Hemorrhage Control Force Multipliers

MAY 2019

HEMORRHAGE CONTROL FORCE MULTIPLIERS How EMS & Fire Departments can leverage the community to ‘Stop the Bleed’ AN EXCLUSIVE EDITORIAL SUPPLEMENT TO JEMS AND FIRE ENGINEERING

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® PRODUCTSWITH A MISSION STOP THE BLEED

INTRODUCTION STOP THE BLEED

BY A.J. HEIGHTMAN, EDITOR-IN-CHIEF, JEMS

Law enforcement officers are usually the first Readying Civilian Responders responders on scene when violence erupts. Because This special supplement to JEMS and Fire Engineering of this, many progressive police departments have details programs that have gone beyond the training of trained and equipped their officers to recognize and police or others in the public safety realm, extending effectively control severe hemorrhage. Stop the Bleed training to civilians: the true “first” The officers are trained to treat not only themselves, responders who can make an impact and save lives when but they’re also trained in what to do when confronted an event happens in their own home, at their school or with a civilian or fellow law enforcement officer while at work, on vacation or simply while enjoying an presenting with significant injuries from a gunshot afternoon in the park with their children or walking wound or other trauma causing severe blood loss. their dogs. The officers are also well-equipped with proper Each of these programs recognizes and teaches that hemorrhage control tools: wound clot gauze, chest a person can bleed to death from a severe wound in five seals, pressure bandages and tourniquets, often minutes or less if no action is taken. packaged in an individual first aid kit (IFAK) or a Each of these programs stresses the need and assists bleeding control kit. in supplying civilians with hemorrhage control products that are essential for them to access immediately, Trained & Equipped to Act wherever thjey are. In late Spring 2017, Corporal Seth Kelly of the This immediate access to the proper equipment is Pennsylvania State Police attended an in-service key, because the reality is that emergency responders training program presented by a tactical medic. can’t always get to patients within five minutes. The instructor told the class that although they These programs are showing us that this is actually carry well-equipped IFAKs in their cruisers, it would OK; the public has responded well to these short, highly be beneficial if officers carried a tourniquet on their interactive and hands-on training programs. Civilians person so they could access and use it rapidly if shot or are recognizes the need and expressing willingness to severely injured while outside of their vehicle. act. In many communities, Stop the Bleed kits are now When he got home after work, Kelly told his wife being placed alongisde AEDs. Philomena, also a police officer, that the in-service Civilians trained to prevent severe hemorrhage are made him realize there was a 50/50 chance of being even purchasing Stop the Bleed kits for their homes. shot on the job. So, he decided they should both wear a Bleeding control kits are now found in restaurants and tourniquet on their belt. He ordered two the next day. gyms and a multitude of other locations where civilian Six months later, on Nov. 7, 2017, Kelly and another responders can make a difference when time is critical. officer were placing a DUI suspect under arrest on Many of these trained civilians are now carrying a highway when a struggle ensued and the suspect tourniquets, wound clot dressings and even chest seals reached into his car and retrieved a handgun. in their cars, purses or briefcases. He shot Kelly four times. It’s time to implement a Stop the Bleed program in your One of the bullets severed the femoral artery in service area. It’s time to ensure that anyone who’s severely Kelly’s left leg. (A video of the incident can be accessed injured doesn’t die needlessly. Time is of the essence. on YouTube: https://youtu.be/HbA9yfeNoA8.) Kelly instinctively dived over a guard rail to shield himself and returned fire. He retrieved the tourniquet from his belt and applied it rapidly. Despite losing 85% of his total blood volume and going into cardiac arrest, Kelly survived.

Stop the Bleed JEMS May 2019 | 3 STOP THE BLEED

CONTENTS

5 A Time to ACT — Antidote, CPR/AED, Tourniquet Novel first-aid program targets opioid overdoses, cardiac arrests & hemorrhage control By Shaughn Maxwell, BHSc, EMT-P

14 Modern-Day Bucket Brigade How University Hospitals implemented a region-wide Stop the Bleed program By Dominic Silvestro, EMT-P, EMS-I & Dan Ellenberger, EMT-P

17 Stop the Bleed & Start the Heart Teaching Texas middle schoolers to ‘see something & do a lot’ By Ashley Hoppe, BBA, NREMT; Courtney Nesloney, RN, BSN; Kelsey Brown, AS; Elizabeth Dillard, BA, NREMT & Harry “Steve” Stevenson, MPA, NREMT

19 Cleveland Hopkins Airport Launches Stop the Bleed Airport fire department acquires 100 kits & trains 2,000 employees By Matt Urie, BS, EMT-P, EMSI

22 Connecticut Schoolteachers Learn Hemorrhage Control A reproducible model of Stop the Bleed training in a suburban school district By Jeremy Fridling, BA, NRP, TP-C; Scott Martus, MS, LP & David Shapiro, MD, MHCM, FACS, FCCM

SR. VICE PRESIDENT & EXECUTIVE DIRECTOR Eric Schlett GROUP PUBLISHER Ted Billick VICE PRESIDENT, GROUP EDITOR Chief (Ret.) Bobby Halton EDITOR-IN-CHIEF A.J. Heightman, MPA, EMT-P EXECUTIVE EDITOR Mike McEvoy, PhD, NRP, RN, CCRN MANAGING EDITOR Ryan Kelley, NREMT ADVERTISING SALES Dillon Corbett, Erin Moriarity, Mike Shear SENIOR ART DIRECTOR Chad Wimmer

COVER PHOTO COURTESY LESLIE HYNES/SOUTH SNOHOMISH COUNTY (WASH.) FIRE & RESCUE

Hemorrhage Control Force Multipliers is a sponsored editorial supplement published by ClarionUX, 1421 S. Sheridan Road, Tulsa, OK 74112; 918-835-3161 (ISSN 0197-2510, USPS 530-710). Copyright 2019 ClarionUX. No material may be reproduced or uploaded on computer network services without the expressed permission of the publisher. Subscription information: To subscribe to JEMS, visit www.jems.com/enewsletter. Advertising information: Rates are available at www.jems.com/advertise or by request from JEMS Advertising Department at 1421 S. Sheridan Road, Tulsa, OK 74112; 800-331-4463. STOP THE BLEED A Time to ACT — Antidote, CPR/AED, Tourniquet Novel first-aid program targets opioid overdoses, cardiac arrests & hemorrhage control

BY SHAUGHN MAXWELL, BHSC, EMT-P

Over time, threats to society have changed.1 In order to mitigate negative consequences and maximize opportunity, society must develop programs designed to adapt to change. The first five minutes of a life- threatening emergency are critical. Citizens must be trained to act in these moments. Unfortunately, the percentage of citizens trained to provide first aid on an annual basis remains in the single digits.2 This article will explain the reasons behind the low percentages of citizens being trained and utilized to address critical emergencies in their community, as well as detail a revised first-aid program that was developed based on these findings and current leading threats to modern society. The ACT (i.e., Antidote, CPR/ AED, Tourniquet) program provides an evidence-based approach that effectively and efficiently empowers a greater portion of the public to save a life. In an effort to improve cardiac resuscitation results and address multiple other emergency response needs, South County Fire Deputy Chief Shaughn Maxwell, EMT-P, and Medical Director Rich Campbell, MD, along with assistance from department staff, researched currently available citizen emergency response programs on the effectiveness of the Hemorrhage control (through tourniquet application and/or wound packing) is one of three programs and derivations that have been vital first-aid skills in the ACT program, an evidence-based reinvention of traditional first aid. proven effective. Maxwell and Campbell PHOTOS COURTESY LESLIE HYNES/SOUTH SNOHOMISH COUNTY (WASH.) FIRE & RESCUE subsequently authored a new program and curriculum to address he needs of both their agency and their community of South 2. CPR/AED delivery with hands-on focused on lifesaving interventions; Snohomish County, Washington. training; and • Focused on interventions for conditions The ACT program consists of a one-hour 3. Tourniquet application and wound that cause death within minutes; hands-on course that teaches three vital packing to stop bleeding. • Taught in a brief (60-minute) time first-aid skills: The ACT program is based on evidence- period, with minimal equipment; and 1. Antidote for suspected opiate overdose based research, supported by over 30 • Designed for rapid deployment and with hands-on naloxone delivery via academic references. The program is: scaling; it has a train-the-trainer training aid and naloxone simulator; • An educational outreach program component, allowing for greater reach

