Article

Stop the Bleed Training Empowers Learners to Act to Prevent Unnecessary Hemorrhagic Death

Authors:
  • McGovern Medical School at the University of Texas Health Science Center at Houston
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Abstract

Background: Uncontrolled bleeding is a leading cause of preventable death from trauma. With the rise in mass casualty events, training of laypersons can be life-saving. "Stop the Bleed" is a campaign to teach the public techniques of bleeding control. We believe that training in these techniques will increase participants' willingness and preparedness to intervene and increase knowledge of trauma/hemorrhage control. Methods: We created a "Stop the Bleed" training program. School nurses, medical students, researchers, and community members participated in the program. Pre- and post-training questionnaires assessed participants' willingness/preparedness to intervene in a casualty event and knowledge of trauma/hemorrhage control. Results: There was a significant change in attitudes after receiving training (p < 0.05). There was also an improvement in knowledge regarding bleeding control techniques. Conclusions: "Stop the Bleed" training empowers participants with the confidence and knowledge to aid others in preventable hemorrhagic death.

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... In a study of STOP THE BLEED ® training for laypeople [17], participants reported improved confidence and willingness to use a tourniquet (before training, 64.2% [140 of 218]; after training, 95.6% [194 of 203]). One way to improve people's likelihood of taking action is to increase their self confidence and perceived self efficacy in hemorrhage control skills [18]. Therefore, we investigated whether intermittent STOP THE BLEED ® reviews were effective for long term retention of hemorrhage control skills and improvements in perceived confidence. ...
... For the five Likert format questions, the median (IQR) total score for the posttraining survey (23 [21][22][23][24][25]) was significantly higher than that for the pretraining survey (14 [11][12][13][14][15][16][17][18]); (p<0.001; Table 2). ...
... For the five Likert format questions on the postintervention survey, median (IQR) total score for intervention group was significantly higher than that for the control group (intervention group, 21 [20][21][22][23][24][25] vs. control group, 16 [14][15][16][17][18][19][20]; p<0.0001; Table 2). ...
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Context: Some medical schools integrate Stop the Bleed training into their curriculums to teach students how to identify and stop life-threatening bleeds which are classes that are taught as a single-day didactic and hands-on training sessions without reviews after the course. To improve retention and confidence in hemorrhage control, additional review opportunities are necessary. Objective: The current study investigated whether intermittent Stop the Bleed reviews were effective for long-term retention of hemorrhage control skills and improving perceived confidence. Methods: First-year osteopathic medical students were asked to complete an 8-item survey (5 Likert-scale and 3 quiz-format questions) before and after completing a Stop the Bleed training session. After the surveys were collected, students were randomly assigned to 1 of 2 study groups. Over a 12-week intervention period, each group watched a 4-minute Stop the Bleed review video (intervention group) or a "distractor" video (control group) at 4-week intervals. After the 12 weeks, the students were asked to complete an 11-item survey. Results: Scores on the posttraining survey were higher than the pretraining survey. The median score on the 5 Likert-scale items was 23 points for the posttraining survey and 14 points for the pretraining survey. Two of the 3 knowledge-based quiz-format questions significantly improved from pretraining to posttraining (both P<.001). On the 11-item postintervention survey, both groups performed similarly on the 3 quiz questions (all P>.18), but the intervention group had much higher scores on the Likert-scale items than the control group regarding the ability to identify and control bleeding (intervention group median=21.4 points vs control group median=16.8 points). Conclusions: Although we found no differences between the intervention and control groups on the three quiz-format questions, the intervention group reported improved confidence in 2 their hemorrhage control skills and indicated they would be more likely to help during a severe bleeding incident. 3
... Exsanguinating hemorrhage can lead to death within a matter of minutes, making prompt hemorrhage control imperative in bleeding scenarios. 1 In 2015 the National Trauma Institute estimated that severe bleeding accounts for greater than 35% of prehospital deaths and 80% of mass casualty victims are transported to the hospital by nonambulance. 2 Therefore, in the minutes before emergency medical technicians (EMT) can arrive to the scene, nonmedical bystanders who are trained in basic techniques to control bleeding can be active participants in decreasing rates of preventable deaths. ...
... Using these skills, participants may be more likely to intervene in a time of need. 1 While these techniques were initially used in mass casualty settings such as warfare, the national campaign for STB training course was inspired by the Sandie Hook elementary school shooting. The utility of these skills in other scenarios or injuries causing massive hemorrhage, such as motor vehicle accidents or penetrating wounds, has been increasingly recognized. 1 Hemorrhage control techniques have the potential to be readily acquired by teenagers and could be particularly applicable in violence-prone areas with high rates of neighborhood shootings and stabbings. ...
... The utility of these skills in other scenarios or injuries causing massive hemorrhage, such as motor vehicle accidents or penetrating wounds, has been increasingly recognized. 1 Hemorrhage control techniques have the potential to be readily acquired by teenagers and could be particularly applicable in violence-prone areas with high rates of neighborhood shootings and stabbings. 7 We believe that inner-city high school students can learn techniques to intervene in a bleeding injury if a family member, friend, or community member is involved in a violent event. ...
Article
Full-text available
Introduction: Unintentional bleeding is the leading cause of death in people 1-44 years of age in the United States. The Stop the Bleed (STB) campaign is a nationwide course that teaches the public to ensure their own safety, call 911, find the bleeding injury, and achieve temporary hemorrhage control by several techniques. Although the national campaign for the training course was inspired by active shooter events, the training can be applied to motor vehicle accidents and small-scale penetrating and gunshot wounds. Extending the audience to inner-city high school students in a violence-prone neighborhood has the potential to save lives if they are first on the scene. Objectives: We hypothesized that students would have a greater degree of comfort, willingness, and preparedness to intervene in acute bleeding after taking the course. Methods: This was a prospective, interventional pilot study in one inner-city high school in Brooklyn, New York. Students were given the option to participate in the STB course with pre- and post-surveys. We recruited 286 students from physical education or health education class to take a 50-minute bleeding control training course. Mean age was 15.7 years old. Students were divided into groups of 20-25 and taught by 2-3 emergency medicine, pediatric, or trauma surgery STB instructors. Each course included 2-3 skills stations for placing a tourniquet, wound packing, and pressure control. Results: Prior to the course, only 43.8% of the students reported being somewhat likely or very likely to help an injured person who was bleeding. After the course, this increased to 80.8% of students even if no bleeding control kit was available. Additionally, there were significant improvements in self-rated comfort level from pre- to post-course 45.4% to 76.5%, and in self-rated preparedness from 25.1% to 83.8%. All three measures showed statistically significant improvement, P <.0001. Conclusion: Teaching the STB course to high school students from a community with high levels of violence resulted in increased comfort level, willingness, and preparedness to act to control bleeding. If these opinions translate into action, students' willingness to act could decrease pre-hospital blood loss and empower youth to perform life-saving interventions.
... Since the STB campaign was launched in 2017, several studies have sought to investigate the efficacy of STB training. [19][20][21][22][23] However, no study to date has provided objective evidence on the performance of STB skills by both LRs and MRs. Thus, the primary objective of this study was to perform a critical systematic evaluation of STB course participant knowledge, attitude, and skills with the goal to provide valuable feedback to continue to enhance the participation in STB courses. ...
... However, no study has critically investigated efficacy of the STB course in both LRs and MRs by objectively assessing their knowledge and skills learned and obtaining their feedback on the course itself. [19][20][21][22][23] Our study demonstrates that STB course participants from different baseline levels of medical training not only had increased confidence after a 1-h STB course but were also able to demonstrate both 1) gains in knowledge of bleeding control techniques and 2) proficiency of critical bleeding control skills. ...
... 22 Lei et al. objectively assessed participant knowledge and willingness to participate in bleeding control before and after STB courses. 23 However, no information was provided on the ability of course participants, in particular LRs, to master STB skills. In addition, only 77 nonmedical providers were included. ...
Article
Background: Bystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. Study design: Course participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. Results: A total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding-LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001-and ability to pack a bleeding wound-LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. Conclusions: This study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.
... In a study of STOP THE BLEED ® training for laypeople [17], participants reported improved confidence and willingness to use a tourniquet (before training, 64.2% [140 of 218]; after training, 95.6% [194 of 203]). One way to improve people's likelihood of taking action is to increase their self confidence and perceived self efficacy in hemorrhage control skills [18]. Therefore, we investigated whether intermittent STOP THE BLEED ® reviews were effective for long term retention of hemorrhage control skills and improvements in perceived confidence. ...
