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Stop the Bleed Training Empowers Learners to Act to Prevent Unnecessary Hemorrhagic Death
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.
... 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. ...
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.
... 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). ...
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.
... 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). ...
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
... 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. ...
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.
... Traumatic hemorrhage remains a significant cause of death for all ages regardless of the form of trauma [5]. It is estimated that 57% of deaths could be avoided with proper control of bleeding [6][7][8]. In 2015, the White House launched the Stop the Bleed (STB) training program to minimize preventable deaths from trauma [9,10]. ...
Background
The Stop the Bleed (STB) training program was launched by the White House to minimize hemorrhagic deaths. Few studies focused on the STB were reported outside the United States. This study aimed to evaluate the effectiveness of a problem-, team- and evidence-based learning (PTEBL) approach to teaching, compared to traditional teaching methods currently employed in STB courses in China.
Methods
This study was a parallel group, unmasked, randomised controlled trial. We included third-year medical students of a five-year training program from the Xiangya School of Medicine, Central South University who voluntarily participated in the trial. One hundred fifty-three medical students were randomized (1:1) into the PTEBL group (n = 77) or traditional group (n = 76). Every group was led by a single instructor. The instructor in the PTEBL group has experienced in educational reform. However, the instructor in the traditional group follows a traditional teaching mode. The teaching courses for both student groups had the same duration of four hours. Questionnaires were conducted to assess teaching quality before and after the course. The trial was registered in the Central South University (No. 2021JY188).
Results
In the PTEBL group, students reported mastery in three fundamental STB skills—Direct Finger Compression (61/77, 79.2%), Packing (72/77, 93.8%), and Tourniquet Placement (71/77, 92.2%) respectively, while 76.3% (58/76), 89.5% (68/76), and 88.2% (67/76) of students in the traditional group (P > 0.05 for each pairwise comparison). 96.1% (74/77) of students in the PTEBL group felt prepared to help in an emergency, while 90.8% (69/76) of students in the traditional group (P > 0.05). 94.8% (73/77) of students reported improved teamwork skills after the PTEBL course, in contrast with 81.6% (62/76) of students in the traditional course (P = 0.011). Furthermore, a positive correlation was observed between improved clinical thinking skills and improved teamwork skills (R = 0.82, 95% CI: 0.74–0.88; P < 0.001).
Conclusions
Compared with the traditional teaching method, the PTEBL method was superior in teaching teamwork skills, and has equally effectively taught hemostasis techniques in the emergency setting. The PTEBL method can be introduced to the STB training in China.
... American College of Surgeons/Stop the Bleed Training (Lei et al., 2019) ⃟ Students were trained on how to properly pack gunshot wounds and apply tourniquet via a program developed by the American College of Surgeons. ...
Firearm violence continues to substantially increase, yet medical education is largely devoid of firearm injury prevention efforts. We evaluated reactions to Gun Violence Prevention Week (GVPW) sessions to initiate a longitudinal curriculum. All 280 participants were invited to evaluate GVPW through post-session surveys and 158 responded; 77% (124/158) were medical students. One hundred nine participants reported no prior training. Themes from open-ended questions confirmed GVPW significance by noting importance of (1) advocacy/community, (2) personal narratives, and (3) skill-based strategies. Participants expressed need for further training. Future directions include required firearm violence prevention training for all medical students.
... 11 Absence of timely treatment in these cases can result in a mortality rate of up to 50%, 11 more than half of which could be prevented with adequate hemorrhage control by bystanders. 12 In LMICs, trauma alone leads to an estimated mortality of 90%, with 80% of them occurring in a prehospital setting, 13 having twice the odds of mortality as compared with HICs. ...
Background
Out-of-hospital cardiac arrest (OHCA) and life-threatening bleeding from trauma are leading causes of preventable mortality globally. Early intervention from bystanders can play a pivotal role in increasing the survival rate of victims. While great efforts for bystander training have yielded positive results in high-income countries, the same has not been replicated in low and middle-income countries (LMICs) due to resources constraints. This article describes a replicable implementation model of a nationwide program, aimed at empowering 10 million bystanders with basic knowledge and skills of hands-only cardiopulmonary resuscitation (CPR) and bleeding control in a resource-limited setting.
