A Call to Action to Develop Programs for Bystanders to Control Severe Bleeding

Abstract

Recent global events have once again turned the medical community's attention toward the preparedness for, and response to, acts of terrorism and intentional harm. These situations are an ever-present reminder of the perils of modern society. While large events will always attract the attention of mass media, countless smaller situations that never make the news will continue to forever alter the lives of those involved. Furthermore, such incidents of intentional harm, including active shooter events, suicide bombers, and terrorist attacks, occupy only a portion of the spectrum of traumatic injury, which remains the number 1 cause of death of Americans ages 1 to 46 years. 1 Severe bleeding represents a major cause of death of trauma patients and accounts for greater than 35% of prehospital deaths. 1 Knowledge of the profound effects of hemorrhage on the mortality and morbidity of trauma patients is not new. For nearly 2 decades, the US military, other global armed forces, along with the civilian tactical medicine communities, have realized the potential of early lifesaving hemorrhage control. Pioneered by the US Military's Committee on Tactical Combat Casualty Care (TCCC), 2 and adapted by the civilian Committee for Tactical Emergency Casualty Care (C-TECC), 3 the importance of early hemorrhage control and the ability to address immediately correctible causes of death has proven to save lives. Now considered standard for military and civilian tactical medical units, these concepts are being adopted by law enforcement and emergency medical services worldwide. 4 The Hartford Consensus (HC) series of expert recommendations recognizes the magnitude that uncontrolled bleeding poses and calls for all responders, including bystanders, to have the education and necessary equipment to stop severe bleeding, similar to how people are empowered to perform cardiopulmonary resuscitation (CPR) and use automated external defibrillators (AEDs) through public access defibrillation programs. The HC III guidelines stress the vital role played by those present in the immediate aftermath of an event resulting in traumatic injuries. 5 These individuals frequently provide immediate lifesaving aid to the injured, including the application of tourniquets, extracting the injured and providing temporizing care until first responder elements can take over. Historically referred to as bystanders, this term suggests the idea of being passive and without direct involvement. Actual experiences suggest the opposite, particularly in mass casualty events, where bystanders themselves function as impromptu responders. 6 Bystanders rushing to help the injured were documented in real time by the media in the immediate aftermath of the Boston Marathon bombings. The occurrence of this during other disasters has

Immediate response to major incidents: defining an immediate responder!

“…Although there are some differences between the experts and the public's views on feasible measures, the sum of all choices defines what an immediate responder should be able to do (Table 8). These findings are in line with earlier reports, of which some claim much more involvement by the public in the medical management of victims of MCIs [1,2,18,[22][23][24][25][26][28][29][30][31][32][33][34][35][36]. In this study, the Swedish public expressed a high willingness to get engaged in the treatment of victims by stabilizing fractures, neck and lower back, implementing a cervical collar, and defending against a perpetrator, which are tasks that were not approved by the expert group or is dangerous for their lives.…”

“…The Hartford Consensus aims to use this therapeutic window to address the number one most preventable cause of death after both military and civilian injuries, i.e., external hemorrhages, using multiple steps, such as education, empowerment, and access [27,[30][31][32][33][44][45][46][47][48][49][50]. Others have discussed the overall possibility for bystanders to perform other measures as immediate responders [15,20,21,35,36].…”

“…The American College of Surgeons introduced "the Hartford Consensus" in 2013. Their guidelines aim to create a national policy to enhance survivability from intentional mass casualties and active shooter events (stop bleeding) [27,[30][31][32][33]. Similarly, a UK charity, "citizenAID," aims to empower civilians to act in life-threatening situations before the EMS arrives [34].…”

“…Similarly, a UK charity, "citizenAID," aims to empower civilians to act in life-threatening situations before the EMS arrives [34]. These two initiatives together with the WHO guidelines may suggest that civilians could be a good source of primary help at the scene of an incident [27,[30][31][32][33][34]. The task should not necessarily be any kind of treatment; rather, the knowledge of not worsening some critical injuries can also be life-saving.…”

Implementation of Stop the Bleed on an Undergraduate College Campus: The Johns Hopkins Experience

“…11,12 Calls to action have encouraged the continued development and broader universal implementation of bleeding control programs. 13 For example, many states (including Maryland) require high school students to be trained in CPR to graduate from high school.…”