COMMENTARY

'Stop the Bleed' Kits--Preparing Everyone for Mass Casualties

Robert D. Glatter, MD; Peter M. Antevy, MD; Joseph V. Sakran, MD, MPH, MPA

Disclosures

January 10, 2019

Robert D. Glatter, MD: Based on a recent analysis of Centers for Disease Control and Prevention (CDC) data by the nonprofit advocacy group Educational Fund to Stop Gun Violence, 39,773 firearm fatalities occurred [in 2017], which equated to 109 deaths each day.[1] Gun deaths have now risen for the third straight year, with a 2017 spike driven largely by rising suicides, which made up nearly 60% of all gun deaths.[2] At the same time, mass-casualty incidents, including school shootings, have become more prevalent in our society. These events make the news and instill great fear in our communities.

These dire situations led to the rationale of arming citizens and bystanders with bleeding control kits. The kits are part of a broader campaign of empowerment and call-to-action to save lives, known as Stop the Bleed which is sponsored by the American College of Surgeons (ACS) Committee on Trauma.[3]

Joining us to discuss such initiatives to better protect citizens against gun violence is Dr Peter Antevy, an emergency medical services (EMS) physician and medical director for the Coral Springs/Parkland Fire Department, who treated victims on scene at the tragedy in Parkland, Florida. He is also a pediatric EMS physician at Joe DiMaggio Children's Hospital.

Also joining us is Dr Joseph Sakran, director of emergency general surgery at Johns Hopkins Hospital and one of the prominent leaders behind the recently created hashtag on Twitter, #ThisISOurLane, in response to a recent National Rifle Association statement on Twitter warning doctors to "stay in their lane" when speaking out against gun violence.[4] It is a pleasure to have both of you here to discuss this very important public health topic.

'Stop the Bleed' Campaign

Glatter: Peter, I want to begin with you. What are the most important aspects of trauma management? Is it the fact that the military-grade or magazine-fed weapons such as the AR-15 are a grim reality that could be a part of any mass-casualty incident? Bullets from these weapons cause significantly more tissue destruction and blood loss compared with bullets from a standard handgun.

In a recent 60 Minutes interview, you urged that we consider dispensing Stop the Bleed kits nationwide along with implementing training sessions in order to better equip our children to deal with the reality of future mass school shootings.[5] Can you elaborate on this campaign and how this campaign can save lives? And what is the military telling us about the type of violence on the streets in the United States?

Peter M. Antevy, MD: Those are great questions. The Stop the Bleed campaign was generated from what we learned in the military with the use of tourniquets, chest seals, and so forth. On the scene at Parkland that day, the lay public needs to understand that my EMS crews received the majority of those patients already with tourniquets and chest seals on, so we had approximately nine tourniquets and seven chest seals when those patients came out to us.

In 180 seconds, the Parkland shooter shot 131 rounds and hit 34 people. Seventeen are alive today because folks used tourniquets and chest seals on them.

Who are truly the first responders? They are laypeople and police officers. We have an RTF, a rescue task force, and we practice incessantly to try to get our medics into those buildings. But on that day and at other scenes around the country, it's very hard to get EMS in the building in the appropriate time. Therefore, our lay public and our police officers are our first responders and that is indeed what happened that day. We have made a big push over the past couple of years to get our entire communities equipped with Stop the Bleed kits and provide a campaign to help them learn how to do that when they have to.

Glatter: The shift to empower the community to do this is remarkable. The public and children in high school years, and maybe even younger, are getting involved so they can do something to intervene to stop the bleeding. Joe, could you go into the genesis of Stop the Bleed?

Joseph V. Sakran, MD, MPH, MPA: The Stop the Bleed program was born in the aftermath of Sandy Hook. A joint committee was convened by the ACS under the leadership of Dr Lenworth Jacobs in collaboration with others in the medical community and representatives from the federal government, the national security council, the US military, the Federal Bureau of Investigation, and governmental and nongovernmental emergency medical response organizations, among others.

The committee's recommendations are called the Hartford Consensus, which consists of four reports.[6] Among the Hartford Consensus recommendations, one called for training immediate responders.[7] These are individuals who are present at the scene who can immediately control bleeding with their hands and equipment that may be available. In October 2015, responding to the Hartford Consensus recommendation that the public should be trained, the White House launched the Stop the Bleed national awareness campaign with a call to action.[8]

Stop the Bleed is intended to cultivate a grass roots effort that encourages bystanders (in other words, immediate responders) to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives.

Stop the Bleed Kits Should Be as Accessible as AEDs

Glatter: The public may be afraid to get involved when blood is involved. What standard precautions have been instituted in order to mitigate the risks to civilians when someone is actively bleeding?