... For the five Likert format questions, the median (IQR) total score for the posttraining survey (23 [21][22][23][24][25]) was significantly higher than that for the pretraining survey (14 [11][12][13][14][15][16][17][18]); (p<0.001; Table 2). ...
... For the five Likert format questions on the postintervention survey, median (IQR) total score for intervention group was significantly higher than that for the control group (intervention group, 21 [20][21][22][23][24][25] vs. control group, 16 [14][15][16][17][18][19][20]; p<0.0001; Table 2). ...
Article
Full-text available
Context: Some medical schools integrate STOP THE BLEED® training into their curricula to teach students how to identify and stop life threatening bleeds; these classes that are taught as single day didactic and hands-on training sessions without posttraining reviews. To improve retention and confidence in hemorrhage control, additional review opportunities are necessary. Objectives: To investigate whether intermittent STOP THE BLEED® reviews were effective for long term retention of hemorrhage control skills and improving perceived confidence. Methods: First year osteopathic medical students were asked to complete an eight item survey (five Likert scale and three quiz format questions) before (pretraining) and after (posttraining) completing a STOP THE BLEED® training session. After the surveys were collected, students were randomly assigned to one of two study groups. Over a 12 week intervention period, each group watched a 4 min STOP THE BLEED® review video (intervention group) or a "distractor" video (control group) at 4 week intervals. After the 12 weeks, the students were asked to complete an 11 item survey. Results: Scores on the posttraining survey were higher than the pretraining survey. The median score on the five Likert scale items was 23 points for the posttraining survey and 14 points for the pretraining survey. Two of the three knowledge based quiz format questions significantly improved from pretraining to posttraining (both p<0.001). On the 11 item postintervention survey, both groups performed similarly on the three quiz questions (all p>0.18), but the intervention group had much higher scores on the Likert scale items than the control group regarding their confidence in their ability to identify and control bleeding (intervention group median = 21.4 points vs. control group median = 16.8 points). Conclusions: Intermittent review videos for STOP THE BLEED® training improved medical students' confidence in their hemorrhage control skills, but the videos did not improve their ability to correctly answer quiz-format questions compared with the control group.
... Therefore, some of the actions used in this military environment can be adopted in the civilian environment, especially after the events that promoted the Hartford consensus which highlights that everyone could save a life [9]. In this way, actions like the campaign "Stop the Bleed" [10][11][12][13] take momentum, approaching training to laypersons so they could learn how to identify different types of hemorrhages and how to control them. ...
... This training could be not only focused on clinicians but also extended to paramedics, nurses and even laypersons. In the literature, there are publications in which laypersons are starting to be trained with a very positive outcome [9][10][11][12]. This is done using simulators which are not automated, and which do not allow objective evaluation of the techniques. ...
Article
Full-text available
One of the main preventable leading causes of death after a trauma injury is the hemorrhagic shock. Therefore, it is extremely important to learn how to control hemorrhages. In this paper, a hemorrhagic trauma simulator for lower limb has been developed and a pilot study has been accomplished to trail the simulator. Four different bleeding scenarios have been tested per participant, gathering information about the manual pressure exerted to control the bleeding. Data, altogether, from 54 hemorrhagic scenarios managed by final year medical students and doctors were gathered. Additionally, a post-simulation questionnaire, related to the usability of the simulator, was completed. All the participants managed to control the simulated bleeding scenarios, but the pressure exerted to control the four different scenarios is different depending if the trainee is a student or a doctor, especially in deep venous hemorrhages. This research has highlighted the different approach to bleeding control treatment between medical students and doctors. Moreover, this pilot study demonstrated the need to deliver a more effective trauma treatment teaching for hemorrhagic lesions and that hemorrhagic trauma simulators can be used to train and evaluate different scenarios.
... Lei [8] recognized that this program provided the participants with confidence and knowledge to help in preventing hemorrhagic death. Dhillon [2] stated the need for improvisation of tools would be needed with an element of creativity is needed because how likely would a layperson carry a tourniquet on their person. ...
... 4 Stop the Bleed is an available civilian emergency training program designed to teach bleeding control. 5 The CAT is used in this program. Stop the Bleed is currently being used to teach school staff, faculty, and students how to use tourniquets and is stocking schools with emergency bleeding response kits that include the CAT. ...
Article
Background: Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets for exsanguinating hemorrhage in severe extremity trauma. The Combat Application Tourniquet (CAT) used with success in adults has not been prospectively tested in children. Our objective with this study was to determine if the CAT is successful in arresting extremity arterial blood flow in school-aged children. Methods: Sixty school-aged volunteers (ages 6-16 years) recruited by age cohort had the CAT applied to an upper arm and thigh while peripheral pulse was monitored by Doppler. The number of windlass turns (maximum allowed: 3 [1080°]) required to arrest arterial pulse was recorded. Success was analyzed by BMI percentile for age and extremity circumference. Results: The CAT was successful in occluding arterial blood flow as detected by Doppler pulse in all 60 (100%) of the upper extremities tested. In the lower extremity, 56 (93%) had successful occlusion. The 3-turn maximum allowed by the protocol was not adequate in some obese, older subjects (BMI >30). In both the upper and lower extremity, the number of turns required to occlude blood flow gradually increased with an increase in arm and thigh circumference. Conclusions: Prospective testing of a cohort of school-aged children 6 to 16 years revealed the CAT tourniquet to be suitable for use in both the upper and lower extremity.
... Our study suggests that a game-based computer application based on curricular objectives of COVID-19 instruction is an effective learning methodology. Other studies of games used to teach medical students have shown that serious games are comparable to lectures in terms of knowledge gains when measured immediately after learning method application, [16][17][18][19][20][21] a result which our study replicates. The advantage of gamebased learning strategies is the active participation and interaction at the center of the learning experience; lectures do not sufficiently engage the medical students. ...
Article
Objective: The sudden disruption of university teaching caused by the coronavirus disease 2019 (COVID-19) pandemic has forced universities to switch to online teaching. It is vital for graduating medical students to learn about COVID-19 because they are likely to treat COVID-19 patients after graduation. We developed a COVID-19 lesson for medical students that used either an online lecture or a serious game that we designed. The aim of this study is to explore the effectiveness of a serious game versus online lectures for improving medical students' COVID-19 knowledge. Materials and Methods: From our university's database of knowledge scores, we collected the prelesson, postlesson, and final test knowledge scores of the students who participated in the lesson and conducted a retrospective comparative analysis. Results: An analysis of scores concerning knowledge of COVID-19 from prelesson and postlesson tests shows that both teaching methods produce significant increases in short-term knowledge, with no statistical difference between the two methods (P > 0.05). The final test scores, however, show that the group of students who used the game-based computer application scored significantly higher in knowledge retention than did the online lecture group (P = 0.001). Conclusion: In the context of the disruption of traditional university teaching caused by the COVID-19 pandemic, the serious game we designed is potentially an effective option for online medical education about COVID-19, particularly in terms of its capacity for improved knowledge retention.
... [20][21][22][23] These courses increase laypersons' theoretical knowledge, self-reported confidence, and willingness to use tourniquets. [24][25][26] Furthermore, individuals among the general population with prior training in first aid and hemorrhage control are more likely to correctly apply a tourniquet compared with those without training, further cementing the benefits of layperson tourniquet training. 27 One notable training approach is the Just in Time method, wherein laypersons are taught tourniquet application onsite during a mass-casualty event; these courses have proven effective at increasing success rates in laypersons. ...
Article
Background: Life threatening hemorrhage is a major cause of preventable mortality in trauma. Studies have demonstrated the effectiveness and safety of commercial tourniquets when used by adult civilians. However, there is no data about tourniquet application by children.This study's goal is to determine which of three commercially available tourniquets is most effective when used by children. Methods: A randomized crossover study was conducted in four elementary schools in Montreal to compare three commercially available tourniquets. The study population is primary school children aged 10-12 years (5th -6th grade). 181 students were invited to participate; 96 obtained parental approval and were recruited.Participants underwent a short 7-minute video training on the use of three commercial tourniquets and were subsequently given a 2-minute practice period. Students were evaluated on their ability to successfully apply the tourniquet and the time to complete application. After applying all three tourniquets, students selected their favorite model.The primary outcome is the proportion of successful applications per tourniquet model. Secondary outcomes include time to successful application for each tourniquet model and tourniquet model preference. Results: The Mechanical Advantage Tourniquet (MAT) outperformed the Combat Application Tourniquet (CAT) and the Stretch Wrap and Tuck Tourniquet (SWATT) in terms of success rate (MAT: 67%; CAT: 44%; SWATT: 24%; p<0.0001), time to application (MAT: 57 sec; CAT: 80 sec; SWATT: 90 sec; p<0.0001) and preference (MAT: 64%; CAT: 30%; SWATT: 6%; p<0.0001). Conclusion: In this study, the MAT performs better in terms of success rate, time to application and preference when used by school aged children. This study can be helpful when facilities are purchasing tourniquets for use by students. Level of evidence: Level 2Study typerandomized crossover study.
