Trauma is a major cause of death for all ages, and the most common injuries leading to death are traumatic brain injury and uncontrolled hemorrhage, says a study published by the International Journal of the Care of the Injured, Trends in 1029 trauma deaths at a level 1 trauma center. Another study published by PubMed.gov, Mortality from isolated civilian penetrating extremity injury, estimated that 57 percent of civilian deaths from hemorrhage could have been prevented with adequate hemorrhage control. If the hemorrhage isn’t stopped, a person can bleed to death in just five minutes.

Unintentionally, other civilians, who may not have medical training, become first responders, as the arrival of hospital and medical personnel may be delayed, or just not arrive at the scene quick enough to save lives.

According to a Reuters report, in the U.S., on average, the length of time between a call for help and the arrival of emergency medical services is about eight minutes –  but that amount increases to 14 minutes in rural areas (where about 10 percent of patients have waited nearly 30 minutes), researchers found. Waiting for first responders to arrive is unavoidable. What is not unavoidable is proof that bystander training is necessary.

Inspired by the aftermath of the Sandy Hook Elementary School shootings in Newtown, Conn., on December 2012, Lenworth M. Jacobs, Jr., MD, FACS, a concerned local trauma surgeon and Regent of the American College of Surgeons (ACS), requested to review victims’ autopsy records. Results showed that the victims died from severe bleeding that if controlled, could have kept them from going into shock until emergency help arrived on the scene.

The findings led trauma surgeons from the ACS to form the Hartford Consensus Joint Committee, composed of experts from emergency medical care, government and law enforcement. The group set a goal to create a national emergency response to improve victim survival following mass shootings and other acts of mass violence. This led to the creation of Stop the Bleed (STB), a national public awareness campaign, which launched in October of 2015, by the White House.

The campaign aims to teach active bystanders techniques of bleeding control. And if civilians have the opportunity to help, the training can provide them with many of the essential techniques of tourniquet placement and wound packing, which may help save a life.

Since then, the campaign has continued to grow, and as of September 2019, the effort has reached more than 100 countries, and more than 1 million people around the world have been trained to save a life.

For example, in the November 14, 2019 shooting at Saugus High in Santa Clarita, Calif., two students were killed and three injured before the gunman fatally shot himself. According to multiple news reports, school officials shepherded students to safe spaces, barricaded doors and pulled window shades. The staffers also used two STB kits, equipped with tourniquets, compression bandages and blood-clotting hemostatic gauze to prevent excessive blood loss. The kits were part of a donation, as California has not yet passed legislation requiring schools to train to STB.

The kits have been pushed throughout school districts across the country. Georgia, for instance, was the first to equip schools with STB kits, for the 2017-2018 academic school year. Deputy director for the Georgia Trauma Commission, Billy Kunkle said that to date, the kits are in about 2,100 of the state’s 2,300 schools, and have been used seven times.

In 2019, Texas, Arkansas and Indiana followed Georgia’s example, and passed legislation to install kits in schools. In September 2019, the Illinois Terrorism Task Force announced plans to distribute 7,000 of the kits to the state’s public schools. Only four states in the U.S. have passed legislation requiring public schools to administer STB training for students and staff.

Many community members and experts in the medical field are taking the lead to spread awareness of the campaign. Scott Hunter, a retired firefighter from the Kern County, Calif. Fire Department and owner of Safety Consulting Services, LLC, is one that is taking the lead in this area.

After the shooting at Saugus High, Hunter says he felt compelled to ensure students and schools had the training and tools necessary to respond to tragic incidents. “I reached out to my local California legislators about possible legislation requiring all schools to train their faculty and staff in STB and make it optional for 7^th grade students and above. The legislation would also require the schools to purchase STB kits to place throughout schools in the district.”

He hopes recent legislation that went into effect on January 1st, 2020 in Texas inspires and leads legislation in California and all U.S. states.

Hunter, however, says that despite the lack of national conversation on STB, there have been many positive changes in the program over the years. “In order to become a STB instructor, you are now required to attend a Basic Bleeding Control (BCon) class and then submit the course completion certificate along with medical credentials (EMR, EMT, Paramedic, LVN, RN, etc).”

When he was first authorized as a STB instructor, Hunter says that it was based on his EMT-credentials and 35 years of field experience. “At the time, the instructor authorizations came from the National Association of Emergency Medical Technicians (NAEMT).” Now, the instructor authorizations are handled by the ACS through their www.bleedingcontrol.org website, he says.

Another positive change Hunter has seen is the quality of available resources. “The original STB slide presentation was 62 slides and had a lot of ‘fluff’ to it,” he says. In May 2019, ACS published an updated version, which is now 30 slides and is more streamlined, he adds.

Is the Training Effective?

Despite its ability to save lives, the campaign has faced some challenges.

According to Hunter, one of the major challenges that the campaign faces is the attitude of the general public. “I believe that many people have the attitude that an active shooter or mass casualty event or incident won’t happen to them, or it won’t happen here, or they have a false sense of security and believe that law enforcement will be there to protect them and keep them safe. Therefore, they feel there is not a need to take a STB class.”
Similarly, a public opinion survey conducted by the Hartford Consensus group revealed that 51 percent of those surveyed would be very likely to assist in severe bleed scenarios, such as shooting victims and car crash victims. However, many of those surveyed expressed significant concern about risks of self-harm, such as contracting disease or personal safety, or of further injuring the victim by causing pain, worsening the existing injury or contributing to bad outcomes such as limb loss or death.