Antevy: There are gloves in the kit so that people can mitigate that risk. We try and teach that as much as we can in our class, but if you look at the Boston bombing and at what people do on scene when they have to help other people, they will just come on in and help. You have a very good point that those risks do have to be mitigated. Joe, do you have any thoughts?

Sakran: In addition to that, we always try to inform the public that if they do become exposed, they should please notify the professionals so that the appropriate implementation and workup can be done to also ensure public safety. But at the end of the day, if someone next to you is bleeding to death, I think most of us as citizens will do anything possible to try to save their life.

Glatter: This effort is so important. There are automated external defibrillators (AEDs) available everywhere. One could argue that we should have access to these kits everywhere—malls, stadiums, airports. Any thoughts on this?

Antevy: I can tell you what we have done. We implemented an ordinance. Two of the cities that I provide medical direction for were the first two cities in the country to do this. We mandate that buildings of a certain size have not just an AED but also a Stop the Bleed kit. Those businesses then have to learn how to use that kit. We have deployed a massive number of resources, all based through the fire department, to teach that. We have also deployed them throughout the school systems and we have trained thousands and thousands of teachers.

Today we ask our citizens to give Narcan, use AEDs, start CPR, and use an Epi-Pen. Even though this is not the answer to gun violence, it's very important that we teach all of our citizens how to use those things across the board.

We have high school students becoming emergency medical technicians prior to graduation. I think that in America today, we are all going to have to have a little bit of a medical degree at some point in our lives because of all the things we are expecting our citizens to do. We have actually put it into the ordinance, into law in our cities, to almost force the function, and that has been very effective.

Sakran: Peter made an important point. The Stop the Bleed campaign is not the solution to preventing gun violence. In fact, Stop the Bleed can be useful for a variety of scenarios. You are at the playground with your children and someone you know has a cut on their leg that needs bleeding control. It could be useful there and in a variety of other scenarios. This is really a grass-roots effort and it's very similar to CPR, which is why we are starting to see them in airports.

A good example is the Pittsburgh synagogue. [Kits] were in there and used during that mass shooting. We are starting to see them spread throughout the country.

Glatter: I believe that even Congress now is implementing some of these kits. I read about a recent meeting, so I think they have gotten the message, and legislatively that seems promising.

Antevy: We have had three saves with non–mass-casualty-incident–type events with bleeding kits. A few weeks ago, we treated a lady who hit a guardrail. The guardrail went through her car and it essentially sliced her leg open. An officer from Florida Highway Patrol, which we had spoken to, used a tourniquet and saved her life.

This does not have to deal with guns, per se. It's just a basic thing that we need to know as citizens. I agree with all that you guys have said.

Glatter: Yes. It is empowering. You are trying to reduce the fear that it's okay to get involved. We want to save lives. We don't want to wait for EMS to arrive because we can do something as the public before paramedics get there. I think that is the message you are sending to the community, and it's been very powerful.

Antevy: When you go into the military, not only do they teach you how to fight, but they also teach each of the soldiers who are not medics how to do this. In Coral Springs at the Parkland shooting, our police officers were ready to treat the victims. In most American cities today, law enforcement officers are told not to treat any victims even though they may have a tourniquet. They have those kits for themselves or for their partners. That has to be changed so that not only laypeople use these kits, but law enforcement officers who are in the building also use those kits on others. That is a big lesson to learn from the military. It's not just for our own; it's for the others in the area as well.

Elevating the Campaign on a National Level

Glatter: Right. Do you think there should be national legislation to make this effort elevated to a greater level?

Antevy: I think this is probably something that would have to be done on more of a local level to get it through the school system on a state-by-state level. As an example, the state of Florida still does not require CPR for high school graduation. It's a state issue. It should be a national issue as well but it's not. I believe legislation would help.

It's sad where we are in America today. It's very sad, but my children know how to stop bleeding.

Sakran: When you look at our country, most of the governing happens at the local level. I think this bleeding control effort is going to require citizens, private public partnerships, and the same sort of force that we saw behind getting CPR out there. But again, this is potentially useful for a variety of different scenarios.

Antevy: Going into our city hall with this ordinance—and again, we have done it twice—was very easy to do. It was very powerful and impactful. I think that every community should walk into their fire department and say, "Here is an ordinance. Let's do this here." That could happen really quickly with just some layperson support.

Raising Stop the Bleed Awareness and Providing Proper Training

Glatter: Do you think the Stop the Bleed campaign could be elevated on social media with how-tos and informational instructional videos to show people how to apply a tourniquet even with mannequins? Some people don't know how. Some don't even know exactly what a tourniquet is.

Sakran: The social media aspect of this is important in regard to building awareness, but we have to be very careful not to dilute a course that was developed in a very thoughtful manner and vetted. It insures that you have 30 minutes of slides and theoretical instruction followed by 30 minutes of practical instruction. A lot of effort went into developing this in the right way to ensure that we are teaching the right techniques.