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Administration of naloxone for suspected opioid overdose victims prior to the arrival of first Prominent Threats & responders is a critical first-aid skill taught in the ACT program. Unprepared Citizens Three prominent life-threatening challenges to modern society include 1) and community penetration. ACT First-Aid: An Evidence- cardiac arrest; 2) opiate overdose; and 3) The overall goal of the ACT program Based Proposal uncontrolled hemorrhage. The increasing is to change outreach training courses to The world is changing at an accelerating prevalence of these threats are related practical application and empower every pace. It’s often stated that change is hard. to cardiac disease, the opioid epidemic, community member to “ACT” against However, failing to change can also be and increased terror attacks. The sequela three leading threats to society: dangerous. Many people are deluged with following these three situations has the 1. Improving administration of naloxone a constant flow of information. potential to cause death in minutes; for suspected opioid overdose victims This constant volume makes it however, rapid, simple citizen intervention prior to the arrival of first responders; challenging to distinguish the important has been proven to be lifesaving. 2. Increasing bystander CPR: The from the unimportant. Humans and According to The National Center for department had always offered CPR organizations struggle to maintain Health Statistics, drug poisoning is a classes to the public but found that currency and adapt to the many changes leading cause of mortality in the United training only 16 to 20 individuals in an facing modern society. This rapid change States.4 Historically, America viewed eight-hour class to be insufficient to is being driven by globalization and rapid terror as an issue afflicting other parts of meet the need for mass training and dissemination of information.3 the world. However, following the attacks response by community members to One area of change relates to emerging of September 11, 2001, views in regard life-threatening emergencies. Bystander and evolving threats to society. Society to the threat of terrorism have shifted in CPR before ACT program initiation was must be prepared to act against current America.5 Concurrently, active-shooter only 58% of Utstein criteria cases; and and developing threats. Citizens who are events are on the rise in the United States.6 3. Stopping life-threating bleeding. prepared to act will save lives. However, few Finally, sudden cardiac arrest is a leading The department’s aggressive goal is to citizens are trained to act on an annual cause of death in the United States.7 train 6,000 citizens in the first year and basis.2 Threats to modern society can Currently, citizen first-aid and CPR assist program participants in procuring be mitigated through the reinvention of courses are four to eight hours in length ACT kits from EMS vendors. To date 4,000 first-aid outreach; one that effectively and and include many important, however, citizens have been trained in schools and efficiently empowers the greatest number non-lifesaving interventions. Training in at community events. of people to save a life. these non-critical interventions consumes

6 | May 2019 JEMS Stop the Bleed STOP THE BLEED valuable time and energy during a first-aid course. The time and complexity of these courses may represent a barrier to training. A very small portion of the general public attends a CPR course on an annual basis. Additionally, underrepresented and underserved populations receive CPR training at tragically low levels.2 Time is a multifactorial issue in regard to this topic. Professional emergency responders rarely arrive in less than five minutes following an emergency.8 Time Citizen first-aid training must move from training courses to training communities. is also a barrier with respect to training a large percentage of the population. Citizens aren’t inclined to attend an eight hour first-aid or CPR course. Courses should focus on the difference- makers in order to reduce the amount of time commitment required to obtain training.

Reinventing First Aid Nearly every person in every area of the Comprehensive CPR training programs have been taught to the public since the 1970s; United States is susceptible to the direct however, overall survival rates remain largely unchanged over the past three decades. or indirect impact of these threats. Today, every person in the community must be prepared to act. There must be a full-scale shown that change requires adaptation their loved ones entering the healthcare reinvention of first-aid and CPR training. in order to assure survival. It should be system. Re-crafting citizen training into an our objective to create a community that’s Over 100 years ago, this layperson efficient model will leverage the ability for adapted to modern threats. intervention was called pre-medical communities to train a higher percentage Threat-adapted communities could treatment or first treatment. Today, the of the population. Citizen first-aid be compared to non-threat-adapted term to describe medical care provided training must move from training courses communities. A community adapted to by citizens and the military is called first to training communities.9 modern threats will enhance the safety of aid.10 Increasing the overall uptake of citizen the community; and experience leveraged A higher portion of the public can be emergency medical training is only opportunities to save lives when tragedy prepared to act against the threats to partially sufficient. It’s important for strikes.9 modern society by identifying the leading EMS systems to develop mechanisms that causes of time-sensitive preventable specifically reach the underrepresented The Birth of First Aid death, developing simplified and efficient and underserved portions of the Healthcare has also not been immune layperson training and identifying barriers population. The training must be to these changes. Therefore, all areas of to effective outreach. condensed into an efficient and effective healthcare must study the changes that The article, “First-aid at the workplace- course that focuses on critical lifesaving may influence the delivery of healthcare. past, current and future,” identifies a need interventions. These focused citizen Leaders must consider where systems in healthcare and how innovative leaders interventions will preserve life until require adaptation in order to optimize should respond to this gap. It’s challenging professional responders arrive. the delivery of care. One area of healthcare to statistically measure morbidity and As referenced earlier, the world is in a that may be minimized or forgotten is the mortality rates on battlefields hundreds constant state of change and history has care provided by citizens prior to them or or thousands of years ago. Empirically,

Stop the Bleed JEMS May 2019 | 7 STOP THE BLEED it’s known that people were dying on the indicates, out of 2,712,630 deaths in the in the U.S. A study of ideological active battlefield and in the workplace. Early U.S., heart disease accounted for 633,842 shooter events identified 324 events medical practitioners understood simple of these lost lives.11 Understanding that from 1960 to 2012. Shooters motivated interventions could save lives.10 cardiac disease is a leading cause of death by ideological reasons represented over The article describes how over the course should guide the focus of public prevention 70% of shooters. Ideologically motivated of time, methods were developed to reduce and intervention outreach efforts. attacks were associated with higher levels morbidity and mortality outside of the Opioid overdose: The opioid epidemic of sophistication and lethality.13 hospital. The first populations served were that’s plaguing the U.S. remains a topic of Although motivations behind the the military; followed by rail, mine and intense research. The specific breakdown active shooter events are being identified, police workers. This article recommends of which opiates are predominantly incidents continue to increase. Until that a higher ratio of workers should be responsible for the lethal overdoses effective prevention efforts are identified trained in first aid.10 remains elusive. Opioids—mainly and validated, society must implement synthetic opioids other than methadone— measures that are proven to reduce loss Changing Causes of Death are currently the main driver of drug of life. The leading causes of death have shifted overdose deaths. The CDC reports that And, until society can prevent these over the last century. Over one hundred 70,237 drug overdose deaths occurred attacks, all citizens should be trained to years ago infectious and parasitic diseases in the United States in 2017. The age- reduce morbidity and mortality during or were a leading cause of death.1 In 2015, adjusted rate of overdose deaths increased immediately following an event.13 heart disease is now the overall leading significantly by 9.6% from 2016 (19.8 per cause of death.11 100,000) to 2017 (21.7 per 100,000). Underprepared Citizens & These quantitative studies of the Long-term solutions will require Simple Interventions population demonstrate that the leading additional research, surveillance and In the U.S., nearly a thousand people causes of morbidity and mortality can understanding. Irrespective of the type, a day experience sudden out of hospital change over time. Healthcare leaders opioid overdose is a leading cause of cardiac arrest (OHCA). The immediate should maintain a high level of situational death.12 It’s extremely important that, treatment for cardiac arrest is CPR. awareness in consideration of these until a long-term solution is established; Comprehensive CPR training programs changes.11 In modern society there are simple life-saving measures should be have been taught to the public since the three leading and evolving threats to life. taught to all citizens. 1970s. However, overall survival rates In some circumstances, simple and rapid Active shooter events/scenes of remain largely unchanged over the past intervention can prevent death. violence: Active shooter events, also called three decades.2 Heart disease: The 2015 National scenes of violence, have been increasing in CPR training rates are tragically low Center for Health Statistics (NCHS) report frequency and lethality since the 1960s among citizens in the U.S. The overall median rate of citizens trained annually in CPR is less than 3%. One survey revealed that most respondents hadn’t received CPR training in over 10 years. Importantly, communities with high levels of poverty or minority populations displayed extremely low levels of citizen CPR training.2 Counties with larger minority populations were inversely proportional to the percentage of people trained in CPR. The odds ratio of a county having low levels of training increased over 1.06 for every five point percentage increase in the minority population, specifically blacks and Hispanics. The study, Cardiopulmonary Resuscitation Training Rates in the United States, clearly identifies a population that’s unprepared to respond to one of the leading causes of death. Importantly, the study highlights that minority and low-income individuals are least likely to receive CPR training or Until society can prevent active shooter or other violent events, all citizens should be trained treatment in the event of OHCA. Current to reduce morbidity and mortality during or immediately following an event. training models are proving inadequate in respect to preparing all citizens to act.2