... A questionnaire was conducted before and after the course (see Additional file 1 and Additional file 2), and it addressed student confidence in STB skills, willingness to rescue at the trauma scene and evaluation of the course, etc., to evaluate the effect of teaching in the control group and the experimental group. The competencies needed for medical students in terms of specific standards were established on the basis of the latest International Medical Association guidelines and other related studies [19][20][21][22][23][24][25]. ...
Article
Full-text available
Background The “Stop the Bleed” (STB) campaign has achieved remarkable results since it was launched in 2016, but there is no report on the teaching of an STB course combined with a trauma patient simulator. This study proposes the “problem-, team-, and evidence-based learning” (PTEBL) teaching method combined with Caesar (a trauma patient simulator) based on the STB course and compares its effect to that of the traditional teaching method among outstanding doctoral candidates training in haemostasis skills. Method Seventy-eight outstanding doctoral candidate program students in five and eight-year programs were selected as the research subjects and were randomly divided into a control group (traditional teaching method, n = 34) and an experimental group (PTEBL teaching method combined with Caesar, n = 44). Their confidence in their haemostasis skills and willingness to rescue injured victims were investigated before and after the course in both groups. Result Students’ self-confidence in their STB skills and the willingness to rescue improved after the class in both groups. Compared with the control group, students in the experimental group were more confident in compressing with bandages and compressing with a tourniquet after a class (compressing with bandages: control group 3.9 ± 0.8 vs. experimental group 4.3 ± 0.7, P = 0.014; compressing with a tourniquet: control group 3.9 ± 0.4 vs. experimental group 4.5 ± 0.8, P = 0.001) More students in the experimental group than the control group thought that the use of Caesar for scenario simulation could improve learning (control group 55.9% vs. experimental group 81.8%, P = 0.024), and using this mannequin led to higher teacher-student interaction (control group 85.3% vs. experimental group 97.7%, P = 0.042). The overall effectiveness of the teaching was better in the experimental group than in the control group (control group 85.3% vs. experimental group 97.7%, P = 0.042). There was a significant positive correlation between teacher-student interactions and the overall effectiveness of teaching ( R = 1.000; 95% CI, 1.000–1.000; P < 0.001). Conclusion The PTEBL teaching method combined with Caesar can effectively improve student mastery of STB skills and overcome the shortcomings of traditional teaching methods, which has some promotional value in the training of outstanding doctoral candidates in STB skills.
... A study by Lei et al 12 showed that Stop the Bleed ® training was successful in increasing both participant confidence and preparedness in performing bleeding control techniques. A similar study by Schroll et al 6 showed increased participant confidence and skill proficiency after STB training. ...
Article
Full-text available
Background Following the Hartford Consensus guidelines and recommendations, third-year medical students from a single institution were offered an optional Stop the Bleed (STB) training course in August 2018. The aim of this study was to assess medical students’ confidence in performing bleeding control techniques and teaching others after completing the STB course. The secondary goal was to assess student perception on integrating mandatory STB training into the medical school curriculum. Materials and Methods A 24-question survey using a 4-point Likert scale was administered to all medical students who completed STB training. Students were anonymously asked to self-report their confidence in performing bleeding control techniques, training others after STB training, and their perception on integrating STB training into medical school curriculum. Results After completing the STB course, 95% of students were comfortable applying a tourniquet, 92% of students were confident in packing wounds, and 99% of students could apply direct pressure to wounds to stop bleeding. Overall, 94% of students reported that STB training would be helpful for their clinical rotations. Conclusion These results demonstrate that medical students are positively impacted by Stop the Bleed courses and validate that the implementation of mandatory STB courses into medical school curriculum will improve medical students’ knowledge and skills for hemorrhage control.
... A questionnaire was conducted before and after the course (see Additional le 1 and Additional le 2) to evaluate the effect of traditional teaching in both the control group and experimental group. The competencies needed for medical students in terms of speci c standards were established on the basis of the latest International Medical Association guidelines and other relative studies [18][19][20][21][22][23][24] . ...
Preprint
Full-text available
Background: The “Stop The Bleed” (STB) campaign has achieved remarkable results since it launched in 2016, but there is no report on the application of a STB course combined with a trauma patient simulator. This study proposes the “problem-, team-, and evidence-based learning” (PTEBL) teaching method combined with Caesar (trauma patient simulator) based on the STB course, and compares its effect with the traditional teaching method in outstanding doctoral candidates training of hemostasis skills. Method: Seventy-eight outstanding doctoral candidates program students (five-years and eight-years) were selected as the research subjects and were randomly divided into a control group (traditional teaching method, n=34) and an experimental group (PTEBL teaching method combined with Caesar, n=44). Their confidence of hemostasis skills and willingness to rescue were investigated before and after the course in both groups. Result: Students’ self-confidence of STB skills and willingness to rescue in both groups were improved after the class. Compared with the control group, students in the experimental group were more confident in compressing with bandages and compressing with a tourniquet after a class (compressing with bandages: control group 3.9±0.8 vs. experimental group 4.3±0.7, P=0.014; compressing with a tourniquet: control group 3.9±0.4 vs. experimental group 4.5±0.8, P=0.001) More students in the experimental group than the control group thought that the use of Caesar for scenario simulation could improve learning (control group 55.9% vs. experimental group 81.8%, P=0.024), and showed higher teacher-student interaction (control group 85.3% vs. experimental group 97.7%, P=0.042) The overall effectiveness of the teaching was better in the experimental group than the control group (control group 85.3% vs. experimental group 97.7%, P=0.042). There was a significant positive correlation between teacher-students interaction and overall effectiveness of teaching (R=1.000; 95%CI, 1.000-1.000; P<0.001). Conclusion: The PTEBL teaching method combined with Caesar can effectively improve students' mastery of STB skills, and overcome the shortcomings of traditional teaching methods, which has a certain promotional value in the training of outstanding doctoral candidates in STB skills.
Article
Full-text available
Objective To identify pandemic and disaster medicine-themed training programmes aimed at medical students and to assess whether these interventions had an effect on objective measures of disaster preparedness and clinical outcomes. To suggest a training approach that can be used to train medical students for the current COVID-19 pandemic. Results 23 studies met inclusion criteria assessing knowledge (n=18, 78.3%), attitude (n=14, 60.9%) or skill (n=10, 43.5%) following medical student disaster training. No studies assessed clinical improvement. The length of studies ranged from 1 day to 28 days, and the median length of training was 2 days (IQR=1–14). Overall, medical student disaster training programmes improved student disaster and pandemic preparedness and resulted in improved attitude, knowledge and skills. 18 studies used pretest and post-test measures which demonstrated an improvement in all outcomes from all studies. Conclusions Implementing disaster training programmes for medical students improves preparedness, knowledge and skills that are important for medical students during times of pandemic. If medical students are recruited to assist in the COVID-19 pandemic, there needs to be a specific training programme for them. This review demonstrates that medical students undergoing appropriate training could play an essential role in pandemic management and suggests a course and assessment structure for medical student COVID-19 training. Registration The search strategy was not registered on PROSPERO—the international prospective register of systematic reviews—to prevent unnecessary delay.
