, 2013, and early control of hemorrhage was identified at this meeting as critical to improving survival.

After the Boston Marathon bombing later that month, the committee’s efforts were expanded to focus on improving survival, not just from active shooter events, but all intentional mass casualty events. In early 2016, the mission was further expanded to include all causes of bleeding, such as unintentional, everyday accidents.

The committee has met four times, and its recommendations are collectively known as the Hartford Consensus.^1-4 The chief tenet of the Hartford Consensus is that no one should die from uncontrolled bleeding.

In October 2015, the White House launched the Stop the Bleed^® campaign, and the Hartford Consensus played a foundational role in this initiative.⁵ The goal of the Stop the Bleed campaign is to promote national resilience by empowering the general public to acquire the skills and confidence to control bleeding in emergency situations—from mass casualty incidents to everyday events—where bleeding control can save lives.

Engagement of law enforcement

In the past, law enforcement’s exclusive duties in active shooter and other intentional mass casualty incidents were to subdue the perpetrator and preserve evidence at the crime scene. Once the police declared the scene to be safe, emergency medical services (EMS) personnel were permitted to enter the area and provide care to victims.

Needless to say, victims in these situations could bleed to death waiting for medical attention. Modification of operational strategies was needed for hemorrhage control to become a core responsibility of law enforcement.

To achieve this objective, law enforcement leaders had to be willing to consider this modification. A member of the Hartford Consensus, Alexander Eastman, MD, FACS, a trauma surgeon and police lieutenant from Dallas, TX, propagated the idea to the Major Cities Chiefs Association (MCCA). The MCCA is a professional organization of police chiefs and sheriffs from the largest cities in the U.S., Canada, and the U.K. It serves as a forum for police executives to share matters related to policing large urban areas. An additional purpose of this group is to influence national law enforcement policies.⁶ The MCCA was critical in bringing about the policy change so that hemorrhage control is now viewed as a responsibility of police officers.

Once law enforcement leaders accepted this change, an educational and an operational strategy had to be implemented to achieve the hemorrhage control objective. An educational course was developed, which was adapted from the Tactical Combat Casualty Care (TCCC) course. The TCCC program teaches members of military combat units to manage trauma on the battlefield.⁷ All soldiers who are deployed to an active theater are educated in bleeding control techniques and provided with an individual kit, which they are required to carry on their person. The kit contains personal protective equipment, tourniquets, hemostatic dressings, and a bandage.

The MCCA has modified and implemented the TCCC process in its bleeding control training, which has now been successfully deployed in police departments across the U.S. More than 300,000 law enforcement officers have been trained and equipped with individual bleeding control kits. There have been numerous reports of patients who have had life-threatening hemorrhage controlled by law enforcement officers, with successful outcomes.⁸

Engagement of EMS

A second initiative in the national Stop the Bleed campaign, at the recommendation of the Hartford Consensus, was to enable EMS personnel to render care earlier in the medical response process. More specifically, part of the initiative sought to change the standard procedure of having EMS personnel remain on the periphery of an event until the scene was clear of risk and secure before rendering care.

Although this new approach appeared to be a logical concept, implementation was fraught with challenges. For instance, EMS personnel are not trained or equipped with gear to protect them from firearms or explosives, nor are they trained to preserve evidence at a crime scene. Before this recommendation could be put in place, it was important that the committee engage in considerable discussion regarding the risks and merits of deploying EMS personnel to an unsecured, active crime scene.

The compromise that emerged from this debate was that bleeding patients would be taken from the Red Zone—or highly dangerous area—to the Yellow Zone, which is secure but not totally safe. In the Yellow Zone, immediate professional medical care would be initiated by trained and appropriately equipped EMS providers. This process was facilitated by Richard Serino, former Deputy Administrator of the Federal Emergency Management Agency (FEMA), and implemented under the direction of Ernest Mitchell, U.S. Fire Administrator.⁹

Engagement of the public

A third recommendation from the Hartford Consensus centered on public engagement. The primary directive of the Stop the Bleed campaign was to recognize that for the first few minutes following a major hemorrhage-producing injury, victims and bystanders can take action to control and limit blood loss. This concept became known as immediate responder hemorrhage control.