Methods
Using the EPIS (Exploration, Preparation, Implementation and Sustainment) framework, we describe the application of a national bystander training program, named ‘Pakistan Life Savers Programme (PLSP)’, in an LMIC. We discuss the opportunities and challenges faced during each phase of the program’s implementation and identify feasible and sustainable actions to make them reproducible in similar low-resource settings.
Results
A high mortality rate owing to OHCA and traumatic life-threatening bleeding was identified as a national issue in Pakistan. After intensive discussions during the exploration phase, PLSP was chosen as a potential solution. The preparation phase oversaw the logistical administration of the program and highlighted avenues using minimal resources to attain maximum outreach. National implementation of bystander training started as a pilot in suburban schools and expanded to other institutions, with 127 833 bystanders trained to date. Sustainability of the program was targeted through its addition in a single national curriculum taught in schools and the development of a cohesive collaborative network with entities sharing similar goals.
Conclusion
This article provides a methodological framework of implementing a national intervention based on bystander response. Such programs can increase bystander willingness and confidence in performing CPR and bleeding control, decreasing preventable deaths in countries having a high mortality burden.
Level of evidence
Level VI.
... Feedback from STB participants across multiple studies indicate an appreciation of the significance of bleeding control training, confidence in the ability to intervene when necessary and willingness to do so, and the desire for regular refresher training. [23][24][25][26] Despite good intentions and willingness to help those injured, barriers to the provision of bleeding control aid in the prehospital setting exist among the lay community and may include: lack of access to supplies such as tourniquets and hemostatic gauze to effectively stop bleeding, fear of disease transmission on the part of the bystander without the use of gloves, fear of inflicting additional pain, fear of being sued by the injured person, concern for lack of physical ability to completely stop active bleeding, and fear of wound contamination or additional tissue damage with tourniquet application. 27 Importantly, the extent to which these or any additional barriers may exist, how they may most effectively be addressed, and the impact they have on bystander intervention have yet to be fully elucidated. ...
Introduction
Uncontrolled trauma-related hemorrhage remains the primary preventable cause of death among those with critical injury.
Study Objective
The purpose of this investigation was to evaluate the types of trauma associated with critical injury and trauma-related hemorrhage, and to determine the time to definitive care among patients treated at major trauma centers who were predicted to require massive transfusion.
Methods
A secondary analysis was performed of the Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) trial data (N = 680). All patients included were predicted to require massive transfusion and admitted to one of 12 North American trauma centers. Descriptive statistics were used to characterize patients, including demographics, type and mechanism of injury, source of bleeding, and receipt of prehospital interventions. Patient time to definitive care was determined using the time from activation of emergency services to responder arrival on scene, and time from scene departure to emergency department (ED) arrival. Each interval was calculated and then summed for a total time to definitive care.
Results
Patients were primarily white (63.8%), male (80.3%), with a median age of 34 (IQR 24-51) years. Roughly one-half of patients experienced blunt (49.0%) versus penetrating (48.2%) injury. The most common types of blunt trauma were motor vehicle injuries (83.5%), followed by falls (9.3%), other (3.6%), assaults (1.8%), and incidents due to machinery (1.8%). The most common types of penetrating injuries were gunshot wounds (72.3%), stabbings (24.1%), other (2.1%), and impalements (1.5%). One-third of patients (34.5%) required some prehospital intervention, including intubation (77.4%), chest or needle decompression (18.8%), tourniquet (18.4%), and cardiopulmonary resuscitation (CPR; 5.6%). Sources of bleeding included the abdomen (44.3%), chest (20.4%), limb/extremity (18.2%), pelvis (11.4%), and other (5.7%). Patients waited for a median of six (IQR4-10) minutes for emergency responders to arrive at the scene of injury and traveled a median of 27 (IQR 19-42) minutes to an ED. Time to definitive care was a median of 57 (IQR 44-77) minutes, with a range of 12-232 minutes. Twenty-four-hour mortality was 15% (n = 100) with 81 patients dying due to exsanguination or hemorrhage.
Conclusion
Patients who experience critical injury may experience lengthy times to receipt of definitive care and may benefit from bystander action for hemorrhage control to improve patient outcomes.