8 | May 2019 JEMS Stop the Bleed STOP THE BLEED

Simplified CPR Training The Heart and Stroke Foundation of Canada argues that obtaining basic first-aid and CPR training should be a fundamental duty of every citizen. It’s challenging to quantify the benefits of citizen first aid; however, CPR is known to enhance cardiac arrest survival. The serious challenge is in relation to how to train a high percentage of the population. In the Canadian Medical Association Journal, experts posit that training may be excessively long and complex.14 Current training programs are excellent, but they may be a barrier to training a large number of citizens. Citizen training should be as simple and brief as possible; as long as effectiveness and quality are not compromised. The most important goal is to train as many citizens as possible. Training in CPR should be brief and effective in order to maximize outreach and save lives. Brief, focused citizen training will leverage the goal of reaching a higher number of citizens.14 The four-hour traditional CPR course compression-only CPR and 19.7% received developed a curriculum to train bystanders has been identified as a barrier against standard CPR. Patients who received in overdose prevention and antidote training large portions of the population. compression-only or conventional CPR administration. During a 15-minute A controlled randomized study evaluated within 15 minutes of collapse exhibited course, non-medical providers taught two CPR training delivery models. similar survival rates. Conventional CPR bystanders how to identify and reverse Researchers randomly assigned 285 did result in a more favorable neurological opiate related overdoses. Over the course adults to undergo either the classical or outcome when resuscitations were over 15 of 15 months, 374 people underwent abbreviated CPR training.15 minutes.16 training. During this same period 74 Participants were evaluated immediately This study demonstrates the overdoses were successfully reversed. The after training and two months post- effectiveness of hands-only CPR and program reported minimal complications. training for retention of key CPR skills. allows for the further abbreviation This study indicates that bystanders can These components included calling 9-1-1, of the training as compared to the be efficiently trained in opiate overdose checking for responsiveness, performing classical program. The study indicated recognition and reversal.18 ventilations and compressions. The results compression-only CPR resulted in Another study demonstrated that the revealed equivocal skill retention at two equivocal effectiveness concerning shorter layperson can be effectively trained to months when comparing the participants duration resuscitations.16 intervene in the setting of opioid overdose. who received 30 minutes of training vs. In many regions of the U.S., first The study was conducted to assess overdose four hours of training.15 responders arrive in under 15 minutes. and antidote administration knowledge Training in CPR, a known lifesaving Healthcare providers in the U.S. are among current and former opioid users. intervention, should be brief and effective trained to include ventilations during The study compared knowledge among in order to maximize outreach and save CPR; this may serve as a mitigating factor opioid abusers who did or did not receive lives. Since this previously noted study in extended resuscitations.17 overdose recognition and response was conducted, citizen CPR has been training.19 further simplified by streamlining the Bystander Opioid Overdose Training Opioid overdose recognition training check for responsiveness and eliminating Death from opioid overdose is a public varied among sites and locations. All ventilations. This modified version of CPR health crisis. In Massachusetts, death programs were brief and included didactic is known as “compression-only CPR” and from opioid overdose increased sixfold and interactive components to the may allow for further reduction in the from 1990 to 2006.18 Death from an training. The results revealed that the non- length of the course. opioid overdose can occur within minutes medically trained individuals displayed The effectiveness of compression- to hours. However, an effective and safe comparable opioid overdose knowledge only CPR was demonstrated in a study antidote can quickly reverse an overdose in comparison to the medical experts and conducted in Japan. The study reviewed and save a life. indicates that lay people can be trained to 55,014 bystander-witnessed cardiac arrests. In order to combat this epidemic, respond to an opioid overdose following a Among the cases reviewed, 22.1% received the Boston Public Health Commission brief training course.19

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Table 1: ACT Instructor Curriculum Summary training should be mitigated in order to A—Antidote: increase uptake. CPR and first-aid courses 1. Overdose, the leading cause of death for people under age 50. should be abbreviated and offered at 2. Death can occur in 3–5 minutes. Simple citizen intervention can be lifesaving. optimal times and locations.23 3. 90% of people who receive an antidote will be alive a year later. Reaching the elderly: The senior C—CPR/AED: population is at risk for cardiac arrest; 1. Sudden cardiac arrest is a leading cause of death. 2. Death can occur in 3–5 minutes. Simple citizen intervention can be life-saving. however, the elderly aren’t as likely to 3. Rapid CPR and AED can increase survival by 50–75%. receive CPR. People under age 35 who T—Tourniquet & Hemorrhage Control: suffer cardiac arrest have been found to 1. Severe bleeding is the leading cause of preventable death in mass shootings, terrorist attacks and earthquakes. be nearly twice as likely to receive CPR as 2. Early management of hemorrhage is the cornerstone of treatment. individuals over age 75. 3. Death can occur in 3–5 minutes. Simple citizen intervention can be lifesaving. Although greater age is associated with 4. Tourniquet application can increase survival by sixfold. lower survival following cardiac arrest; seniors who are successfully resuscitated Bystander Hemorrhage 15 minutes.21 This study demonstrates had equal or better quality of life compared Control Training that hemorrhage control techniques can to the general population.24 In consideration of the rising incidence be rapidly acquired and enhanced using The elderly population is also less of active shooter events, all citizens simple instructional methods. confident, less trained and less likely to should be trained in hemorrhage control. perform CPR. Targeted elder CPR training Hemorrhage control techniques can Barriers to First-Aid represents an untapped opportunity to be taught quickly and effectively to the Outreach & Intervention train a greater portion of the public. Elderly untrained citizen. In this fast-paced society, it’s challenging outreach should impress upon seniors that Hemorrhage control courses are for people to see important signals through they are capable of CPR; and that it’s a excellent; however, instructor requirements the noise. The internet, social media and worthwhile endeavor to perform.24 and the time required to attend the course mobile phones create a constant flow of Transportation: Transportation has may represent barriers.20 Hemorrhage information and distraction. Arguably, been identified in the literature as a barrier control courses should be delivered via a the world has shifted from not enough to adequate and ongoing healthcare. One model that’s both efficient and effective. information, to an overabundance of systematic literature review revealed that Delivering courses that require minimal information. There’s also a fear of missing millions of Americans couldn’t access time commitment will maximize the out on information.22 adequate health care due to transportation number of citizens who are trained This can make it challenging for issues. The barrier of transportation in hemorrhage control techniques. government and other public advocacy has the highest impact on special and The Uniformed Services University groups to call the public’s attention to vulnerable populations. Health access can demonstrated that untrained citizens can important issues. Additionally, in this impact health outcomes.25 be rapidly trained in the use of tourniquets highly connected world, some groups are A study that assessed rates of CPR for hemorrhage control. The study missed or isolated. It’s the responsibility of training in the U.S. revealed special randomized 194 volunteer participants to government to assure all groups experience populations beyond the elderly also have either apply a tourniquet with or without equal access to healthcare, including first- very low uptake of CPR training.2 just-in-time instructions.21 aid and CPR training. First-aid training is generally offered For this study, selected participants CPR training rates are low in the U.S. at centralized locations similar to other received just-in-time training in the form and the reasons are poorly understood. forms of healthcare delivery. It’s likely of an instruction card. The control group Historically, end of course surveys has that transportation barriers represent an didn’t receive an instruction card. Both been one of the few ways to assess student impediment to the healthcare with respect groups were briefed on a mass casualty perceptions of CPR courses. These surveys to first-aid and CPR training. scenario and provided with a tourniquet provide limited insight. Researchers Health literacy: It’s well documented to apply. The group that received the have used Twitter as a novel way to better that health literacy is tied to health instruction card applied the tourniquet understand the perceptions and barriers outcomes. Educating a larger portion of correctly more than double the rate of to CPR training.23 the population in regard to the conditions the control group; 44.14% vs. 20.41%, Researchers evaluated 1,000 tweets. of cardiac arrest, overdose and severe respectively.21 The results indicated that the majority hemorrhage is a health literacy issue. A The just-in-time training group took of the tweets in regard to CPR training greater understanding of these issues will an average of two minutes to apply the were negative 53% versus 47% positive. likely improve health outcomes. Health tourniquet, 48 seconds longer than Specifically, the aspects of curriculum, literacy is the ability for a person to the control group. Finally, 84% of all time of day and duration of course received acquire, understand and take action as it participants indicated they’d be willing to the highest levels of negative tweets. relates to healthcare decisions.26 apply a tourniquet in a real-life situation. Because CPR is a known lifesaving Health literacy disparities are The entire evolution and survey took intervention; known barriers to CPR greatly influenced by demographic and

