Implementation of Bleeding Control Strategies for the Public

by | Sep 22, 2016 | Bleeding Control | 0 comments

Written by Brian E. Reilly, CL360 Founder & CEO

John Schoppmann

Recently, I was asked to speak at a luncheon for the Nassau County Municipal Police Chiefs Association, an organization comprised of local police agency heads including state, county and village police departments. I felt privileged to be able to share information on a very important topic – The Implementation of Bleeding Control Strategies for the Public. I don’t hesitate to repeat the message, because it’s not law enforcement sensitive; in fact, the whole notion is to increase awareness among the public about the topic.

This initiative is an outgrowth of many efforts over the last several years to improve survivability in intentional mass casualty incidents, such as the Boston Marathon bombing and Sandy Hook School shooting.

Personally, I have been involved with the issue of medical preparedness for a number of years now; in my last assignment with the NYPD, I participated in counter-terrorism and emergency management measures for the New York City public school system. This included a fairly robust training program for police officers, school security personnel and school staff, where the primary emphasis was on response measures for active shooter and intentional mass casualty events.

The 3 main categories essentially were:

  • Advanced firearms tactics for police officers
  • Medical response to address the critically injured
  • Building response protocols at the affected site, including lockdowns and evacuations

The fact is that our nation’s threat from intentional mass casualty events remains elevated. And so, there are a few overarching principles when we talk about responding to – and mitigating – these types of incidents, once they’ve already occurred:

  1. The name of the game is to IMPROVE SURVIVABILTY in IED, active shooter and intentional mass casualty events!!
  2. This is accomplished by STOPPING THE KILLING (law enforcement naturally has the role to neutralize the subject)… and then by STOPPING THE DYING (where potentially anyone may have a role in caring for the wounded, personal safety permitting.)
  3. Those bystanders present at the point and time of the wounding are generally in the best position to respond to the initial hemorrhage control needs of the wounded.
  4. Enhancing public resilience to these types of incidents has become a PRIORITY for national preparedness, namely, empowering the public to provide appropriate care through education and the strategic placement of life-saving equipment.

The effort to enlist the assistance of the general public is entirely consistent with the National Preparedness Goal in Presidential Policy Directive 8; PPD 8’s objective is to get the whole community — not just first responders — involved in immediate response measures to save lives, and meet basic humans needs in the aftermath of a catastrophe.

Perhaps the biggest impetus behind the notion of getting the public more involved with addressing the hemorrhage control needs of victims is the “Hartford Consensus”. The Hartford Consensus is a series of published opinions & recommendations based on a number of meetings led by the American College of Surgeons; this was in response to the Sandy Hook School shooting, and other intentional mass casualty events.

  • A major theme was that NO ONE should die from uncontrolled bleeding.
  • One of the biggest takeaways is that bleeding control is the responsibility of the public, and that it is well within their capabilities.
  • Their slogan is “IF YOU SEE SOMETHING… DO SOMETHING!”

They describe 3 levels of responders:

  1. IMMEDIATE RESPONDERS (teacher, security guard, bystander)
  2. PROFESSIONAL FIRST RESPONDERS (police, fire, EMS)
  3. TRAUMA PROFESSIONALS (ER staff, surgeons)

Performance expectations would naturally depend on the level of responder, and supplies available at the time. For instance, layperson John Q Citizen – without any equipment – could be expected to apply direct pressure to a bleeding wound with both hands, until a first responder arrives. The first responder would then be expected to have access to more sophisticated supplies (tourniquet, hemostatic dressing) and know how to properly apply them, taking over care of the patient. In the future, more and more of the public will become knowledgeable about how to use medical supplies such as tourniquets, and these supplies will be more readily accessible in public places.

T.H.R.E.A.T.

The Hartford Consensus put forth an acronym, “THREAT”, to summarize the necessary response measures in sequential order.

The “T” in THREAT stands for THREAT SUPPRESSION, and the rest of the acronym deals with STOPPING THE DYING.