... Arterial rupture leading to uncontrollable bleeding is a major cause of death worldwide [1][2][3]. Arterial injuries under emergency and adverse conditions, such as combat trauma and traffic accidents, often result in death or amputation due to the lack of suturing conditions [4,5]. Complex and time-consuming surgical suturing is the "gold standard" for arterial repair, requiring highly skilled surgical techniques and has a high failure rate [6][7][8]. ...
Arterial injuries, particularly in emergency situations or challenging environments, demand convenient, safe, and efficient repair strategies. Herein, we developed and evaluated a portable, suture-free, ultra-thin arterial repair membrane, referred to as the tissue-adhesive biphasic hydrogel membrane (TBHM). The TBHM was developed using electrospinning technology and a biphasic photosensitive hydrogel, composed of nitrobenzene-modified hyaluronic acid (HA-NB) and methacrylated polyvinyl alcohol (PVA-MA), with lithium phenyl-2,4,6-trimethylbenzoylphosphinate (LAP) as the photoinitiator. The TBHM was characterized by rapid bonding, high adaptability, and the ability to withstand a maximum burst pressure of 441.9 ± 25 mmHg. This membrane is capable of rapidly crosslinking and sealing a wound within 23 s. In vitro cell culture assays validated the biocompatibility and safety of the TBHM. Using a rabbit carotid artery rupture model, the TBHM allowed for immediate suture-free repair. Postoperative CT and Doppler ultrasound examinations confirmed restoration of normal anatomical structure and function. Histopathological analysis and molecular biology tests suggested that TBHM has potential anti-inflammatory and tissue regeneration-promoting properties. This study thus presented the TBHM as a promising novel strategy for the rapid, suture-free repair of arterial injuries, which may revolutionize emergency trauma and hemorrhage control scenarios.
... In 2018, the American College of Surgeons (ACS) developed STOP THE BLEED, a training course for nonhealthcare personnel to mitigate acute hemorrhage in the event of a firearm injury [6]. The training offers the general public knowledge on how to correctly apply tourniquets and pack gunshot wounds (GSWs). ...
Firearm injuries are now the leading cause of pediatric mortality in the United States. With the number of firearm injuries increasing at an alarming rate, the American Medical Association (AMA) declared firearm violence a public health crisis. In response to this emerging public health issue, the American College of Surgeons (ACS) developed the STOP THE BLEED training to educate laypersons on how to mitigate acute hemorrhage following gunshot wounds (GSWs) and other ballistic injuries. Stabilization of patients following GSWs is often handled by a multidisciplinary team of trauma and reconstructive surgeons. Here, we describe the history and ongoing role of reconstructive surgeons in preventing and addressing firearm morbidity and mortality. Hand surgeons are uniquely positioned to counsel patients on firearm safety, e.g., educating patients on proper firearm storage away from minors in the home, in an effort to mitigate accidental firearm injury to the upper extremity. As the evolving climate of firearm violence continues to rise, plastic and reconstructive surgeons will continue to play a critical role in restoring form and function among patients afflicted with GSWs.
... Stopping the bleeding in the first few minutes is crucial for meaningful survival, considering the delays between injury and definitive trauma care. Trained first responder is the most critical, and the weakest link in the chain of survival of golden hour [7][8][9]. ...
Trauma is a global challenge and India has one of the highest trauma deaths in the world. Despite United Nations target to halve the global number of deaths and injuries from road traffic crashes by 2030, death tolls from Road Traffic Injuries (RTI) rising in India. In pediatric age groups, falls from height add to the burden of trauma. Uncontrolled bleeding from exsanguination on scene is estimated to account for nearly 40% of RTI trauma related mortality. Stopping the bleeding in the first few minutes is crucial for meaningful survival and hence the role of training lay public who can reach the scene in minutes. Active Bleeding Control (ABC) pilot research project to simulation train the bystanders to stop the bleed showed promising outcomes in Hyderabad, India. This paper describes the ABC project and discusses the role of pediatricians in training the public to reduce morbidity and mortality from uncontrolled bleeding at trauma scene.
... Subgroup analysis results were different from the main analysis by the ability to put direct pressure on, confidence to stop bleeding, and willingness to apply a hemostatic dressing in a real-world situation. Seven studies 19,21,22,32,34,42,44 evaluated the trainees' willingness to apply a hemostatic dressing in a real-world situation: risk ratio (post / pre) is 1.05 (95% CI 1.02-1.09, p = 0.002) in other countries compared to 1.33 (95% CI 1.07-1.65, ...