10 | May 2019 JEMS Stop the Bleed STOP THE BLEED socioeconomic factors. In one study, which most people have an incorrect and outdated preventable death, developing simplified provided a breakdown of influencing view of the current world.29 layperson training and identifying barriers factors with respect to health literacy Through the application of complex to effective outreach. These efforts will scores, women scored five points higher adaptive systems theory, citizen first aid improve the health and safety of both than men.26 can be re-created, designed for change individuals and communities. Income correlated health literacy and updated over time. Healthcare scores as well: for every $1,000 increase organizations must view themselves as ACT: Citizen First-Aid in income, literacy scores increased a complex adaptive systems; therefore, for Modern Society quarter point. African Americans, foreign- programs deployed around healthcare Society is in a constant state of change in and native-born Hispanic and Latinos must include complex adaptive systems the U.S. and around the world. The impact scored significantly lower compared to theory. To assure maximum impact; citizen of societal changes can be positive, negative white respondents with respect to health first-aid outreach programs should be re- and interconnected. Society must develop literacy.26 invented to align with modern society.30 agile programs to rapidly adapt to evolving The authors of the study recommend that The complex adaptive system theory threats to society. health literacy can be improved by creating takes into consideration that outreach When citizens call 9-1-1, the fire enhanced engagement within multiple systems must be created for constant department strives to expeditiously social constructs. The recommended change and interconnectedness with other respond to the emergency. The modern components include improving self- systems and theories. fire service is designed to respond within efficacy, personal empowerment and Historically, first-aid outreach has minutes. However, the fire department will civic engagement. These components are generally been designed as a standard rarely arrive at the scene in less than five directly supported when citizens are taught course with standardized curriculums, minutes. During this gap in time, citizens first aid and CPR.26 content and guidelines. The contents can be empowered to make a difference in are often updated to match the current patient outcomes. First Aid as a Pathway to Peace science; however, the overall program hasn’t The current model of training citizen There’s violence across the world that’s changed significantly over time.30 first aid is long and complex. The training devolving healthcare infrastructure. This Experts believe that first-aid program requires eight hours on a Saturday. is leaving the most vulnerable populations development and deployment will be This training is both excellent and without emergency care when tragedy enhanced by integrating complex adaptive comprehensive; however, the course includes occurs. The World Health Organization system theory into the course. This many non-lifesaving interventions. Due to advocates for the scaling of brief first-aid will allow the courses to be designed for the length and location of these courses, courses to untrained laypeople. This will constant adaptation to meet the needs of they’re often viewed negatively.23 Under the empower people to respond to emergencies a changing society. The course content current course model, an extremely small when professional help is unavailable.27 and time requirements can and should be portion of the population receives training One article highlights additional designed for change. on an annual basis.2 benefits that can be obtained when Threats, science and society are in a First-aid training must evolve into a delivering brief first-aid courses. The state of constant change. Using complex rapidly-deployable and adaptable program; authors brought together four tribes in adaptive system theory, first aid can be designed to keep pace with societal change. Sudan. Over the course of three days, 50 designed for constant change. Using this A reinvented citizen first-aid program will members of different tribes were taught theory, first-aid outreach will no longer be focus on the key difference makers; this a brief course in first aid. The lifesaving designed as a static course; first-aid courses will reestablish the relevance of first aid in benefits of first-aid training are intuitive; will be dynamic, agile and expected to a rapidly changing world.28 the authors describe a secondary benefit. change over time. This new approach to first aid training In the right context, there’s a significant Complex adaptive systems theory can be will only include training that is focused opportunity to bring people together using used to assure citizen first aid is created on lifesaving interventions; interventions these courses to build community.27 with change in mind, designed for change; that focus on conditions that are capable The U.S. isn’t immune to this violence; and, it’s understood the program will of causing death within minutes. They will there’s value in using brief first-aid courses change with time. Applying this theory be interventions that can be easily taught to empower citizens and build peace in will assure citizens are properly prepared in a brief period of time with minimal American communities. to meet new challenges as society evolves. A equipment, and will empower a greater society with programs designed for change portion of the population to be prepared Complex Adaptive Systems Theory will be enabled to adapt to change. to act to save a life. Thousands of years ago, the ancient In addition, the leading causes of Adopted and implemented by South Greek philosopher Heraclitus posited that preventable death and threats are changing. County Fire in Snohomish County, no two things are alike and that change Large portions of the public should be Washington, north of Seattle, the concept is constant.28 The world is in a state of trained to act against the threats to of an evolved, next-generation first-aid constant, interconnected and often modern society. This can be accomplished course was conceptualized as a solution to invisible change. According to Rosling, by identifying the leading causes of meet a constellation of challenges.

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A reinvented citizen first-aid program that focuses on the key difference makers, such as hemorrhage control, will reestablish the relevance of first aid in a rapidly changing world.

The new ACT citizen first-aid program the program to reach a greater portion The traditional first-aid curriculum is a brief low-barrier training program of the population in less time than with was also a noted negative component of that focuses on the predominant threats traditional, limited instructor programs. the standard first-aid course. Although to modern society; conditions where rapid Each of the modules include an instructor- the study didn’t reveal specific reasons citizen intervention can be lifesaving. led practical evolution. The students will be indicating why participants had a poor These threats include overdose, cardiac taught to identify each of the conditions and impression of the curriculum, in today’s arrest and severe hemorrhage. The goal effect countermeasures.32 The students will society, it is likely citizens value courses of this new training is to be brief, simple, also be provided a checklist for use during that are concise and more sensitive to their effective and supported by the literature.14 the training and during actual events. time commitment. Each letter of “ACT” represents one of The goal of the ACT program is to three key lifesaving interventions that A Reason for Evidence- train as many people as possible, in a will be taught in one hour. “A” stands Based Change shortened period of time and at times and for “antidote,” the 15-minute module The study referenced earlier provides locations more conducive to their busy will cover opioid overdose recognition insights in relation to the barriers of schedules. It is theorized, based on other and response. “C”stands for “CPR,” the greater uptake of citizen first-aid. The programs of this nature, that a course with 15-minute module that will cover cardiac ACT course specifically answers these a positive rating will likely attract more arrest recognition and response. This challenges. participants.23 module also includes automatic external Time is a challenge and people surveyed The Canadian Medical Association has defibrillator (AED) training. “T” stands for had a negative impression with respect to been advocating for a change to citizen “tourniquet,” the 15-minute module that the length of the class and time of day. first-aid; training that’s simplified and will cover severe hemorrhage control.31 However, the ACT course can be taught abbreviated in order to equip as many The program is designed in a train-the- in one hour, and is designed to fit into people as possible to save a life.14 trainer model to involve citizens from the a classroom period or workplace lunch Studies reveal that hemorrhage control community, effect rapid scaling, and allow break. and overdose interventions can be