Article
Background: National Stop the Bleed Day (NSTBD) was created to increase public awareness of the official Stop-the-Bleed initiative and the Bleeding Control Basic course. The goal was to develop and employ an effective national social media strategy that would encourage and support efforts already in place to train the public in basic bleeding control techniques. Methods: March 31, 2018, was designated as NSTBD. Analysis focused on a 2-week window centered on NSTBD. The number of courses offered, number of instructors registered and total number of students trained overall during this period was derived from the American College of Surgeons (ACS) website bleedingcontrol.org. Courses not registered with the ACS were not included. Data on overall website activity were also included for analysis. Results: Forty-three states and 18 countries participated in NSTBD. During the study period, there were 1884 courses registered on bleedingcontrol.org. Comparatively, over a 4-month period from August to November 2017, the mean number of registered courses per month was 834. There were 34,699 students trained during the two-week study period as opposed to August to November 2017, the mean number of people trained per month was 9,626. In addition, 576 new B-Con instructors were certified during this time window. Additionally, the international coordinators reported 1500 students were trained during the study period. During this time, the ACS reported a significant increase in website activity. This included 10,530 new visitors, 12,772 visitors overall and 35,342 page views recorded during the study period. Conclusion: The NSTBD effort was successful in generating widespread interest for the Stop-the-Bleed initiative. The use of a targeted social media campaign in this context was successful in driving people to available training opportunities while also increasing awareness of the overall effort. While only in its early stages, the NSTBD concept is a good one and should be developed further in coming years. Level of evidence: Retrospective, Level V.
Article
Background: Uncontrolled bleeding is the leading preventable cause of death after injury. Stop the Bleed (STB) is a bleeding control training with proposed expansion into schools. However, the attitudes of guardians, specifically those with past trauma/injury, towards expanding STB into schools are unknown. Methods: A cross-sectional survey evaluated guardian attitudes towards STB training in high schools, and compared responses between guardians based on the experience of prior trauma. Logistic regression models evaluated the association between prior trauma and guardian-reported acceptability of STB training. Results: Of 750 guardians who received the survey, 484 (64.5%) responded. Most guardians (95.3%) wanted their child trained. Few (4.2%) felt this training would be harmful; 44.9% felt their child might be held responsible if something went wrong, and 28.4% reported it might be too scary for their child. In adjusted models, guardians with prior trauma were more likely to want their child trained (odds ratio [OR] = 3.50, 95% confidence interval [CI] 1.11-15.50), and identify STB as important to them (OR = 4.07, 95% CI 1.66-12.26). Conclusion: Our results support STB training in high schools, and guardians with a trauma history may be more likely to want their child trained. Further work to understand the perceived potential harm, and work to design trauma-informed first-response trainings is warranted.
Article
Objectives: To evaluate "Stop the Bleed" (STB) training among/K12 personnel in an Alabama school system, and to assess participants' perceived readiness to train peers in STB methods. Design and sample: We performed a cross-sectional observational study with a convenience, nonprobability sample of 466 full-time personnel who received STB training. Data were collected using an anonymous online survey. Measurements: We asked participants to recall feelings related to STB both prior to and after completing training using a 5-point Likert scale (5 = "Strongly Disagree", 1 = "Strongly Agree"). We used logistic regression to evaluate the association among posttraining feelings and perceived preparedness to train others in STB. Results: Participants were primarily female (78%), aged 41 ± 10 years, who held faculty positions (94%). Results revealed increased knowledge of (4 [IQR 2-4] vs. 2 [1-2], p < .001) and comfort with (4 [2-5] vs. 2 [1-2], p < .001) STB skills. Participants felt more empowered to organize STB training (4 [3-5] vs. 3 [2-4], p < .001); those who felt empowered to organize STB training were eight times more likely to feel capable of teaching STB. Conclusions: After STB training, K-12 personnel felt empowered to organize additional STB trainings and capable of teaching STB methods to others.
Article
With the continued threat of mass casualty incidents in schools and surrounding communities, it is essential for school nurses to be knowledgeable regarding the recognition of hemorrhagic shock due to massive bleeding and the acute management of these victims. In the past decade, increased interest and research in acute bleeding control have led to published evidence-based guidelines to reduce morbidity and mortality for victims of violent acts. It is essential that healthcare providers, including nurses who are the first responders in schools, are aware of methods to assess and control massive bleeding. This article summarizes the most up-to-date recommendations for the management of children with traumatic bleeding.
Article
Introduction In response to mass casualty events, The Hartford Consensus brought together subject matter experts across multiple disciplines in health care and public safety to create guidelines and publications intended to improve survivability in active shooter events. Among the recommendations was the earlier recognition and treatment application of life-threatening hemorrhage control. These recommendations culminated in efforts to create the Stop the Bleed Campaign, which aims to empower the layperson to render aid in a life-threatening bleeding emergency. As of February 2020, the program has held over 86,000 courses, trained over 1.4 million attendees, and over 77,000 instructors since its inception. In addition to spreading within the United States, American College of Surgeons (ACS) Stop the Bleed (StB) classes have been held in 118 different countries. This systematic narrative review aims to answer the following research question: What does the ACS StB Initiative do well, and where can it improve? Materials and Methods The following search terms were utilized: “Stop the Bleed,” “American College of Surgeons,” “bleeding control,” “first-aid,” tourniquet, “wound pack,” “direct pressure” hemorrhage, and bystander. The inclusion criteria were that the article needed to speak to the program or some aspect of bystander first aid, the article needed to be in a civilian setting, the article needed to be more than a case study or overview, and the first aid tools needed to be in the StB curriculum. 4 databases were searched, which produced 138 articles for screening. One hundred four full-text articles were able to be retrieved, and 56 articles were determined to meet the inclusion criteria once the full text was reviewed. Results Fifty-six articles were included in the final review and were placed into the following categories: Needs Within the Community, Confidence and Knowledge, Training Modalities, Barriers and Gaps in Training, Instructor Selection, Skill Retention, and Patient Outcomes. The articles were then organized into each outcome for synthesis and reporting of the results. The program overwhelmingly improves short-term confidence, but gaps in skill retention, data collection on patient outcomes, and settings that would benefit were identified. Conclusion StB is an effective tool in building confidence in laypersons, which is its biggest strength. A review of the literature shows several areas where the curriculum and materials could be better developed. Research can also be further refined to better quantify the program’s impact.
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Background: Currently, several initiatives have emerged to empower the public to act as immediate responders in front of hemorrhaging victims. We aimed to evaluate the effectiveness of implementing the Stop the Bleed campaign and the association between the instructors' background and the theoretical and practical competences achieved by the participants in Latin America. Methods: Medical students and general surgeons taught both allied health students and nonallied health students at a local university; the training had a master class followed by a practical component and a written test, as well as tourniquet placement was tested. Results: 265 individuals received the training, and data were available for 243. Of these, 126 (52.07%) were women and the median age was 21 (IQR: 20-22) years. 121 (49.79%) were trained by general surgeons (group A) and 122 (50.21%) by medical students (group B). After the training, more than 98% of all participants perceived that they would most likely be capable of aiding correctly a bleeding victim by applying direct pressure and more than 90% of them felt confident in being able to apply a tourniquet. There were no statistically significant differences among both groups when comparing their post-training competence evaluations [Theoretical test score: group A = 5 (IQR: 4-5); group B = 5 (IQR: 4-5); P = 0.41] and [Practical competency of tourniquet deployment: group A = 119 (66.39%) versus group B = 120 (65.83%); P = 0.93]. Conclusions: The Stop the Bleed campaign can be effectively implemented in Latin America, and it can be taught by prequalified medical students without altering the learning objectives of the course.
Article
Introduction: Bystander training to control life-threatening hemorrhage is an important intervention to decrease preventable trauma deaths. We asked if receiving a trauma first aid (TFA) kit in addition to Bleeding Control (BC) 1.0 training improves self-reported confidence among community members (CM) and medical professionals (MP). Methods: Anonymous pre- and post-course surveys assessed exposure to severe bleeding, BC knowledge, and willingness to intervene with and without TFA kits. Surveys were compared using chi-squared tests. Results: 80 CM and 60 MP underwent BC training. Both groups demonstrated improved confidence in their ability to stop severe bleeding after the class; however, post-class confidence was significantly modified by receiving a TFA kit. After training, CM confidence was 36.1% without versus 57.0% with a TFA kit(p = 0.008) and MP confidence was 53.8% without versus 87.6% with a TFA kit(p = 0.001). Conclusion: Receiving a TFA kit was significantly associated with increased post-training confidence among CM and MP. Summary: Stop the Bleed training improves confidence in stopping severe bleeding among both medical professionals and community members. By providing participants with a trauma first aid kit, post-class confidence improves significantly regardless of medical training.