OBJECTIVE
Our object was to comprehensively analyze the existing body of evidence to evaluate the Stop the Bleed (STB) course effectiveness and satisfaction and find the direction of improvement for the future.
STUDY DESIGN
A literature search with the term “Stop the Bleed” in the electronic databases PubMed, Web of Science, EMBASE, Cochrane Library was performed, retrieving records from January 1, 2013 to April 13, 2022 based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram. In addition, all selected papers' references were examined for qualified studies that were missed during the first search. Original publications were included that reported on (1) clinical studies of the STB course implementation; and (2) studies comparing students' hemostasis ability and attitude (comfort, confidence, and willingness) before and after the STB course. The literature search and data extraction were done independently by 2 writers. To establish consensus, disagreements will be handled with the help of a third reviewer. For data synthesis, the most inclusive data from studies with repeated data were abstracted. Changes in hemostasis questionnaire scoring and operation evaluation after the STB course were the main outcomes.
RESULTS
This systematic review and meta-analysis includes 36 trials with a total of 11,561 trainees. Thirty-one of them were undertaken in the USA, while the other 5, accounting for 13.9%, were conducted in other regions. Among various evaluation methods, 3 trials with 927 trainees indicated that scores of correct uses of tourniquet significantly increased after the STB course (mean difference of post versus pre groups, 44.28; 95% CI 41.24-47.32; p < 0.001). Significant difference was also observed in the willingness to apply a hemostatic dressing in a real-world situation (risk ratio for post versus pre groups, 1.28; 95% CI 1.08-1.52; p = 0.004) (7 studies and 2360 participants). The results indicate that hemostasis knowledge and skills after the STB course had improved, but statistics indicated that STB courses implemented in the USA were more effective than other regions.
CONCLUSIONS AND RELEVANCE
Meta-analysis showed that comparison before and after the STB course were significantly different. However, the outcome measures in each study were different and could not, therefore, be compiled in all cases. The effectiveness and worth of implementation of STB in different countries should be continuously evaluated in the future.
... 18 Personnel involved in prehospital care should be trained in the Stop-the-Bleed protocol to avoid preventable hemorrhagic death. 19 Our hospital is the regional referral center for many surrounding cities. Although some of these patients could potentially be managed locally, in practice most patients with traumatic vascular injuries are sent to our center. ...
Background:
Despite significant improvements in outcomes, traumatic arterial limb injuries remain a significant cause of limb loss and mortality.
Objectives:
This study sought to identify predictors of mortality and major amputation in patients undergoing revascularization after femoropopliteal arterial trauma.
Methods:
This was a retrospective review of a trauma registry from an urban trauma center in Brazil. All patients admitted to our hospital with a femoropopliteal arterial injury from November 2012 to December 2017 who underwent vascular reconstruction were included. Univariate analyses and logistic regression analyses were conducted to identify factors independently associated with the primary outcome of amputation and the secondary outcome of mortality.
Results:
Ninety-six patients were included. Eleven patients (11.5%) had an amputation and 14 (14.6%) died. In the logistic regression model for amputation, patients with ischemia duration greater than 6 hours were approximately 10 times more likely to undergo an amputation compared to those with ischemia duration less than or equal to 6 hours (adjusted odds ratio (AOR) [95% confidence interval (CI)]: 9.6 [1.2-79.9]). The logistic regression model for mortality revealed that patients with ischemia duration greater than 6 hours were approximately 6 times more likely to die compared to those with ischemia duration less than or equal to 6 hours (AOR [95% CI]: 5.6 [1.3 to 24.7).
Conclusions:
Ischemia duration remains the most important factor independently associated with limb loss and mortality for patients undergoing femoropopliteal arterial revascularization after traumatic injuries. Physiological status on admission and trauma scores are also important.
... 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]. ...
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.
... 21 Several studies found the same results in their research on medical school students and health care employees. [22][23][24][25][26] The literature on the general population shows similar results. Schroll et al. 27 identified significant differences in precourse and postcourse groups as well as a 99.3% ...
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.
... 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] . ...
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.
... 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. ...
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.
... 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. ...