12 | May 2019 JEMS Stop the Bleed STOP THE BLEED

effectively taught to non-medically trained We have implemented an evidence-based for out-of-hospital cardiac arrest of cardiac origin. Resuscitation. 2011;82(1):3–9. individuals in brief 15-minute courses.18,19,21 course that trains citizens in one hour 17. HeartCode BLS. (n.d.) American Heart Association. It has also been shown that CPR course to ACT against threats that can cause Retrieved Aug. 24, 2018, from https://cpr. length can be shortened as well and still death in minutes. Using three 15-minute heart.org/AHAECC/CPRAndECC/Training/ produce equivocal skill retention as modules, citizens are trained to intervene HealthcareProfessional/BasicLifeSupportBLS/ UCM_476242_HeartCode-BLS.jsp. compared to a full length course.15 when faced with the leading threats to our 18. Doe-Simkins M, Walley AY, Epstein A, et al. Saved The World Health Organization has communities. The ACT program can be by the nose: Bystander-administered intranasal also identified first-aid courses as a taught via community workshops, during naloxone hydrochloride for opioid overdose. possible peacebuilding activity. First-aid lunch breaks or within a classroom period. Am J Public Health. 2009;99(5):788–791. courses may be used to build relationships The ACT program has reinvented the 19. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for by bringing groups together; groups that concept of citizen first-aid training. It’s naloxone: An evaluation of six overdose training normally do not spend time together. brief, effective and evidence-based. It’s a and naloxone distribution programs in the United Community may develop when groups simple solution for complex times. ✚ States. Addiction. 2008;103(6):979–989. or individuals learn a new skill in a safe 20. Stop the Bleed. (Oct. 1, 2015.). Department of Homeland Security. Retrieved May 24, 2018, environment. This area of benefit may References from https://www.dhs.gov/stopthebleed be measured through the methods of 1. Berk A, Paringer LC, Woolsey TD. Estimating deaths 21. Goolsby C, Branting A, Chen E, et al. Just-in-time observation and surveys.27 for the United States in 1900 by cause, age, and to save lives: A pilot study of layperson tourniquet sex. Public Health Reports. 1978;93(5):479–482. application. Acad Emerg Med. 2015;22(9):1113–1117. Conclusion 2. Anderson ML, Cox M, Al-Khatib SM. Cardiopulmonary 22. MyLife.com. (January 2008). National survey resuscitation training rates in the United States. reveals consumers are overwhelmed by social Society will always be in a state of change. JAMA Internal Medicine. 2014;174(2):194–201. media. Business Wire. Retrieved May 17, Programs that are designed to interact with 3. Collyer S: Managing amidst rapid change. Project 2019, from www.businesswire.com/news/ society must, therefore, be designed for Management Institute: Newtown Square, Pa., 2015. home/20120801005524/en/National-Survey- Reveals-Consumers-Overwhelmed-Social-Media. change. Programs that aren’t designed to 4. Alpert M, McCaig L, Uddin S. (April 09, 2015.) 23 McGovern SK, Blewer AL, Murray A, et al. change will eventually become obsolescent Emergency department visits for drug poisoning: United States, 2008–2011. National Center for Characterizing barriers to CPR training attainment and ineffective. Health Statistics. Retrieved May 24, 2018, from using Twitter. Resuscitation. 2018;127:164–167. First aid is fundamentally a mechanism www.cdc.gov/nchs/data/databriefs/db196.htm. 24. Brinkrolf P, Bohn A, Lukas RP, et al. Senior for citizens and society to reduce morbidity 5. DeValve MJ: Terrorism. In: Salem Press Encyclopedia. citizens as rescuers: Is reduced knowledge the Salem Press: Hackensack, N.J., 2017. reason for omitted lay-resuscitation-attempts? and mortality. Citizen first-aid outreach Results from a representative survey with 2004 6. Hunter Martaindale M, Sandel WL, Pete Blair J. is susceptible to both change and interviews. PLoS One. 2017;12(6):e0178938. Active-shooter events in the workplace: Findings obsolescence. Society must maintain a and policy implications. Journal Of Business 25. Syed ST, Gerber BS, Sharp LK. Traveling towards constant state of situational awareness as Continuity & Emergency Planning, 11(1), 6-20. disease: Transportation barriers to health care access. J Community Health. 2013;38(5):976–993. it relates to changing threats. 7. Jentzer JC, Clements CM, Murphy JG, et al. 26. Rikard RV, Thompson MS, McKinney J, et al. Threats challenging modern society Recent developments in the management of patients resuscitated from cardiac arrest. J Examining health literacy disparities in the can be mitigated through the creation Bus Contin Emer Plan. 2017;11(1):6–20. United States: A third look at the National of agile outreach programs. Society can Assessment of Adult Literacy (NAA7L). 8. Bryan P, Pane P. Evaluating fire service delivery. BMC Public Health. 2016;16:975. address these changing threats through the Fire Engineering. 2008;161(4):207–210. 27. Ratner KG, Katona LB. The peacebuilding reinvention of first-aid outreach. Modern 9. Maxwell SG: Designing for better health in the potential of healthcare training programs. first-aid must be designed to effectively and future. Grand Canyon University: Arizona, 2018. Confl Health. 2016;10(1):29. efficiently empower the highest number of 10. Priolcar X. First-aid at workplace-past, current and 28. Johnson W. Never the same river. ETC: A Review future. . 2012;16(1):1–2. people to save lives. Indian J Occup Environ Med of General Semantics. 2004;61(3):381–390. An adaptable society is a prepared 11. National Center for Health Statistics. (May 3, 29. Galeener CA. Factfulness: Ten reasons we’re wrong 2017.) Deaths and mortality. Centers for Disease about the world—and why things are better than you society; a community where everyone is Control and Prevention. Retrieved Aug. 23, 2018, think. Texas Public Health Journal. 2018;70(3):6–7. from www.cdc.gov/nchs/fastats/deaths.htm. prepared to save a life, a nation prepared 30. Chaffee MW, McNeill MM. A model of to ACT. 12. Seth P, Rudd RA, Noonan RK, at al. Quantifying the nursing as a complex adaptive system. South County Fire is working to build a epidemic of prescription opioid overdose deaths. Nurs Outlook. 2007;55(5):232–241. Am J Public Health. 2018;108(4):500–502. resilient threat-adapted community. Today 31. Maxwell SG. (May 21, 2018.). A.C.T. First 13. Capellan JA. Lone wolf terrorist or deranged Aid & Antidote - CPR/AED - Tourniquet ~ everyone must be trained to respond. We shooter? A study of ideological active shooter Accelerated Citizen Training [conference have realigned and refocused outreach to events in the United States, 1970–2014. Studies presentation]. Washington Fire Chiefs Annual the challenges facing modern society. Three in Conflict & Terrorism. 2015;38(6):395–413. Conference: Kennewick, Washington, 2018. leading threats include the opioid epidemic, 14. Skura E. Pros and cons of first aid training? CMAJ. 2010;182(12):E549–E550. cardiac arrest and scenes of violence. Shaughn Maxwell, BHSc, EMT-P, is the EMS and 15. Einspruch EL, Lynch B, Aufderheide TP, et al. community paramedic chief for South Snohomish We designed a program that focuses on Retention of CPR skills learned in a traditional the difference makers and has substantially AHA Heartsaver course versus 30-min video County (Wash.) Fire & Rescue. He’s the recipient of three national awards in EMS excellence and accelerated our ability to build a self-training: A controlled randomized study. Resuscitation. 2007;74(3):476–486. innovation, including being a double recipient of EMS10 community prepared to ACT; prepared to 16. Kitamura T, Iwami T, Kawamura T, et al. Time- Innovator of the Year awards, presented by JEMS and save a life in those critical minutes before dependent effectiveness of chest compression-only Physio-Control. He›s actively working on his Masters in the first- responder arrival. and conventional cardiopulmonary resuscitation Psychology, with a focus in Human Factors.

Stop the Bleed JEMS May 2019 | 13 STOP THE BLEED

Modern-Day Bucket Brigade How University Hospitals implemented a region-wide Stop the Bleed program

BY DOMINIC SILVESTRO, EMT-P, EMS-I & DANIEL ELLENBERGER, EMT-P

University Hospitals (UH), located in program that can be mimicked in schools would expect this to happen—although Northeast Ohio, serves 20 counties with and businesses across the country. I don’t think we expect these events to 10 community hospitals, a Level 1 trauma happen anywhere. It all hit very close center and four Level 3 trauma centers. Innovation Stems from Tragedy to home: our sheriff and deputies had We also operate five freestanding EDs Emergency response programs often students at that school, as did one of our in the community and provide medical start after a tragic event. Ours was medical directors. direction and oversight of the equipment, no different. Chardon is a quiet rural The event prompted a lot of thought, education, drugs and protocols for 171 community in Geauga County, which is fear and discussion; what could we do EMS services. about 25 miles from Cleveland. This is in to improve care and ultimately improve UH is also responsible for disaster the heart of what’s called the “snow belt”— outcomes should a horrific event of this preparedness for the health system and the when other areas get two inches of snow in nature occur again? communities it serves. We also provide event a day, they get three feet of snow. People felt helpless and handcuffed. medicine services, including at Cleveland On Feb. 27, 2012, students were starting They didn’t have the equipment they Browns football games, marathons, and their day at school as usual; there was a needed; they didn’t know what to do. At other events. We manage five American group of students in the cafeteria waiting this time a lot of the tactical emergency Heart Association training centers and offer for a bus that would take them to their casualty care (TECC) strategies were five paramedic training programs. vocational education program. coming out around the country. Our system decided early in the A 17-year-old male sitting with the group Tourniquet use was coming back in vogue, development of a national Stop the Bleed pulled a gun out of his gym bag and opened but we didn’t have a formal way of training initiative that we would implement a fire in the cafeteria, taking the life of three people to do this. comprehensive program for our region. students and injuring two others—one of So, we met with the Geauga County Our program started in our eastern region the injured is now permanently paralyzed. Sheriff, and looked at what UH could do and quickly snowballed. We believe it’s a This was not a community where you to outfit the police cruisers with bleeding control kits. Because police cruisers are usually the first responders on scene, we felt they needed to have the equipment to make an impact on saving a life. So, we developed a bleeding control kit. We put a program together specifically for police officers that trained them what to do if they came upon a shooting. We taught them when they might need a chest seal, needle decompression, combat gauze or a tourniquet. These bleeding control kits were placed in each police cruiser. When our main campus hospital—a Level 1 trauma center—learned of the Stop the Bleed program through the Department of Defense, we filed the proper paperwork and became a Stop the Bleed training center. Our next goal was to begin teaching the program and Firefighters and students from Ashland Middle School fill Stop the Bleed buckets with expanding it throughout the communities supplies for hemorrhage control as well as for sheltering in place. we served in Northeast Ohio to enhance PHOTO COURTESY NOELLE BYE/TIMES-GAZETTE community preparedness.