Glatter: Could an app or something teach people through social media? Obviously one should attend classes—no question. But could the use of apps or the power of the phone reach people in that sense?

Antevy: When the White House put this out, they wanted "just-in-time" training. If you had never seen a tourniquet before, you would have the ability at the actual AED cabinet for there to be a screen, for example, or [instruction would be available], like you said, on an app.

One thing that I don't want to have happen is like what happened with CPR. We have forced people into a 4- or 8-hour course for CPR and then when it gets time to do CPR, they think it's so complicated. I think CPR should be taught in 10 minutes. With Stop the Bleed, I think we still have to do the didactic and have people get on the floor and do the tourniquets, so that does take a little bit of time, but it surely shouldn't be a 4-hour ordeal. It could be something like 30 or 40 minutes. 

Glatter: With virtual reality and augmented reality now, we are teaching surgeons and emergency physicians how to do procedures. Maybe this is part of the solution to empower people through those mediums in the future.

Sakran: It's a really good thought and we are already starting to see technology that can help be an additive to this. The course is now down to 1 hour, which I think is reasonable. In everyone's very hectic schedules, we should be able to take that time to learn a potentially lifesaving skill.

Antevy: Seattle has the best bystander CPR rate in the country because when the children are young, they are taught these basic things of how to push on someone's chest. We have to get [education on bleeding management] in early. We have to teach it young, as young as 9 years of age. There are data on that. The earlier the better. School systems are the way to do it, and if not, we should have quick and easy access to applications and so forth.

When Talking About Bleeding Becomes Personal

Glatter: This is personal for you, Peter. From what I understand, your [12-year-old] son told you that he was concerned about going to school, and you brought up an idea for a way he could empower or protect himself.[9] Do you want to talk about that a little bit?

Antevy: Yes. I was on scene [at Parkland] the entire day. We tried to keep it from my kids where I was, but obviously by the next morning the word was out, and my kids knew about it. It gets me emotional to this day, but my son looked at me and said, "Do I have to go to school today?" I thought about things to stop gun violence and so forth, which seemed so far away and complicated, and my instinct was to say, "Let's teach you how to stop the bleed if you have to do it on yourself or on your friend."

It's sad where we are in America today. It's very sad, but my children know how to stop bleeding. They know how to do CPR. I think children should start teaching children how to do this. We have to get it into the fabric of our country. As sad as it is, it's the world that we live in.

Glatter: Yes. Joe, any thoughts about that?

Sakran: Stop the Bleed is fine, but we as a country have a moral responsibility—and possibility—to come up with solutions that can really curve the public health crisis we are seeing when it comes to gun violence. As you know, we see this a lot in the media when mass shootings happen, but day in and day out across our inner cities, there are young black men being killed by gun violence. This is an epidemic that we're facing. It's unique to our country.

'Broader Solution' Is Needed

Antevy: I have an interesting story. A friend who is a trauma surgeon was asked to give a talk in the largest trauma center in Israel. He went and said, "I'm from Florida and I'm wondering: How many gunshot wounds do you treat per year?" He's expecting in the hundreds or the thousands. They looked at him and said, "Two." He came back to Florida and in his next shift, he had four victims. It's a major problem. I'm just an "on the ground guy" trying to fix the problems after they happen. There is a much larger question and much larger issue here. I think that what we are doing now is curving to try to save lives.

I have some numbers in front of me just to show you. When this shooter came in to Parkland, in 120 seconds he shot 70 rounds, he hit 24 people, and 13 of those people are alive today. In 60 more seconds on the third floor, he shot 61 rounds, he hit 10 people, and four of them are alive today. Seventeen kids are alive today because of the quick action and quick work of those folks who put on tourniquets and chest seals. We have to adjust to the environment that we are living in today, as sad as that may be.

Glatter: Joe, has that been your experience in Baltimore? Have you seen implementation of these kits or tourniquets? Have you seen anyone coming into the emergency department already in tourniquet?

Sakran: Yes. We do teach Stop the Bleed out of Johns Hopkins, and we teach it to different communities and schools and organizations. I would be remiss if I didn't mention again the fact that this program was born out of Sandy Hook. Dr Lenworth Jacobs, who really spearheaded this, looked at all of the autopsies from Sandy Hook. Unfortunately, none of those kids would have survived had there been the Stop the Bleed training at that time because of the type of injuries they had and the close proximity.

I definitely appreciate being able to mitigate what happens after the fact, but I think we have to recognize that there needs to be a broader solution to this.

Glatter: Absolutely. The data recently from the CDC that looked at the number of gun deaths in 2017[1,2] is just a chilling reminder that we have so much work to do on so many fronts and that all of us are in this together. I want to thank both of you for a very informative discussion.

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