  • Threat suppression – law enforcement STOPS THE KILLING by neutralizing the subject(s)
  • Hemorrhage Control – (potentially everyone’s role)
  • Rapid
  • Extrication to Safety – moving casualties from areas of direct threat to less dangerous areas, or locations that have been deemed entirely safe
  • Assessment by Medical Providers – generally EMS or a Rescue Task Force (medics embedded with law enforcement); casualties are NO LONGER expected to remain untreated for significant periods of time until the area is completely secure
  • Transport to Definitive Care – Generally EMS removes patient(s) to the ER and they quickly go into surgery.  The new focus is on reducing the time between the first gunshot and the last ambulance door closing.

EDUCATION

A critical step in strengthening national resilience is to inspire the public to obtain bleeding control training through PSA’s and slogans; The U.S. Department of Homeland Security (DHS) has a nationwide program called “Stop the Bleed”. However, I surmise that it will take government at all levels, including the private sector to help this campaign get the traction it will require to become successful. The Hartford Consensus envisions that potential content distribution networks would include The Red Cross, The Medical Response Corps, The National Disaster Medical System, The National Guard, Boy & Girl Scouts, local health departments and emergency service agencies.

There is some good training out there in this field, including:

  • Tactical Combat Casualty Care (TCCC)
  • Tactical Emergency Casualty Care (TECC)
  • Law Enforcement/First Response Tactical Casualty Care (LEFR-TCC)
  • Bleeding Control for the Injured (B-Con)
  • First Aid through American Heart Association and American Red Cross (now cover tourniquet training)
  • CommandLogic 360’s Point-of-Wounding Care training

The Hartford Consensus also advocates that all potential responders should be able to recognize signs of life-threatening bleeding, including:

  • Pulsatile, or steady bleeding coming from the wound
  • Blood is pooling on the ground
  • The overlying clothes are soaked in blood
  • Bandages or makeshift bandages used to cover the wound are ineffective and becoming soaked with blood
  • Arm or leg is traumatically amputated
  • The patient was bleeding and is now in shock (unconscious, confused, pale)

Recommended topics of training for the public should include:

  • Actions to ensure personal safety including appropriate interactions with first responders/law enforcement
  • How to ID life-threatening bleeding
  • Use of hands to apply direct pressure
  • Proper use of hemostatic dressings that expedite clotting (e.g., QuickClot Combat Gauze)
  • Use of commercial tourniquets (e.g., CAT)
  • Use of improvised tourniquets as a last resort

EQUIPMENT

The Hartford Consensus further calls for the placement of public access hemorrhage control Kits – collocated with AED’s. This would include clear messaging and signage so it’s easily identified and accessed.

Potential sites for the bleeding control kits include:

  • Shopping malls
  • Museums
  • Schools
  • Theatres
  • Sports Venues
  • Transportation Centers
  • Remote areas or facilities where access will be delayed
  • Houses of worship

The kits should be secure but accessible, and supplies contained therein should be able to be used within 3 minutes.

Contents should include:

  • Personal protective gloves
  • Hemostatic dressing
  • Tourniquets
  • Pressure bandages

There is a call for public awareness of the aforementioned locations as “Bleeding Safe” communities, similar to “Heart Safe” communities that promote survival of out-of-hospital cardiac arrests.

CURRENT NATIONAL OPINION

In November 2015, HC conducted a national survey to about 1,000 people in all 50 states.

The results were encouraging:

  • Large majorities of able-bodied Americans report that they are willing to offer such aid, especially if training and supplies are made available.
  • There is broad support for further equipping and training first responders; many feel that bleeding control should be part of police officers’ duties.
  • Near unanimous support for the deployment of kits in public places

Some concerns were:

  • Getting injured during active shooter event
  • Causing greater pain or injury
  • Being responsible for bad outcomes
  • Contracting disease

These topics are generally addressed in most Casualty Care & Active Shooter courses.

In conclusion, there is a broad consensus that the public can and should act as immediate responders to stop major external bleeding – regardless of whether it’s caused by an act of violence, an accident or a natural disaster. We must do what we can to band together as a community in the aftermath of a catastrophe — stopping a preventable death through effective bleeding control is no exception!