Support for the public to act as immediate responders was documented in a national poll of a representative sample of the general public in the U.S.¹⁰ In all, 92 percent of the respondents to the Hartford Consensus survey said they would be very likely or somewhat likely to try to stop bleeding in someone they did not know. When asked if they would provide assistance in a mass shooting event, 94 percent of respondents said they would try to stop bleeding if it seemed safe to do so. Interest in learning bleeding control techniques was substantial, with 82 percent of respondents indicating they would be interested in attending a local two-hour class on bleeding control and other first-aid techniques. The survey results indicate that the public is willing to help bleeding individuals and is keen on learning how to do so.¹⁰ Strategies are needed to inform, educate, and empower laypeople to act as immediate responders for hemorrhage control.

Bringing bleeding control to the public

Based on the results of the survey, the ACS and other contributors to the Hartford Consensus determined that now is the time to train the public to be immediate responders at mass casualty events.

Bleedingcontrol.org

The ACS designed and implemented a website, bleedingcontrol.org, which contains a compendium of the four Hartford Consensus documents, including Barack Obama’s Presidential Policy Directive that addresses national preparedness and resilience, among other resources (see Figure 1).^11-12 Multiple government agencies, including the U.S. military, the Department of Homeland Security, FEMA, the Federal Bureau of Investigation, and the National Security Council, provided guidance to the consensus findings. Bleedingcontrol.org also includes a list of Hartford Consensus partners.

Figure 1. Bleedingcontrol.org home page

In addition, the site serves as a comprehensive repository of bleeding control resources. Free educational materials such as videos, diagrams, and an instruction booklet are accessible from this website. A list of bleeding control classes offered throughout the country is available on the website, along with registration information.

Bleedingcontrol.org has an online store where bleeding control kits, wall-mounted stations for public places, and training materials and mannequins for practicing the techniques are available for purchase. The bleeding control kits contain an instruction booklet; a tourniquet; bandages, including hemostatic dressings; and protective gloves. All equipment in the kits meets the highest military-grade standard, and the U.S. Armed Forces have tested and deployed this equipment with positive results.

Because the kit meets the military’s high standards, the U.S. Department of Defense has authorized the ACS through a licensing agreement to co-brand the equipment. All the kits now bear the logos of the Stop the Bleed campaign, the ACS, the Hartford Consensus, and the ACS Committee on Trauma, which oversees the initiative on the College’s behalf. These endorsements assure the public that the equipment and the educational materials are of the highest quality.

The need to control bleeding is not limited to mass casualty situations, however, and the website is of equal value to individuals seeking bleeding control resources for everyday emergencies, such as motor vehicle crashes, machinery accidents, and so on.

Since the website launched in August 2016, bleedingcontrol.org has been accessed more than 100,000 times. Complementing the website is the Twitter account, @bleedingcontrol, which also launched in August 2016. The number of followers grows daily and stood at more than 1,600 at press time.

Hollywood lends a hand

On October 10, 2016, the cast of the CBS prime-time show Code Black gave a boost to our efforts with its CBS Cares public service Stop the Bleed promotion. The public service announcement (PSA), which aired that evening after Code Black, featured actors Rob Lowe and Marcia Gay Harden and was shown to millions of viewers on CBS affiliates throughout the U.S. Besides making a compelling case for having bleeding control kits on hand, the PSA prominently featured the bleedingcontrol.org web address.

B-Con courses

The ACS Committee on Trauma and the National Association of Emergency Medical Technicians are co-sponsoring a Bleeding Control (B-Con) course suitable for individuals without medical training.¹³ The course was developed under the leadership of Peter Pons, MD, FACS, and the late Norman E. McSwain, Jr., MD, FACS. B-Con, a two- to three-hour course, is specifically designed to teach people how to save a life before professional rescuers arrive on the scene, including methods to control bleeding and secure an airway.

An hour-long B-Con Basic course has been developed to train the public in the three ways to stop bleeding. These techniques include using one’s hands to apply pressure, using hemostatic dressings and other materials such as clothing to pack a wound, and applying a tourniquet to control severe bleeding from an extremity.

To successfully bring bleeding control education to the general public, a cadre of instructors and facilities is needed. To meet the anticipated demand, the ACS will now require its verified trauma centers to offer bleeding control courses to the public. As a first step toward achieving this goal, the College offered a course at Clinical Congress 2016 in Washington, DC, to teach surgeons how to educate the public to apply the principles of bleeding control in the field (see photos, this page). More than 300 surgeons were trained as instructors during the meeting. In addition, the Eastern Association for the Surgery of Trauma provided similar education at its Scientific Assembly in January 2017.