Article
Objectives Stop the Bleed (STB) is a national initiative that provides lifesaving hemorrhagic control education. In 2019, pharmacists were added as health-care personnel eligible to become STB instructors. This study was conducted to evaluate the efficacy of pharmacist-led STB trainings for school employees in South Texas. Methods Pharmacist-led STB trainings were provided to teachers and staff in Laredo, Texas. The 60-min trainings included a presentation followed by hands-on practice of tourniquet application, wound-packing, and direct pressure application. Training efficacy was assessed through anonymous pre- and postevent surveys, which evaluated changes in knowledge, comfort level, and willingness to assist in hemorrhage control interventions. Student volunteers (predominantly pharmacy and medical students) assisted in leading the hands-on portion, providing a unique interprofessional learning opportunity. Results Participants with previous training ( N = 98) were excluded, resulting in a final cohort of 437 (response rate 87.4%). Compared with baseline, comfort level using tourniquets (mean, 3.17/5 vs 4.20/5; P < 0.0001), opinion regarding tourniquet safety (2.59/3 vs 2.94/3; P < 0.0001), and knowledge regarding tourniquets (70.86/100 vs 75.84/100; P < 0.0001) and proper tourniquet placement (2.40/4 vs 3.15/4; P < 0.0001) significantly improved. Conclusions Pharmacist-led STB trainings are efficacious in increasing school worker knowledge and willingness to respond in an emergency hemorrhagic situation.
Article
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Purpose of Review We aim to determine the various models of training and identify educational strategies that would be efficacious in teaching bleeding control to the public. Recent Findings Recent studies have examined various educational strategies of bleeding control education including lectures, web-based classes, and hands-on training. The effectiveness of these trainings can not only be measured in increases in knowledge, but also in feelings of confidence, preparedness, and willingness to assist in a bleeding emergency. When looking at retention or skills and knowledge, we found that multiple studies showed decreases in ability to stop life-threatening bleeding when retested weeks or months after training. These issues of retention and a lack of education in general lead to a discussion about the possible benefits of having just-in-time (JiT) information during a bleeding emergency. Summary Based on the recent findings, bleeding control trainings have proven to be a very effective method of providing the general public with necessary skills. Therefore, moving forward, it is crucial to look at retention and the use of JiT information in longitudinal studies.
Article
Introduction Tourniquets (TQs) save lives. Although military-approved TQs appear more effective than improvised TQs in controlling exsanguinating extremity hemorrhage, their bulk may preclude every day carry (EDC) by civilian lay-providers, limiting availability during emergencies. Study Objective The purpose of the current study was to compare the efficacy of three novel commercial TQ designs to a military-approved TQ. Methods Nine Emergency Medicine residents evaluated four different TQ designs: Gen 7 Combat Application Tourniquet (CAT7; control), Stretch Wrap and Tuck Tourniquet (SWAT-T), Gen 2 Rapid Application Tourniquet System (RATS), and Tourni-Key (TK). Popliteal artery flow cessation was determined using a ZONARE ZS3 ultrasound. Steady state maximal generated force was measured for 30 seconds with a thin-film force sensor. Results Success rates for distal arterial flow cessation were 89% CAT7; 67% SWAT-T; 89% RATS; and 78% TK (H 0.89; P = .83). Mean (SD) application times were 10.4 (SD = 1.7) seconds CAT7; 23.1 (SD = 9.0) seconds SWAT-T; 11.1 (SD = 3.8) seconds RATS; and 20.0 (SD = 7.1) seconds TK (F 9.71; P <.001). Steady state maximal forces were 29.9 (SD = 1.2) N CAT7; 23.4 (SD = 0.8) N SWAT-T; 33.0 (SD = 1.3) N RATS; and 41.9 (SD = 1.3) N TK. Conclusion All novel TQ systems were non-inferior to the military-approved CAT7. Mean application times were less than 30 seconds for all four designs. The size of these novel TQs may make them more conducive to lay-provider EDC, thereby increasing community resiliency and improving the response to high-threat events.
Article
Background The “Stop the Bleed” (StB) campaign aims to educate laypersons on performing bleeding control techniques in any setting that requires hemorrhage control, such as motor vehicle crashes or mass casualty incidents. Participants undergo a didactic and practical session, the latter incorporating a mannequin. We hypothesized that participants would increase content knowledge after StB participation and that the training could be improved by a more life-like bleeding modification of the mannequin. Materials and methods From July 2017 to January 2018, hospital and community members from a major metropolitan area participated in StB training. Participants provided demographic data regarding prior emergency training and were asked pre- and post-test questions (five-point Likert scale) regarding their response to hemorrhage. Individuals also evaluated the mannequin on bleeding simulation. Scores were reported as means with standard deviation or medians with interquartile ranges (IQRs) with subset analysis stratified by experience. Results Of 402 participants, 310 provided complete data. On the composite, pre-test self-assessment, participants had a median score of 24 of 30 points (IQR 16-30). Post-testing demonstrated a statistically significant increase with a median score of 29 (IQR 25-30, P < 0.05). Subset analysis by prior emergency training (n = 102) demonstrated that both those with prior emergency training and those with no prior emergency training had significant improvement. On evaluation of the mannequin, participants reported that a more realistic model would increase their confidence in technique. Both subgroups reported that training would be enhanced if the mannequins were more realistic. Conclusions StB is an effective education program. Those without prior experience or training in hemorrhage cessation demonstrated the most improvement. Regardless of background, participants reported overwhelmingly that the training would be more effective if it were more realistic. Future work to design and develop cost-effective mannequins demonstrating pulsatile blood flow and cessation of hemorrhage could enable learners to actually “Stop the Bleed”.
Article
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Emergency services worldwide face increasing cost pressure that potentially limits their existing resources. In many countries, emergency services also face the issues of staff shortage–creating extra challenges and constraints, especially during crisis times such as the COVID-19 pandemic–as well as long distances to sparsely populated areas resulting in longer response times. To overcome these issues and potentially reduce consequences of daily (medical) emergencies, several countries, such as Sweden, Germany, and the Netherlands, have started initiatives using new types of human resources as well as equipment, which have not been part of the existing emergency systems before. These resources are employed in response to medical emergency cases if they can arrive earlier than emergency medical services (EMS). A good number of studies have investigated the use of these new types of resources in EMS systems, from medical, technical, and logistical perspectives as their study domains. Several review papers in the literature exist that focus on one or several of these new types of resources. However, to the best of our knowledge, no review paper that comprehensively considers all new types of resources in emergency medical response systems exists. We try to fill this gap by presenting a broad literature review of the studies focused on the different new types of resources, which are used prior to the arrival of EMS. Our objective is to present an application-based and methodological overview of these papers, to provide insights to this important field and to bring it to the attention of researchers as well as emergency managers and administrators.
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Objectives To evaluate and analyze the efficacy of implementation of hemorrhage-control training into the formal medical school curriculum. We predict this training will increase the comfort and confidence levels of students with controlling major hemorrhage and they will find this a valuable skill set for medical and other healthcare professional students. Methods After IRB and institutional approval was obtained, hemorrhage-control education was incorporated into the surgery clerkship curriculum for 96 third-year medical students at the University of Arkansas for Medical Sciences using the national Stop The Bleed program. Using a prospective study design, participants completed pre- and post-training surveys to gauge prior experiences and comfort levels with controlling hemorrhage and confidence levels with the techniques taught. Course participation was mandatory; survey completion was optional. The investigators were blinded as to the individual student’s survey responses. A knowledge quiz was completed following the training. Results Implementation of STB training resulted in a significant increase in comfort and confidence among students with all hemorrhage-control techniques. There was also a significant difference in students’ perceptions of the importance of this training for physicians and other allied health professionals. Conclusion Hemorrhage-control training can be effectively incorporated into the formal medical school curriculum via a single 2-hour Stop The Bleed course, increasing students’ comfort level and confidence with controlling major traumatic bleeding. Students value this training and feel it is a beneficial addition to their education. We believe this should be a standard part of undergraduate medical education.
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The crisis of gun violence in the United States disproportionately affects disadvantaged communities. Many solutions posit law enforcement-based, targeted policing, and sentencing strategies. This chapter provides an overview of community-focused, trauma-informed programs.
Article
Purpose of review: This review will explore the underlying causes of healthcare disparities among trauma patients and offer considerations for reducing inequities to improve trauma care. Recent findings: Newly recognized racial disparities exist with respect to triaging trauma patients and in acute pain management. Social Determinants of Health offers a model to understand disparity in trauma care. Summary: Race, ethnicity, socioeconomic status, and access to healthcare drive outcome disparity among trauma patients. These disparities include reduced healthcare services, inadequate pain management, reduced postdischarge care, and increased mortality. Increasing workforce diversity may mitigate implicit bias and improve cultural competency. Social determinants of health impact the disparities in trauma care and offer a framework to address care through creative solutions.