... [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. ...
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.
... 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. ...
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.
Trauma is the leading indication for amputation in young patients and accounts for 15% of amputations annually in the United States. Although blunt trauma is the predominant cause of traumatic amputation, the incidence of penetrating trauma resulting in amputation has steadily increased over the last two decades. These are primarily due to gunshot wounds and stab injuries. When the penetrating trauma results in a combined arterial and skeletal injury, the risk for primary amputation greatly increases secondary to greater disruption of collaterals, soft tissues, and nerves.
Background
In many regions of the world, most trauma deaths occur within 1–2 h of injury due to uncontrolled bleeding. For this reason, training lay first-person responders in trauma care, focusing on hemorrhage control, has been recommended. We hypothesized that STOP THE BLEED (STB) training courses that teach laypersons how to stop traumatic compressible bleeding immediately are needed to potentially prevent deaths due to hemorrhage. This systematic review will analyze the effect of the STB training course on the knowledge, skill, and attitudes of lay first-person responders for hemorrhage control.
Methods
PubMed and Google Scholar databases were used to identify relevant peer-reviewed research articles describing evaluations of STB courses for laypersons from December 1 2013 to October 31 2022. In addition, a hand search of article references was undertaken. Studies were included if they implemented the STB course; trainees were laypersons, and the study had some outcome measures such as knowledge, skill, confidence gained, and willingness to provide or utilization of care provided to and outcomes of trauma patients.
Results
The database searches yielded 2,893 unique papers. We retained 33 articles for full-text review, resulting in 24 eligible papers. Gray literature and manual searches yielded 11 additional publications for a total of 35 studies. The most reported finding was a statistically significant increase in hemorrhage control knowledge or tourniquet application skills in 26 studies. Twenty-two studies reported statistically significant improvements in willingness, confidence, comfort, and likelihood to respond to a bleeding patient, and 6 studies reported substantial reductions in the retention of bleeding control knowledge or skills. Only one study reported on the effect on patient outcomes.
Conclusion
STB courses for laypersons have demonstrated significant improvements in knowledge, skill, confidence, and willingness to intervene to stop traumatic exsanguination. The evaluation of clinically relevant patient outcomes, specifically their effect on preventable deaths from traumatic exsanguination, is needed to strengthen further the evidence behind the recommendations for more widespread teaching of “STB” courses.
Objectives
To provide a narrative review of hospital violence (HV) and its impact on critical care clinicians.
Data Sources
Detailed search strategy using PubMed and OVID Medline for English language articles describing HV, risk factors, precipitating events, consequences, and mitigation strategies.
Study Selection
Studies that specifically addressed HV involving critical care medicine clinicians or their practice settings were selected. The time frame was limited to the last 15 years to enhance relevance to current practice.
Data Extraction
Relevant descriptions or studies were reviewed, and abstracted data were parsed by setting, clinician type, location, social media events, impact, outcomes, and responses (agency, facility, health system, individual).
Data Synthesis
HV is globally prevalent, especially in complex care environments, and correlates with a variety of factors including ICU stay duration, conflict, and has recently expanded to out-of-hospital occurrences; online violence as well as stalking is increasingly prevalent. An overlap with violent extremism and terrorism that impacts healthcare facilities and clinicians is similarly relevant. A number of approaches can reduce HV occurrence including, most notably, conflict management training, communication initiatives, and visitor flow and access management practices. Rescue training for HV occurrences seems prudent.
Conclusions
HV is a global problem that impacts clinicians and imperils patient care. Specific initiatives to reduce HV drivers include individual training and system-wide adaptations. Future methods to identify potential perpetrators may leverage machine learning/augmented intelligence approaches.
The number one cause of preventable death in trauma is uncontrolled bleeding. Considering the burden of injury and fatality from motor vehicle collisions, accidental injury, and now increasing school shooting incidents, more should be done to prepare and protect students from this preventable cause of death. A school-based hemorrhage control training program is one approach to improve survivability, school preparedness, injury prevention strategies, and to increase access to this life-saving training. As advocates and health educators, school nurses can play an important role in developing strategies to coordinate and implement hemorrhage control training curricula giving our youth the greatest chance for survival. To maximize the impact of school-based hemorrhage control training this project aims to understand student and faculty perceptions to help direct and inform future implementation and dissemination of hemorrhage control training.