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The Stop the Bleed buckets include supplies for hemorrhage control (e.g., tourniquets, combat gauze, bandages, scissors, gloves, marker), as well as items that teachers and students might need should they have to shelter in place (e.g., duct tape, door stops, rope, elastic bandages, stretch wrap, toilet paper).

PHOTO COURTESY KTRK-TV

The snowball began to grow. We had We took his lead and adopted the bucket involve local first responders, whether expanded from teaching sheriff’s and local concept. After all, a five-gallon bucket is they’re EMS, Fire or law enforcement. police departments to businesses. Then, pretty conspicuous—it wouldn’t be as When we come in to train, we train all somebody came up with the idea of schools. likely to get tucked away like a small first- of the teachers as well as the support staff If we could train teachers and staff on how aid or bleeding control kit. The additional (e.g., administrators, bus drivers, etc.). We to stop bleeding by applying tourniquets, space is important, as each bucket not only can train as many as 150 people in one then we could keep blood inside the patient contains bleeding control supplies (e.g., classroom in about 90 minutes. and get them to a trauma center, where tourniquets, combat gauze, bandages, To date we have trained over 4,000 they’d have the best chance of survival. scissors, gloves, marker) but also the teachers and staff in over 100 school supplies needed for a situation where the districts across the 21 counties we serve. Adopting the ‘Go-Bucket’ class would have to shelter in place. This We’ve placed buckets in each of those Convinced that we could train and also includes duct tape (in multiple colors classrooms, and have deployed over 3,000 prepare teachers to control bleeding in for sealing doors, blacking out windows Stop the Bleed buckets total. response to an active shooter event, we were or putting messages on outside windows), in need of a kit that would allow them to door stops, rope, elastic bandages, stretch Bringing Buckets to have everything they’d need in one place. It wrap and, yes, even toilet paper. Your Community wouldn’t only contain items for bleeding Our idea was to put one of these buckets Each of the buckets costs around $70. control, but also common items they might in every classroom in the communities we It’s not a lot, but it adds up, and the total need if they had to shelter in place during serve. We started down this road by meeting cost of our program is between $300,000 a lockdown that might last several hours. with the school district superintendents, to $400,000. Conversely, if you’re a small As we searched for a solution, we learned resource officers and teachers to get buy- health district and you have only one that an assistant principal at one of the in for the program. They gave us valuable elementary school with 15 classrooms, schools had developed a “go-bucket” in input and feedback, even helping us to for example, you’re only looking at about case of a radiation emergency—the Perry decide what to put in the buckets. $1,000 to put this together. Nuclear Power Plant was near the school In addition, we’ve worked with school Hospitals typically invest back into and they had to have a shelter plan. safety forces and all of our programs the communities they serve; and UH has

Stop the Bleed JEMS May 2019 | 15 STOP THE BLEED

Above: Mantua-Shalersville Fire Captain Mike Pender demonstrates proper tourniquet application to teachers and staff at Crestwood Primary School.

Left: Crestwood Principals Michelle Gerbrick, right, and Cindy Ducca receive tourniquet application training from University Hospitals’ Amelia Lomas, a community outreach medic, and Matt Sheehan.

PHOTOS COURTESY ANDREW DOLPH/UNIVERSITY HOSPITALS

funded our program using community Piggy back on work you’ve already done other community members must be able benefit funds. But it doesn’t matter if in the community, too. CPR training to apply a tourniquet or pack a wound—it you’re part of a big hospital system or a classes can easily be adapted to also just might save their child’s life. ✚ single station Fire department in a small include Stop the Bleed. And you don’t rural community, there are many ways you need fancy simulation manikins; we Dominic Silvestro, EMT-P, EMS-I, is EMS coordinator can go into the community and find funds started this program by having students and educator at the University Hospitals EMS to do something like this in your region. packing “wounds” we had cut into swim Training and Disaster Preparedness Institute in There are plenty of funds or donations noodles. Creativity can sometimes save a Northeast Ohio. He’s served as a career firefighter/ paramedic for the Richmond Heights (Ohio) Fire out there. Target local scouting and other lot of money. Department for the last 25 years, and is also civic-oriented groups (e.g., Kiwanis, Finally, don’t forget to drum up adjunct faculty at Cuyahoga Community College, Eagles) who routinely give money away support and find allies—they’re where he teaches EMT-Basic classes as well as for programs that benefit the local everywhere. Go to the local PTA meetings anatomy and physiology. community. Reach out to big-box retail and explain the importance of bleeding stores; they may not provide cash, but control directly to parents—tell them Daniel Ellenberger, EMT-P, is the director of the they may gladly help by donating buckets, that their kids can’t just wait for EMTs University Hospitals EMS Training and Disaster rope, duct tape, etc. or paramedics to arrive. Teachers and Preparedness Institute in Northeast Ohio.

16 | May 2019 JEMS Stop the Bleed STOP THE BLEED Stop the Bleed & Start the Heart Teaching Texas middle schoolers to ‘see something & do a lot’

BY ASHLEY HOPPE, BBA, NREMT; COURTNEY NESLONEY, RN, BSN; KELSEY BROWN, AS; ELIZABETH DILLARD, BA, NREMT & HARRY “STEVE” STEVENSON, MPA, NREMT

On June 14, 2014, a law was passed in Texas that requires every high school student to take a CPR course prior to graduation. A distinct challenge to this mandate was—and remains—funding. Like other states, Texas schools struggle financially to provide students with their core educational requirements. So, how do financially challenged school districts find the resources to meet the reality of training for a catastrophic medical event? Here’s what the Centre For Emergency Health Sciences did in South Central Texas to address what could only be described as an emergent need.

Making It Happen Smithson Valley Middle School students in Spring Branch, Texas, learned to Stop the Bleed To avoid confusion in what we were and Start the Heart. proposing to teach, we made sure everyone knew that we would be providing affordable, simple, fun and lifesaving education Fishing in a Well-Stocked Pond grassroots efforts that encourage for anyone willing to be trained. The In January and February, with help bystanders to become trained, equipped Stop the Bleed, Start the Heart program from the school’s health services and and empowered to stop life-threatening targeted specific actions needed to athletics coordinators, we identified the bleeding before help arrives,” says Ashley immediately save a life: sixth, seventh and eighth grade physical Hoppe, BBA, NREMT, business director at • Tourniquet application; education period as an ideal time slot to CEHS, as well as the program’s energizing • Choking relief; provide the lifesaving education. facilitator. “We simply sat down as a • AED usage; and This decision meant that some students team to chat about what was working in • Compression-only CPR. would miss a day of athletics or dance our community and then we watched it As an engaged, informed and fun- class. Crushing as that might first appear, logically morph into our Stop the Bleed loving community partner, the Centre everyone realized that the physicality and Start the Heart program. It was as if for Emergency Health Sciences (CEHS) involved with each effort would likely align someone finally put the keys to the front joined with our colleagues at the Comal with the day’s usual activity level. door right in our hands.” Independent School District (CISD)—key Given that we were all foundational “The overarching goal of our allies in our 2016 Stop the Bleed efforts— friends in the national Stop the Bleed program is to empower each student to along with our corporate partner North initiative, our staff as well as school district immediately act upon identifying massive American Rescue, to train 5,642 middle staff knew from past experience that we bleeding, choking or cardiac arrest,” says school students at each of the CISD’s could teach “kids” to “see something and Hoppe. “We emphasize each portion of seven middle schools in the rural Texas do something,” (i.e., stop the bleed), but the program to remove the shock factor Hill Country. we also believed that with the right nudge, from an emergency while simultaneously Our alliance assured each participant these young people would be able to “see giving them the power of hands-on received state of the science training something and do a lot.” training and knowledge.” taught by professional, engaged—and Middle school students are the ideal age entertaining—educators from CEHS. Our One Plus One Equals group to participate in this type of training educators were supported by CISD faculty, Something Entirely New because they are genuinely engaged and who were all well-trained in hemorrhage “On the surface, Stop the Bleed is a eager, and they nearly always pass the control and CPR by CEHS staff. national program intended to cultivate information on to other family members and