Bleeding control training efforts have evolved into an international collaboration. Physicians in the Netherlands, guided by the leadership of Prof. L. M. G. Geeraedts, Jr., MD, have trained 130 individuals in bleeding control, 56 of whom meet the criteria to be instructors. A website similar to bleedingcontrol.org is available for a Dutch audience at www.stopdebloedingredeenleven.nl.

One of the more exciting public awareness initiatives that is taking shape was spearheaded by a partner organization, Johnson & Johnson, which engaged the awarding-winning advertising agency of BBDO Worldwide to develop a campaign to raise public awareness about how anyone can help to save lives by learning the basics of bleeding control. The campaign includes creative posters, website banners, and t-shirts that convey this message. At press time, plans to roll out the campaign were being finalized.

Our work has just begun

Although this campaign is still a nascent operation in many respects, our work is gaining traction and attention both domestically and internationally. Requests come in daily from esteemed organizations that want to partner with us, offer training courses, or make bleeding control kits available for purchase. The ACS and other participants in the Hartford Consensus initiative are excited about these expressions of interest but mindful of the need to grow the program responsibly. Each decision must be made judiciously, with an eye toward ensuring the long-term sustainability of a high-quality, effective program.

Through the deployment of the Department of Defense’s Stop the Bleed campaign and the efforts of the Hartford Consensus sponsored by the ACS, excellent strategies to inform, educate, and empower the public to act as immediate responders in severe bleeding situations have been established. But our work has just begun. We must continue to raise the public’s awareness regarding how they can become immediate responders, increase the number of certified instructors, offer classes throughout the country to teach basic bleeding control, and secure funding so that we can provide training and bleeding control kits to underserved areas. (See “Bleeding control training: An opportunity for local volunteerism, community engagement, and peer education” for details about how an ACS Fellow is bringing bleeding control training to community centers in Upstate New York.)

Four years ago, the ACS took a leadership role in this endeavor. This leadership, along with that of our partners, is beginning to empower the public to be immediate responders who are trained to control severe bleeding from any cause.

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References

1. Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. Improving survival from active shooter events: The Hartford Consensus. Bull Am Coll Surg. 2013;98(6):14-16.
2. Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. Active shooter and intentional mass casualty events: The Hartford Consensus II. Bull Am Coll Surg. 2013;98(9):18-22.
3. Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events. The Hartford Consensus III: Implementation of bleeding control. Bull Am Coll Surg. 2015;100(7):20-26.
4. Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooter Events. The Hartford Consensus IV: A call for increased national resilience. Bull Am Coll Surg. 2016;101(3):17-24.
5. The White House. Office of the Press Secretary for President Barack Obama. Fact sheet: Bystander: “Stop the Bleed” broad private sector support for effort to save lives and build resilience. Washington, DC. October 6, 2015. Press release. Available at: obamawhitehouse.archives.gov/the-press-office/2015/10/06/fact-sheet-bystander-stop-bleed-broad-private-sector-support-effort-save. Accessed April 26, 2017.
6. Major Cities Chiefs Association. About. Available at: www.majorcitieschiefs.com. Accessed April 5, 2017.
7. National Association of Emergency Medical Technicians. TCCP-MP guidelines and curriculum. Available at: naemt.org/education/TCCC/guidelines_curriculum. Accessed April 5, 2017.
8. Hsieh A, Whooley S, Navarro K. When minutes matter: Lifesaving care in mass casualty incidents. Bound Tree University. Available at: bit.ly/2ok8bbw. Accessed April 5, 2017.
9. U.S. Fire Administration, FEMA. Fire/emergency medical services department operational considerations and guide for active shooter and mass casualty incidents. Available at: www.usfa.fema.gov/downloads/pdf/publications/active_shooter_guide.pdf. Accessed April 10, 2017.
10. Jacobs LM, Burns KJ, Langer G, Kiewiet de Jonge C. The Hartford Consensus: A national survey of the public regarding bleeding control. J Am Col Surg. 2016;222(5):948-955.
11. Obama B. Presidential Policy Directive/PPD-8: National Preparedness. Available at: www.dhs.gov/presidential-policy-directive-8-national-preparedness. Accessed April 10, 2017.
12. Biden JR, Jr. Letter from the Vice-President. In: Schneidman D (editor), Jacobs LM, Burns KJ (guest editors). Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium. Bull Am Coll Surg. 2015;100(1S):9.
13. National Association of Emergency Medical Technicians. Bleeding control for the injured (B-Con). Available at: www.naemt.org/education/B-Con/WhatIsB-Con.aspx. Accessed April 5, 2017.