Several medical practitioners have set out to dispel and mitigate those concerns among civilians, as evidence has shown that civilians can be trained to effectively assist victims prior to the arrival of first responders.

A May 2018 study, Stop the Bleed Training empowers learners to act to prevent unnecessary hemorrhagic death, claims that training in BCon techniques and improving baseline knowledge of hemorrhage and bleeding control techniques increases participants’ willingness and preparedness to intervene in an emergency.

For the study, researchers at the University of Texas Health Sciences Center at Houston, McGovern Medical School, created a STB training program and reached out to surrounding communities and local schools. The ACS certified training course included three components: a didactic lecture, interactive discussion of BCon components and hands-on training with certified instructors on tourniquet placement technique and hemorrhage control with wound packing.

A pre- and post-training questionnaire was created to evaluate participants’ baseline knowledge of trauma and hemorrhage, to assess their attitudes towards intervention and to follow changes in their knowledge to assess effectiveness of the teaching.

Over the course of six months, during the 2017-2018 academic year, BCon instructors taught 13 STB sessions. In total, 604 individuals received potentially life-saving training. Analysis of the data was divided according to the professional background of the participants: school nurses, medical students, interdisciplinary group and community members.

According to the researchers, there was a statistically significant shift between feelings of both willingness and preparedness. Following training, participants felt more willing and more prepared to assist in caring for a stranger who was bleeding. Before BCon training, the overall willingness to help a bleeding stranger was 92 percent.

There were no differences in willingness to help between groups: 92 percent of school nurses, 93 percent of medical students, 88 percent of the interdisciplinary group and 96 percent of community members showed an inclination to help.

Regarding preparedness, there were significant group differences. While 80 percent of school nurses felt prepared, only 19 percent of medical students, 34 percent of the interdisciplinary group and 48 percent of community members responded positively.

After the STB intervention, every participant group had increased confidence in willingness (99 percent of school nurses, 99 percent of medical students, 99 percent of the interdisciplinary group and 99 percent of community members); and preparedness (100 percent of school nurses, 98 percent of medical students, 99 percent of the interdisciplinary group and 99 percent of community members).

In late 2018, research by the Harvard Medical School and the Department of Military & Emergency Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., revealed that self-reported prior first aid and hemorrhage control training, while associated with increased likelihood to correctly apply a tourniquet, results in one-third of individuals correctly performing the skill.

However, the same study notes that evidence has shown that the placement of a tourniquet by emergency medical personnel decreases the risk of death only if placed before the onset of hemorrhagic shock, a role only civilians can fill by already being on the scene.

Hunter contends that civilians can learn to STB without any previous medical training. “The way that the program is laid out makes it easy for the students to follow along and learn STB techniques. I have had children as young as nine years old in some of my classes,” he says.

However, it is important to make sure the training is easy to follow, he notes. “I break my STB classes into two parts: first I go over the presentation and demonstrate the skills taught (direct pressure, wound packing and applying a tourniquet),” he notes. “When that is over, I have the students practice the STB skills on each other in the class. I have them practice each skill until they all become comfortable with it, then move on to the next one.”

A National Conversation

As work continues in empowering and training civilians to act as immediate first responders, these findings highlight the importance of the campaign. The findings should also help inform national conversation surrounding the need for STB training in schools, workplaces and various other organizations.

Just in 2019, there were 417 mass shootings and 31 mass murders in the U.S., says the Gun Violence Archive (GVA), a nonprofit research group that tracks shootings and their characteristics in the U.S. Mass shootings, as defined by GVA, are incidents in which four or more people, excluding the perpetrator(s), are shot in one location at the same time. As of January 21, 2020, the GVA has recorded 14 mass shootings, one mass murder and more than 2,198 deaths due to gun violence.

Hunter hopes that the STB campaign continues to grow and experience positive changes. One positive change he sees the need for is the availability of funds or grants to instructors that purchase equipment needed for the free STB training classes they provide. For instance, the training kit provided by the ACS costs $950.

The costs of equipment, training props and availability of training and resources to train to STB may only decrease as the campaign gains more traction with the public and enterprise security leaders, he notes. This would ensure those in charge of legislation are inspired to copy recent legislation requiring schools and workplaces to implement a STB program.

In the event that a STB kit is not available, citizens can still help, Hunter notes. Some of the best ways to prepare to control bleeding is knowing the amount of resources available during an incident: a shirt, a towel, or a rag. “You could use the same shirt, towel or rag to pack a wound. As for an improvised tourniquet, you can use a belt, shirt or towel torn into a strip at least 1” wide, that is long enough to wrap around the arm, and tighten with anything that can act as a ‘windlass’ to apply the pressure necessary to control the bleed.”

“I would like to encourage all security enterprise leaders and security professionals to really consider putting their officers and team members through the STB training class,” Hunter continues. “The class is free and lasts 1-1.5 hours, and the training is invaluable, as they could potentially use the training to save a life, including their own.”

“Depending on what type of event or contract security professionals are working, things can happen, and they may need to become an immediate responder,” he adds.

“The bottom line is that you can stop the bleed using many items found in your workplace,” Hunter says. “We are just often limited by our imagination.”