Article
Background Hemorrhage is a frequent complication that nurses and midwives must recognize and manage to avoid life-threatening consequences for patients. There is currently no synthesis of evidence on educational interventions in nursing and midwifery regarding hemorrhage, thus limiting the definition of best practices. Objective To map the literature on nursing and midwifery education regarding the recognition and management of hemorrhage. Design Scoping review based on the Joanna Briggs Institute guidelines. Data sources Quantitative studies evaluating the effect of educational interventions with students, nurses, or midwives published in English or French, with no time limit. Review methods Study selection, data extraction, and quality assessment were conducted by two independent reviewers. We characterized educational interventions based on the Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching. We categorized learning outcomes using the New World Kirkpatrick Model. Methodological quality appraisal was performed with tools from the Joanna Briggs Institute. Findings were synthesized using descriptive statistics and graphical methods Result Most of the 38 studies used a single-group design (n = 26, 68%) and were conducted with professionals (n = 28, 74%) in hospital settings (n = 20, 53%). Most were of low (n = 14; 37%) or moderate (n = 18, 47%) methodological quality. Most interventions focused on postpartum hemorrhage (n = 34, 89%) and combined two or more teaching strategies (n = 25, 66%), often pairing an informational segment (e.g., lecture, readings) with a practical session (e.g., workshop, simulation). Learning outcomes related to the management (n = 27; 71%) and recognition of hemorrhage (n = 19, 50%), as well as results for patients and organizations (n = 9, 24%). Conclusion Considerable heterogeneity in interventions and learning outcomes precluded conducting a systematic review of effectiveness. High-quality, controlled studies are needed, particularly in surgery and trauma. Reflection on the contribution of nurses and midwives to the detection, monitoring, and management of hemorrhage could enrich the content and expected outcomes of hemorrhage education.
Article
Background Civilians are often first-line responders in hemorrhage control; however, windlass tourniquets are not intuitive. Untrained users reading enclosed instructions failed in 38.2% of tourniquet applications. This prospective follow-up study replicated testing following Stop the Bleed (STB) training. Materials and Methods One and six months following STB, first-year medical students were randomly assigned a windlass tourniquet with enclosed instructions. Each was given one minute to read instructions and two minutes to apply the windlass tourniquet on the TraumaFX HEMO trainer. Demographics, time to read instructions and stop bleeding, blood loss, and simulation success were analyzed. Results 100 students received STB training. 31 and 34 students completed tourniquet testing at one month and six months, respectively. At both intervals, 38% of students were unable to control hemorrhage (P = 0.97). When compared to the pilot study without STB training (median 48 sec, IQR 33–60 sec), the time taken to read the instructions was shorter one month following STB (P <0.001), but there was no difference at 6 months (P = 0.1). Incorrect placement was noted for 19.4% and 23.5% of attempts at 1 and 6 months. Male participants were more successful in effective placement at one month (93.3% versus 31.3%, P = 0.004) and at six months (77.8% versus 43.8%, p = 0.04). Conclusions Skills decay for tourniquet application was observed between 1 and 6 months following STB. Instruction review and STB produced the same hemorrhage control rates as reading enclosed instructions without prior training. Training efforts must continue; but an intuitive tourniquet relying less on mechanical advantage is needed.
Article
Background: The Stop the Bleed (STB) campaign was developed in part to educate the lay public about hemorrhage control techniques aimed at reducing preventable trauma deaths. Studies have shown this training increases bystanders' confidence and willingness to provide aid. One high-risk group might be better solicited to take the course: individuals who have been a victim of previous trauma, as high rates of recidivism after trauma are well-established. Given this group's risk for recurrent injury, we evaluated their attitudes toward STB concepts. Methods: We surveyed trauma patients admitted to 3 urban trauma centers in Baltimore from January 8, 2020 to March 14, 2020. The survey was terminated prematurely due to the COVID-19 pandemic. Trauma patients hospitalized on any inpatient unit were invited to complete the survey via an electronic tablet. The survey asked about demographics, prior exposure to life-threatening hemorrhage and first aid training, and willingness to help a person with major bleeding. The Johns Hopkins IRB approved waiver of consent for this study. Results: Fifty-six patients completed the survey. The majority of respondents had been hospitalized before (92.9%) and had witnessed severe bleeding (60.7%). The majority had never taken a first aid course (60.7%) nor heard of STB (83.9%). Most respondents would be willing to help someone with severe bleeding form a car crash (98.2%) or gunshot wound (94.6%). Conclusions: Most patients admitted for trauma had not heard about Stop the Bleed, but stated willingness to respond to someone injured with major bleeding. Focusing STB education on individuals at high-risk for trauma recidivism may be particularly effective in spreading the message and skills of STB.
Article
Background: The Bleeding Control Basics (B-Con) Course was developed to teach lifesaving hemorrhage control techniques to the public. Currently, medical students (MS) without prior clinical experience (CE) may not act as autonomous instructors, limiting the instructor pool. Purpose: To assess the bleeding control knowledge of MS (phase I) and compare the knowledge of students taught by a certified instructor vs a medical student (phase II). Methods: Phase I: 20 MS, 6 with prior CE and 14 without clinical experience (NCE) completed a pre-course and post-course knowledge assessment. Results were assessed by independent sample t-tests. Phase II: 91 first-year MS were taught the B-Con Course by either a third-year MS (n = 45) or certified instructor (n = 46). An analysis of covariance (ANCOVA) was performed to compare scores by instructor type (certified vs MS) using prior CE and pretest scores as confounding variables. Results: In Phase I, the CE group scored higher on the pretest assessment compared to the NCE group (P = .003). All students improved in posttest scoring, and there was no difference in posttest scores between the groups (P = .597). In Phase II, despite no difference in pretest scores between groups, the MS taught learners scored significantly higher on the posttest compared to the certified instructor group (P < .01). Prior CE did not correlate to posttest scores (P = .719). Discussion: Medical students are as effective as certified instructors at conveying the B-Con learning objectives. Based on near-perfect assimilation of content by students, MS should be permitted to teach B-Con Courses.
Article
Introduction and Objectives: Massive hemorrhage (MH) is a growing pathology in military settings and increasingly in civilian settings; it is now considered a public health problem in the United States with large-scale programs. Tourniquets are the fastest and most effective intervention in MH if direct pressure is not effective. The Liaison Committee on Resuscitation (ILCOR) recognizes a knowledge gap in optimal education techniques for first aid providers. This review aims to describe training and evaluation methods for teaching tourniquet use to both health care and military professionals. Methods: The MEDLINE, CINAHL, WEB of Science, and Scopus databases were reviewed (from 2010 through April 2020). The quality of the selected studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) scale. Studies that met at least 65% of the included items were included. Data were extracted independently by two reviewers. Results: Ten of the 172 articles found were selected, of which three were randomized clinical trials. Heterogeneity was observed in the design of the studies and in the training and evaluative methods that limit the comparison between studies. Conclusions: The results suggest that the training strategies studied are effective in improving knowledge, attitudes, and practical skills. There is no universal method, learning is meaningful but research should be directed to find out which ones work best.
Article
Background The number of intentional mass casualty incidents (IMCI) has increased in recent years, and hemorrhage control is one of the important life-saving techniques used in these events. Objective The objective of this study is to understand the perceptions and experiences of nursing students subjected to a simulated intentional mass-casualty incident after receiving a training action within their curriculum, focused on how to respond to active threats and bleeding control. Design A qualitative phenomenological study on nursing students (n=74) enrolled in the Nursing Care for Critical Patients course, facing a simulated IMCI in November 2019. Data sources A total of 7 focus groups were performed, containing 8 to 12 participants each. Findings Participants reported a feeling of vulnerability and fear of an IMCI occurrence. Based on this context, the participants reported not knowing how to react to this type of situation, which is why training activities such as this one is seen as a way of improving participants’ self-protection and safety. Likewise, a simulated IMCI is considered useful for any citizen and as a training exercise for life-saving techniques, such as hemorrhage control. Conclusions Training on the subject of hemorrhage control using a simulated IMCI setting could increase self-efficacy and self-control, as well as reducing feelings of fear and vulnerability. Such training intervention could be primary prevention measures of an IMCI as well as a sustainable way to train knowledge-transmitting instructors.