Acute hemorrhage in sport is a common issue for the sideline professional. The severity of bleeding ranges from mild to severe and life- or limb-threatening. The mainstay of management of acute hemorrhage is achieving hemostasis. Hemostasis is frequently accomplished via direct pressure but may require more invasive management including tourniquet use or pharmacologic management. With concerns for internal bleeding, dangerous mechanism of injury, or signs of shock, prompt activation of the emergency action plan is required.
Death and disability associated with traumatic injury can be significantly decreased with timely and appropriate care. Patients in rural areas tend to have disproportionately decreased access to this care, with the pediatric age group acting as a particularly difficult challenge for pre-hospital and rural hospital settings due to the unfamiliarity of those trauma response teams with pediatric age specific management guidelines as well as a disparity in resource availability. In this review, we attempt to discuss the challenges facing pediatric trauma care in the rural and low resourced communities, as well as initiatives that are being carried out to optimize this kind of care, such as pediatric readiness, rapid transportation to higher levels of care, availability of blood in rural centers as well as in transit, and the utility of telemedicine in improving rural pediatric trauma care.
Objective
The objective of this study is to explore the perception of teachers, parents and students’ regarding implementation of a school-based lifesaving skills program and help predict potential barriers and solutions.
Methods
This qualitative exploratory study was conducted in Karachi, Pakistan, from December 2020- to October 2021. We included students, teachers, and parents of secondary (grades VIII, IX, and X) and higher secondary level students (grades XI and XII) in Karachi, Pakistan's public and private schools and colleges. We selected one public, two semi-private, and two private schools. We recruited students, teachers, and parents through convenience sampling. We conducted fifteen focus group discussions (FGDs) with the students, six FGDs with the teachers, and eighteen in-depth interviews (IDIs) with parents. We transcribed the data from audio recordings and translated it into the English language. Finally, we manually analyzed the data using thematic analyses.
Results
This study found that bystanders' main barriers to performing lifesaving skills are lack of knowledge, fear of legal involvement, fear of hurting the patient by incorrect technique, lack of empathy among community stakeholders, and gender bias. The participants had a positive and supportive attitude toward implementing lifesaving skills training in schools. They suggested starting student training in the early teenage years, preferred medical staff as trainers, and suggested frequent small sessions in English/Urdu both or Urdu language and training via theory and practical hands-on drills. Furthermore, it was proposed that the training be integrated into the school curriculum to make it sustainable. Finally, the government needs to support the program and make the legal environment more conducive for the bystanders.
Conclusion
This study identified the significant barriers to performing lifesaving skills in an emergency in a low- and middle-income country (lmic). The participants showed support for implementing a national lifesaving skills program in schools and colleges. However, the participants expressed that support is needed by the government for sustainability, integrating the lifesaving skills into the school curriculum, providing legal support to the bystanders, and creating awareness among the general public.
Introduction
Uncontrolled bleeding is a leading cause of preventable death. The “Stop the Bleed” (StB) program trains laypersons in hemorrhage control. This study evaluated the efficacy of video-based StB training.
Methods
Participants watched two different videos: a didactic video (DdV) and a technical video (TeV) demonstrating proper techniques for StB skills (i.e., direct pressure [DP], wound packing [WP], and tourniquet application [TA]). Then, they completed a standardized skills examination (SE). Participants were surveyed at three different time points (baseline, post-DdV, and post-SE) for comparison. We compared paired categorical and continuous variables with the McNemar-Bowker test and Wilcoxon signed-rank test, respectively. Alpha was set at 0.05.
Results
One hundred six participants were enrolled: 52% were female and the median age was 23 y (22, 24). At baseline, 29%, 8%, and 13% reported being somewhat or extremely confident with DP, WP, and TA, respectively. These percentages increased to 92%, 79%, and 76%, respectively, after the DdV (all, P < 0.0001). After the TeV and SE, percentages increased further to 100%, 96%, and 100% (all, P < 0.0001). During the SE, 96%, 99%, and 89% of participants were able to perform DP, WP, and TA without prompting. Among participants, 98% agreed that the video course was effective and 79% agreed that the DdV and TeV were engaging.