Stop the Bleed JEMS May 2019 | 17 STOP THE BLEED

In addition to teaching our middle school students lifesaving skills, our ninth- grade students receive didactic instruction in their biology classes, and compression- only CPR training is a requisite for high school graduation. By combining these initiatives early, we know that as the students grow, the lessons will get easier to teach, skills retention will increase, and lives will undoubtedly be saved. CISD staff members are trained annually by campus nurses on bleeding control and tourniquet usage. In addition, school nurses attend several enhanced training sessions on casualty and trauma care—utilizing human cadavers—to maximize their preparation for incidents that may occur on campus or in the community. This enhanced training is part of CISD and CEHS commitment to Educators from the Centre for Emergency Health Sciences collaborated with well-trained “connecting experience with the future.” school district faculty to teach middle schoolers how to Stop the Bleed, Start the Heart. ‘Imagine’—Not Just friends. “Through wee [i.e., small of stature] step, students were also shown how to apply Lyrics to a Song force multiplication, our community and use an AED with continued emphasis “The final note in this successful melody network of immediate responders, who can on minimally-interrupted compressions. was the overwhelming desire to put pressure act quickly and appropriately, exponentially After briefly discussing these three where it was needed, and compress lifesaving grew and became stronger.” steps, each student individually practiced skills into a fun and memorable event,” chest compressions on a manikin. This was says Hoppe. “Our team imagined and Bringing it Together actively accomplished with faculty and then created an example of community, The combination of CEHS educators peers on the gymnasium floor. corporate and school district leadership, and well-trained CISD faculty, in concert For the Stop the Bleed component, in a village that needed more than just with the right supplies (CPR and choking students were taught an expedited talking points.” ✚ manikins, AED trainers and CAT approach to tourniquet application, along tourniquets) in the right place, allowed with easy-to-remember tips, including, “If Ashley Hoppe, BBA, NREMT, is the business director multiple things to happen. CEHS brought it won’t quit, tourniquet,” and “high or die.” for the Centre for Emergency Health Sciences. fun, science and additional expertise, “The simple act of knowing how to Courtney Nesloney, RN, BSN, is the health services North American Rescue helped with use a tourniquet can have an instant coordinator for Comal Independent School District. resources, and together with the school and profound effect on both the patient Kelsey Brown, AS, is a laboratory technician at the faculty, we provided guiding hands to and our immediate responders,” Hoppe Centre for Emergency Health Sciences. teach our lifesaving message. says, “especially since our students [both Elizabeth Dillard, BA, NREMT, is a laboratory technician The CPR and AED lesson was divided rural- and urban-oriented] can encounter at the Centre for Emergency Health Sciences. into three simple steps that facilitated easy emergencies in their everyday lives, from Harry “Steve” Stevenson, MPA, NREMT, is a retired recall and immediate action: ordinary household and recreational United States Air Force colonel and is a volunteer Step 1: “Hey, hey, are you OK?” accidents to unthinkable catastrophes.” faculty member for the Centre for Emergency Health Sciences. Students were taught to verify whether or not the person who is ill needs CPR or Commitment to Our Future some other kind of medical assistance. “Our Stop the Bleed project at Comal Acknowledgements: The authors would like to Step 2: Dial 9-1-1. Independent School District began four acknowledge the U.S. Army Institute of Surgical Students were taught the importance years ago in response to the increase in Research, the Committee on Tactical Combat Causality Care, and all of who have bravely served others in of the 9-1-1 system and how it works for school shootings nationwide,” says CISD’s their time of need. Your work beyond walls and borders everyone. health services coordinator Courtney remains an inspiration and guiding light to us all. Step 3: Push hard. Push fast. Nesloney, RN, BSN. “At that time, Directly as a result of your service, stewardship and Students were taught compression-only tourniquets and Stop the Bleed stations sacrifice, lives have been—and will continue to be—saved. A special thanks to the Comal Independent CPR where they learned that high-quality, were purchased, with help from North School District Board of Trustees and School minimally interrupted chest compressions American Rescue, and placed in all Comal Administrators for believing in their students, faculty, are easy, yet crucial, to survival. With this Independent School District campuses.” community and our team.

18 | May 2019 JEMS Stop the Bleed STOP THE BLEED Cleveland Hopkins Airport Launches Stop the Bleed Airport fire department acquires 100 kits & trains 2,000 employees

BY MATT URIE, BS, EMT-P, EMSI

Every year, more than 9 million people travel through Cleveland Hopkins International Airport (CLE) in Cleveland, Ohio. With the possibility of severe hemorrhage from a multitude of sources, including escalators, machinery, active shooter events or other terrorism events, the Stop the Bleed program felt like a perfect fit for an airport. The CLE Fire Department started research of the Stop the Bleed program several months ago, and wanted to make sure the program was a perfect fit for both CLE and nearby Burke Lakefront Airport (BKL)—a public airport on the shore of Lake Erie, in the northeast part of downtown Cleveland. CLE is the eighth airport in the nation to implement the Stop the Bleed program on the airport property, and first in the city of Cleveland to implement the program on a city property. With over 50 automated external defibrillators (AED) on the airport property, we identified those locations as buddy locations to co-locate the Stop the Bleed kits. Other kits were added at areas where injuries could occur, such as the base of six escalators, as well as ticketing and baggage locations. In addition, kits were added to each building on the airport property, including those where many airplane mechanics, baggage handlers and other support personnel work each day. This brought the number of kits to 95 at CLE and five at BKL.

Acquiring Stop the Bleed Kits One component in the Stop the Bleed kit, the tourniquet, was identified as a potential issue. The standard put forth by the national Stop the Bleed program is The Cleveland Hopkins International Airport fire department has deposited public access bleeding control kits in the over 50 public access AED cases on the airport property as well the CAT tourniquet; however we proposed as additional locations. to have Stop the Bleed kits with the SWAT-T tourniquets. As a department, PHOTOS COURTESY MATT URIE

Stop the Bleed JEMS May 2019 | 19 STOP THE BLEED we decided the benefit of including the EMS Coordinator Jackie Haumschild SWAT-T tourniquet outweighed the and Medical Director Susan Tout, MD, cost. With the many different types of assisted in having the Southwest General tourniquets available, performance, cost Foundation purchase 100 Stop the Bleed and successful application were all factors kits to outfit both CLE and BKL airports. in our decision. Areas for the kits were identified In a conversation with Eric Goralnick, and labeled with the CLE Airport Fire MD, MS, medical director of emergency Department logo and the national Stop preparedness for Brigham and Women’s the Bleed logo. These labels identify kit Hospital in Boston and assistant professor locations to those traveling through the of emergency medicine at Harvard Medical airport that may have received training in School, he stated the overall success of other locations. The decision was made bleeding control training with application to place the kits prior to training airport of the CAT tourniquet was 88%.1 employees because of the necessity of With the higher percentage of public access and prior knowledge. successful placement of the CAT Another layer to our public knowledge of tourniquets versus other commercial Stop the Bleed locations and accessibility tourniquets including the SWAT-T, this is the integration of the PulsePoint will decrease that amount of time needed application. CLE is the first location in to apply a tourniquet and decrease the Northeast Ohio to integrate the locations amount of time a patient would have a life of the Stop the Bleed kits into PulsePoint, threatening bleed. The CAT tourniquets which denotes the locations of AEDs also will provide an easier, less extensive within public spaces to assist laypersons method to apply for a lay person. in assisting with CPR or bleeding control. The Cleveland Hopkins International Airport The CLE Airport Fire Department Clearly identifying these kits ensures is the first location in Northeast Ohio to approached our medical direction and the public can locate them to reduce the integrate the locations of Stop the Bleed kits EMS partner, Southwest General Health amount of time a person is bleeding and into PulsePoint. Center, to help us to acquire commercially decrease the time of life-threating bleeding. produced Stop the Bleed kits. As an airport responders in a situation is different than fire department not affiliated with a larger Training Airport Employees a general bleeding control training of city fire department, our opportunity Training over 2,000 airport employees public persons. Having over 50 paramedics to receive grants and other funding is a large undertaking. Identifying groups within the fire department who can act options are limited. Southwest General of employees who may serve as potential as instructors for the Stop the Bleed program, and share valuable knowledge of the pathophysiology and reasons behind bleeding control, has been beneficial in training airport employees. We first identified different areas we felt may be more likely to potentially be involved in an active shooter situation or a situation where hemorrhage control is necessary. This led us to select Transportation Security Administration (TSA) agents and airline ticket agents as likely lay person “first responders” in situations where immediate bleeding control might likely be necessary. We identified multiple dates and times to set up training for different shifts of airport employees, and have identified different locations that benefit the employees in ease of training. The CLE Airport Fire Department has started training the management team The Stop the Bleed kits at both airports include dressings, trauma scissors, a tourniquet of CLE on bleeding control. Having and easy-to-follow instructions. champions of the Stop the Bleed program from the management team was key in