Article
Background The American College of Surgeons Bleeding Control Course (B-Con) empowers bystanders with hemorrhage control skills to manage prehospital emergencies, but demonstrates poor skill retention. The point of care use of a free Stop the Bleed mobile phone application on the retention of hemorrhage control skills from the B-Con Course was explored. Methods Convenience sample of college students previously trained in B-Con were randomized into mobile application (MA) or control groups. The use of a mobile application during a simulated emergency scenario with tourniquet and situational awareness skills was assessed. Wound packing skill retention without intervention was also assessed. Survey data allowed for comparison of participant perceptions of skills with actual performances. Results MA (n = 30) was superior to control (n = 32) in correct tourniquet application (62.5% versus 30.0%; P = 0.01) with longer placement times (163 sec versus 95 sec; P < 0.001) and in calling 911 (31.3% versus 3.3%, P = 0.004). Participants maintain inflated perceptions of their skills, but generally feel underprepared for a future bleeding emergency. Conclusions Mobile apps improve tourniquet and situational awareness skills and may serve as potential aids to improve bystander hemorrhage control skills in real-time, but require further prospective investigation into its use.
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To determine the impact of the increasing aging population on trauma mortality relative to mortality from cancer and heart disease in the United States. The population in the United States continues to increase as medical advancements allow people to live longer. The resulting changes in the leading causes of death have not yet been recognized. Data were obtained (2000-2010) from the Web-based Injury Statistics Query and Reporting System database of the Centers for Disease Control and Prevention. We defined trauma deaths as unintentional injuries, suicides, and homicides. From 2000 to 2010, the US population increased by 9.7% and the number of trauma deaths increased by 22.8%. Trauma deaths and death rates deceased in individuals younger than 25 years but increased for those 25 years and older. During this period, death rates for cancer and heart disease decreased. The largest increases in trauma deaths were in individuals in their fifth and sixth decades of life. Since 2000, the largest proportional increase (118%) in crude trauma deaths occurred in 54-year-olds. Overall, in 2010, trauma was the leading cause of death in individuals 46 years and younger. Trauma remains the leading cause of years of life lost. Trauma is now the leading cause of death for individuals 46 years and younger. The largest increase in the number of trauma deaths and the highest crude number of trauma deaths occurred in baby boomers. Policy makers allocating resources should be made aware of the larger impact of trauma on our aging and burgeoning US population.
Article
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Abstract This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage.
Article
Importance Several national initiatives have emerged to empower laypersons to act as immediate responders to reduce preventable deaths from uncontrolled bleeding. Point-of-care instructional interventions have been developed in response to the scalability challenges associated with in-person training. However, to our knowledge, their effectiveness for hemorrhage control has not been established. Objective To evaluate the effectiveness of different instructional point-of-care interventions and in-person training for hemorrhage control compared with no intervention and assess skill retention 3 to 9 months after hemorrhage control training. Design, Setting, and Participants This randomized clinical trial of 465 laypersons was conducted at a professional sports stadium in Massachusetts with capacity for 66 000 people and assessed correct tourniquet application by using different point-of-care interventions (audio kits and flashcards) and a Bleeding Control Basic (B-Con) course. Non-B-Con arms received B-Con training after initial testing (conducted from April 2017 to August 2017). Retesting for 303 participants (65%) was performed 3 to 9 months after training (October 2017 to January 2018) to evaluate B-Con retention. A logistic regression for demographic associations was performed for retention testing. Interventions Participants were randomized into 4 arms: instructional flashcards, audio kits with embedded flashcards, B-Con, and control. All participants received B-Con training to later assess retention. Main Outcomes and Measures Correct tourniquet application in a simulated scenario. Results Of the 465 participants, 189 (40.7%) were women and the mean (SD) age was 46.3 (16.1) years. For correct tourniquet application, B-Con (88% correct application [n = 122]; P < .001) was superior to control (n = 104 [16%]) while instructional flashcards (n = 117 [19.6%]) and audio kit (n = 122 [23%]) groups were not. More than half of participants in point-of-care arms did not use the educational prompts as intended. Of 303 participants (65%) who were assessed 3 to 9 months after undergoing B-Con training, 165 (54.5%) could correctly apply a tourniquet. Over this period, there was no further skill decay in the adjusted model that treated time as either linear (odds ratio [OR], 0.98; 95% CI, 0.95-1.03) or quadratic (OR, 1.00; 95% CI, 1.00-1.00). The only demographic that was associated with correct application at retention was age; adults aged 18 to 35 years (n = 58; OR, 2.39; 95% CI, 1.21-4.72) and aged 35 to 55 years (n = 107; OR, 1.77; 95% CI, 1.04-3.02) were more likely to be efficacious than those older than 55 years (n = 138). Conclusions and Relevance In-person hemorrhage control training for laypersons is currently the most efficacious means of enabling bystanders to act to control hemorrhage. Laypersons can successfully perform tourniquet application after undergoing a 1-hour course. However, only 54.5% retain this skill after 3 to 9 months, suggesting that investigating refresher training or improved point-of-care instructions is critical. Trial Registration clinicaltrials.gov Identifier: NCT03479112
Article
Background The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency. Methods This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency. Results Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001). Conclusion In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign. RossEM , RedmanTT , MappJG , BrownDJ , TanakaK , CooleyCW , KharodCU , WamplerDA . Stop the bleed: the effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency .
Article
National implementation of the Hartford Consensus is a meticulous and incremental process. It consists of many elements that require collaboration and strategic leadership to achieve an efficient, effective, knowledgeable, resilient, and prepared citizenry. We strongly believe the public can and should act as immediate responders to stop bleeding from all hazards, including active shooter and intentional mass casualty events. The ACS has a long history of setting standards and educating responders through its Committee on Trauma and its programs. The ACS is therefore well-positioned to use its national and international networks to implement bleeding control education to improve survival and enhance resilience.
Article
Background: To date, no civilian studies have demonstrated that pre-hospital (PH) tourniquets improve survival. We hypothesized that late, trauma center (TC) tourniquet use would increase death from hemorrhagic shock compared to early (PH) placement. Methods: All patients arriving to a Level 1, urban TC between October 2008 and January 2016 with a tourniquet placed before (T-PH) or after arrival to the TC (T-TC) were evaluated. Cases were assigned the following designations: indicated (absolute indication [vascular injury requiring repair/ligation, operation within 2 hours for extremity injury, or traumatic amputation] or relative indication [major musculoskeletal/soft tissue injury requiring operation 2-8 hours after arrival, documented large blood loss]) or non-indicated. Outcomes were death from hemorrhagic shock, physiology upon arrival to the TC, and massive transfusion requirements. After univariate analysis, logistic regression was carried out to assess independent predictors of death from hemorrhagic shock. Results: A total of 306 patients received 326 tourniquets for injuries to 157 upper and 147 lower extremities. Two hundred eighty-one (92%) had an indication for placement. Seventy percent of patients had a blunt mechanism of injury. T-TC patients arrived with a lower systolic blood pressure (SBP, 101 [86, 123] vs. 125 [100, 145] mm Hg, p < 0.001), received more transfusions in the first hour of arrival (55% vs. 34%, p = 0.02), and had a greater mortality from hemorrhagic shock (14% vs. 3.0%, p = 0.01). When controlling for year of admission, mechanism of injury and shock upon arrival (SBP ≤90 mm Hg or HR ≥120 bpm or base deficit ≤ 4) indicated T-TC had a 4.5-fold increased odds of death compared to T-PH (OR 4.5, 95% CI 1.23-16.4, p = 0.02). Conclusions: Waiting until TC arrival to control hemorrhage with a tourniquet was associated with worsened blood pressure and increased transfusion within the first hour of arrival. In routine civilian trauma patients, delaying to T-TC was associated with 4.5-fold increased odds of mortality from hemorrhagic shock. Level of evidence: Level IV.
Article
Every minute counts in the case of an emergency, and bystanders, such as family, friends, and good samaritans, play a crucial role in increasing the likelihood of survival until professional medical care arrives. In light of the increasing rate of unfortunate events, such as 9/11, the Boston Marathon bombing, and mass shootings like at the Pulse nightclub in Orlando, Florida, there has been an increase in national policy efforts to enhance survivability from intentional mass casualty and active shooter events. A better understanding of the time it takes for emergency medical service (EMS) personnel to arrive on the scene of an emergency, as presented in the study by Mell and colleagues,¹ is crucial to the development of interventions to save lives.