Conclusions
We describe a novel paradigm of video-based StB learning combined with an in-person, standardized SE. Confidence scores in performing the three crucial StB tasks increased significantly during and after course completion. Through remote learning, StB could be disseminated more widely.
Objective
The objective of this study is to explore the perception of teachers, parents and students’ regarding implementation of a school-based lifesaving skills program and help predict potential barriers and solutions.
Methods
This qualitative exploratory study was conducted in Karachi, Pakistan, from December 2020- to October 2021. We included students, teachers, and parents of secondary (grades VIII, IX, and X) and higher secondary level students (grades XI and XII) in Karachi, Pakistan's public and private schools and colleges. We selected one public, two semi-private, and two private schools. We recruited students, teachers, and parents through convenience sampling. We conducted fifteen focus group discussions (FGDs) with the students, six FGDs with the teachers, and eighteen in-depth interviews (IDIs) with parents. We transcribed the data from audio recordings and translated it into the English language. Finally, we manually analyzed the data using thematic analyses.
Results
This study found that bystanders' main barriers to performing lifesaving skills are lack of knowledge, fear of legal involvement, fear of hurting the patient by incorrect technique, lack of empathy among community stakeholders, and gender bias. The participants had a positive and supportive attitude toward implementing lifesaving skills training in schools. They suggested starting student training in the early teenage years, preferred medical staff as trainers, and suggested frequent small sessions in English/Urdu both or Urdu language and training via theory and practical hands-on drills. Furthermore, it was proposed that the training be integrated into the school curriculum to make it sustainable. Finally, the government needs to support the program and make the legal environment more conducive for the bystanders.
Conclusion
This study identified the significant barriers to performing lifesaving skills in an emergency in a low- and middle-income country (lmic). The participants showed support for implementing a national lifesaving skills program in schools and colleges. However, the participants expressed that support is needed by the government for sustainability, integrating the lifesaving skills into the school curriculum, providing legal support to the bystanders, and creating awareness among the general public.
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.
Objectives:
To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage.
Methods:
A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines.
Results:
Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care.
Conclusions:
Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Preparing for disasters both natural and anthropogenic requires assessment of risk through hazard vulnerability analysis and formulation of facility and critical care–specific disaster plans. Disaster surge conditions often require movement from conventional to contingency or crisis-level operations to meet the needs of the many under our care. Predisaster planning for modification of critical care space, staffing, and supplies is essential to successful execution of operations during a surge. Expansion of intensive care unit beds to nonconventional units such as perioperative areas, general care units, and even external temporary units may be necessary. Creative, tiered staffing models as well as just-in-time education of noncritical care clinicians and support staff are important to multiply capable personnel under surge conditions. Finally, anticipation of demand for key equipment and supplies is essential to maintain stockpiles, establish supply chains, and sustain operations under prolonged disaster scenarios.
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.
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.
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”.
Objectives:
Uncontrolled bleeding is the leading cause of preventable death after a traumatic event, and early intervention to control bleeding improves opportunities for survival. It is imperative to prepare for local and national disasters by increasing public knowledge on how to control bleeding, and this preparation should extend to both adults and children. The purpose of this study is to describe a training effort to teach basic hemorrhage control techniques to early adolescent children.
Methods:
The trauma and emergency departments at a combined level I adult and level II pediatric trauma center piloted a training initiative with early adolescents (grades 6-8) focused on 2 skills: packing a wound and holding direct pressure, and applying a Combat Application Tourniquet. Students were evaluated on each skill and completed presurveys and postsurveys indicating their likelihood to use the skills.
Results:
Of the 194 adolescents who participated in the trainings, 97% of the students could successfully pack a wound and hold pressure, and 97% of the students could apply a tourniquet. Before the training, 71% of the adolescents indicated that they would take action to assist a bleeding victim; this increased to 96% after the training.
Conclusions:
Results demonstrate that basic hemorrhage control skills can be effectively taught to adolescents as young as 6th grade (ages 11-12 years) in a small setting with age-appropriate content and hands-on opportunities to practice the skills and such training increases students' perceived willingness to take action to assist a bleeding victim.
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.
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.
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.
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
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 .
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.
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.
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.
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.
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.
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 . . .
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
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Epidemiology of mass causality incidents in the United States
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A Study of Active Shooter Incidents
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