Article
Background: The United States military considers tourniquets to be effective for controlling bleeding from major limb trauma. The purpose of this study was to assess whether tourniquets are safely applied to the appropriate civilian patient with major limb trauma of any etiology. Methods: Following IRB approval, patients arriving to a level-1 trauma center between October 2008 and May 2013 with a prehospital (PH) or emergency department (ED) tourniquet were reviewed. Cases were assigned the following designations: absolute indication (operation within 2 hours for limb injury, vascular injury requiring repair/ligation, or traumatic amputation); relative indication (major musculoskeletal/soft-tissue injury requiring operation 2-8 hours after arrival, documented large blood loss); and non-indicated. Patients with absolute or relative indications for tourniquet placement were defined as indicated, while the remaining were designated as non-indicated. Complications potentially associated with tourniquets, including amputation, acute renal failure, compartment syndrome, nerve palsies, and venous thromboembolic events, were adjudicated by orthopedic, hand or trauma surgical staff. Univariate analysis was performed to compare patients with indicated versus non-indicated tourniquet placement. Results: A total of 105 patients received a tourniquet for injuries sustained via sharp objects, i.e., glass or knives (32%), motor vehicle collisions (30%), or other mechanisms (38%). A total of 94 patients (90%) had indicated tourniquet placement; 41 (44%) of which had a vascular injury. Demographics, mechanism, transport, and vitals were similar between patients that had indicated or non-indicated tourniquet placement. 48% of the indicated tourniquets placed PH were removed in the ED, compared to 100% of the non-indicated tourniquets (p < 0.01). The amputation rate was 32% among patients with indicated tourniquet placement (vs. 0%; p = 0.03). Acute renal failure (3.2 vs. 0%, p = 0.72), compartment syndrome (2.1 vs. 0%, p = 0.80), nerve palsies (5.3 vs. 0%; p = 0.57), and venous thromboembolic events (9.1 vs. 8.5%; p = 0.65) and were similar in patients that had indicated compared to non-indicated tourniquet placement. After adjudication, no complication was a result of tourniquet use. Conclusion: The current study suggests that PH and ED tourniquets are used safely and appropriately in civilians with major limb trauma that occur via blunt and penetrating mechanisms.
Article
Background: Active shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders. Objective: To develop and implement tiered educational programs designed to teach police officers and lay bystanders the principles of initial trauma care and bleeding control using as a foundation the U.S. military's Tactical Combat Casualty Care course and the guidelines of the Committee on Tactical Emergency Casualty Care. Discussion: The Tactical Casualty Care for Law Enforcement and First Responders course is a 1-day program combining didactic lecture, hands-on skills stations, and clinical scenarios designed primarily for police officers. The Bleeding Control for the Injured is a 2- to 3-h program for the potential citizen responder in the skills of hemorrhage control. In addition, we document the application of these skills by law enforcement officers and first responders in several real-life incidents involving major hemorrhage. Conclusions: Developing and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival.
Article
Abstract Objective. We sought to characterize and estimate the frequency of mass casualty incidents (MCIs) occurring in the United States during the year 2010, as reported by emergency medical services (EMS) personnel. Methods. Using the 2010 National EMS Database of the National Emergency Medical Services Information System (NEMSIS), containing data from 32 states and territories, we estimated and weighted the frequency of MCIs documented by EMS personnel based on their perception of the event to produce incidence rates of MCIs per 100,000 population and MCIs per 1,000 9-1-1 calls requesting EMS service. We conducted descriptive analyses to characterize the MCIs by geographic location, incident type, and time of day as well as the MCI patients by demographic and health information. We used chi-squared tests to compare response delays and two-tailed t-tests to compare system response times between EMS responses documented as MCIs and those not. Results. Among the 9,776,094 EMS responses in the 2010 National EMS Database, 14,504 entries were documented as MCI. These entries represented an estimated 9,913 unique MCIs from the National EMS Database: 39.1% occurred in the South Atlantic region of the United States where only 19.1% of the population resides, 60.9% occurred in an urban setting, and 58.4% occurred on a street or highway. There were an estimated 13,677 MCI patients. The prehospital EMS personnel's primary impressions of the patients ranged from electrocution (0.01%) to traumatic injury (40.7%). Of the patients with a primary impression of injury (N = 7,960), motor vehicle traffic crash was the cause of injury for 62.7%. Among the MCI EMS responses, 47.6% documented experiencing a response delay compared to only 12.3% of non-MCI EMS responses. Conclusions. This study demonstrates the range of health conditions and characteristics of EMS responses that EMS personnel perceive as MCIs, suggests that response delays are common during MCIs, and indicates there may be underreporting of all persons involved in an MCI. The National EMS Database is useful for describing MCIs and may help guide national leadership in strengthening EMS system preparedness for MCIs.
Article
On April 15, two improvised explosive devices (IEDs) were detonated in short succession near the finish line of the Boston Marathon, in the middle of a densely packed crowd of thousands of runners, families, friends, and spectators. Three people were killed and 264 were injured,(1) with more than 20 sustaining critical injuries. Yet in the face of these tragic and horrifying events, despite catastrophic injuries not commonly seen in civilian medicine and the fact that these were the first IEDs to cause mass injuries in the United States, the overall medical response has generally been considered successful.(2) Victims at the . . .
Article
Although studies have ascertained that ten percent of soldiers killed in battle bleed to death from extremity wounds, little data exists on exsanguination and mortality from extremity injuries in civilian trauma. This study examined the treatment course and outcomes of civilian patients who appear to have exsanguinated from isolated penetrating extremity injuries. Five and 1/2 years' data (Aug 1994 to Dec 1999) were reviewed from two Level I trauma centers that receive 95% of trauma patients in metropolitan Houston, TX. Records (hospital trauma registries, emergency medical system (EMS) and medical examiner data) were reviewed on all patients with isolated extremity injuries who arrived dead at the trauma center or underwent cardiopulmonary resuscitation (CPR) or emergency center thoracotomy (ECT). Fourteen patients meeting inclusion criteria were identified from over 75,000 trauma emergency center (EC) visits. Average age was 31 years and 93% were males. Gunshot wounds accounted for 50% of the injuries. The exsanguinating wound was in the lower extremity in 10/14 (71%) patients and proximal to the elbow or knee in 12/14 (86%). Ten (71%) had both a major artery and vein injured; one had only a venous injury. Prehospital hemorrhage control was primarily by gauze dressings. Twelve (86%) had "signs of life" in the field, but none had a discernable blood pressure or pulse upon arrival at the EC. Prehospital intravenous access was not obtained in 10 patients (71%). Nine patients underwent ECT, and nine were initially resuscitated (eight with ECT and one with CPR). Those undergoing operative repair received an average of 26 +/- 14 units of packed red blood cells. All patients died, 93% succumbing within 12 hours. Although rare, death from isolated extremity injuries does occur in the civilian population. The majority of injuries that lead to immediate death are proximal injuries of the lower extremities. The cause of death in this series appears to have been exsanguination, although definitive etiology cannot be discerned. Intravenous access was not obtainable in the majority of patients. Eight patients (57%) had bleeding from a site that anatomically might have been amenable to tourniquet control. Patients presenting to the EC without any detectable blood pressure and who received either CPR or EC thoracotomy all died.
Trends in 1029 trauma deaths at a level 1 trauma center
  • B T Oyeniyi
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Oyeniyi BT, Fox EE, Scerbo M, Tomasek JS, Wade CE, Holcomb JB. Trends in 1029 trauma deaths at a level 1 trauma center. Injury. 2017;48(1):5e12. https://doi.org/10.1016/j.injury.2016.10.037.
Texas tourniquet study group
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Teixeira PGR, Brown CVR, Emigh B, et al. Texas tourniquet study group. J Am Coll Surg. 2018;226(5):769e776.
Emergency medical services response times in rural, suburban, and urban areas
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Mell HK, Mumma SN, Hiestand B, Carr BG, Holland T, Stropyra J. Emergency medical services response times in rural, suburban, and urban areas. JAMA Surg. 2017;152(10):983e984.
Epidemiology of mass causality incidents in the United States
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A Study of Active Shooter Incidents
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Blair JP, Schweit KW. A Study of Active Shooter Incidents, 2000-2013. Texas State University and the Federal Bureau of Investigation, US Department of Justice; 2014.