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proficient in the basic bleeding control injury.”2 Having readily available Stop procedures on an annual basis. the Bleed kits and airport employees The Stop the Bleed training of airport who are trained in basic bleeding control employees also fell in line with our recent will be of great assistance to the CLE training in Rescue Task Force. Recently, Fire Department, as well as the trauma CLE Fire Department completed Rescue centers where we deliver these patients, Task Force training in the active shooter likely ensuring a higher success rates of scenario. The training took place in a recovery for patients suffering traumatic concourse that’s currently vacant and bleeding events. ✚ allowed the department to train in real- life simulations. This training was key References to illustrate to the first arriving fire and 1. Goralnick E, Chaudhary MA, McCarty JC, et al. police department units how successful Effectiveness of instructional interventions for hemorrhage control readiness for laypersons the Rescue Task Force is in active shooter in the public access and tourniquet training situations. The Stop the Bleed program study (PATTS): A randomized clinical More than 50 paramedics with the Cleveland complements the Rescue Task Force to trial. JAMA Surg. 2018;153(9):791–799. doi:10.1001/jamasurg.2018.1099 Hopkins International Airport are training over ensure that the potential for loss of life 2,000 airport employees to Stop the Bleed. secondary to hemorrhage is minimal. 2. Pons PT, Jacobs L. (2017.) What everyone should know to stop bleeding after an injury. BleedingControl.org. Retrieved Feb. 13, 2019, from ensuring the success of the CLE program. Conclusion www.bleedingcontrol.org/~/media/bleedingcontrol/ It’s noted in one study on appropriate The Stop the Bleed program’s website files/stop%20the%20bleed%20booklet.ashx. tourniquet application that after 3–9 states, “Uncontrolled bleeding is the months, the appropriate application of number one cause of preventable death Matt Urie, BS, EMT-P, EMSI, is a firefighter/ tourniquets falls to 54.5%.1 Therefore we from trauma. The greater the number of paramedic at Cleveland Hopkins International have instituted a yearly review of the Stop people who know how to control bleeding Airport Fire Department, firefighter/paramedic and EMS officer for Parkman Township (Ohio) Fire the Bleed training, and will ensure that in an injured patient, the greater the Department and lead paramedic instructor for those trained in basic bleeding control are chances a victim has of surviving that Auburn Career Center.

NEW 2ND EDITION COURSE!

NAEMT TACTICAL www.naemt.org/education EMERGENCY CASUALTY CARE / TECC • Provides all-new patient simulations and scenarios • Addresses current TEMS domains • Consistent with C-TECC guidelines • Only TECC course endorsed by ACS • Focused MARCH assessment lessons • Immediate action tourniquet drills throughout the course • New content in the care of pediatric casualties • 16 hours of CAPCE-approved credit

TECC PREPARES EMS PRACTITIONERS TO RESPOND DURING TACTICAL EVENTS

Stop the Bleed JEMS May 2019 | 21 STOP THE BLEED Connecticut Schoolteachers Learn Hemorrhage Control A reproducible model of Stop the Bleed training in a suburban school district

BY JEREMY FRIDLING, BA, NRP, TP-C; SCOTT MARTUS MS, LP & DAVID SHAPIRO, MD, MHCM, FACS, FCCM

Following the 2012 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, the American College of Surgeons (ACS) convened the Hartford Consensus in Hartford, Connecticut, with the goal of maximizing survival in mass casualty and intentional violence events. Following recommendations from the Hartford Consensus, many Fire and EMS agencies placed an emphasis on training their providers in hemorrhage control techniques. The Hartford Consensus also advocated for empowering members of the public to act as immediate responders and initiate the chain of medical care before trained first responders arrive. The ACS Committee on Trauma (COT) North Haven, Connecticut, school teachers practice applying a tourniquet during the practical and the National Association of Emergency training breakout component of the North Haven School District’s Stop the Bleed training program. Medical Technicians (NAEMT) therefore created a public-access hemorrhage- PHOTOS COURTESY BAILEY WRIGHT control training program—the Bleeding Control Basic Course (BCON)—as well as Improving School Safety The town of North Haven employs 321 the Stop the Bleed campaign to increase In March 2018, a joint school safety teachers at its seven public schools and public access to hemorrhage control meeting was held in North Haven. The programs divided among four elementary equipment and training. NHFD and the North Haven Police schools, two middle schools and one high The BCON course is a one-hour class Department presented recommendations school.5 The school system enrolled 3,162 designed to train community citizens to the administration of the North Haven students in the 2016–2017 academic year. with any level of inexperience to control School District for improving the safety of The goal of the Stop the Bleed campaign life-threatening hemorrhage. Nationally, the town schools following the shooting at is to make communities safer by involving the class has been taught since 2015 to Marjory Stoneman Douglas High School the public in the care immediately more than 350,000 people by more than in Parkland, Florida. following traumatic injury. Trauma is the 28,500 instructors through Fire and The district superintendent agreed leading cause of death in individuals aged EMS departments, hospitals and other that Stop the Bleed training would be a one to 44, making schools a vulnerable organizations.1 time- and cost-efficient way to improve the environment with a large number of Early evidence shows that Stop the Bleed students’ safety and scheduled the training children concentrated in a space with training builds resilience-associated traits for a professional development day. proximity to windows, vehicles, and in participants2 and that trauma patients Although the session was organized playground equipment.6 experience enhanced survival with earlier by the NHFD deputy chief, executing Fire and EMS departments are uniquely field hemorrhage control.3,4 the training required coordination positioned with the expertise, experience This article demonstrates a model Stop from instructors across Connecticut, and outreach ability necessary to run the Bleed training program for a suburban including representatives from various a successful Stop the Bleed training district’s schoolteachers organized and hospitals, Fire and EMS departments, and program. Hemorrhage control classes can delivered by a Fire and EMS service. commercial EMS services. provide crucial training for a department’s

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The didactic component of the North Haven School District’s Stop the Bleed training was delivered by a single instructor over one hour.

EMS providers and deliver lifesaving Delivering the Training The participants were divided into two knowledge to members of the community. The North Haven Fire Department sessions, each lasting two hours. Instructor Fire and EMS departments are frequently (NHFD) is a combination career and materials and official training equipment involved in town, city or county government, volunteer Fire, Rescue, and EMS are available to instructors at the ACS giving them connections that can be department in the suburban town of North bleeding control website.7 used to advocate trainings for different Haven, Connecticut. Existing healthcare The didactic component was delivered populations. Fire and EMS departments providers were certified as BCON by a single instructor over one hour, and delivering hemorrhage control training to instructors by the ACS after completion then each participant was assigned to school staff makes sense for both parties of the BCON course and recruited by the one of 15 breakout rooms to complete but organizing the training has previously NHFD to instruct the course. their practical training over the next been a difficult task. hour. Each breakout room included two Although Stop the Bleed is often instructors, two training manikins, and interpreted as preparation for mass multiple tourniquets, gauze packs, and shooting events, the skills may be utilized compression bandages. in a multitude of community-experienced On Nov. 6, 2018, 34 instructors traumatic events. Though the skills simultaneously participated in the district- covered in the training may be applied to wide training event. Of the school district’s treat victims of shootings, reducing the 321 teachers, 278 registered for the training application of hemorrhage control skills (86.6%). Of these, 100% participation was only to events of gun violence ignores the noted (278 of 278). more common traumatic emergencies Following didactic training, participants were of motor vehicle collisions, power tool assigned to one of 15 breakout rooms to Future Training & Recertification injuries, playground accidents and complete their practical training. The North Haven School District kitchen/cooking incidents. Superintendent found the training to be

Stop the Bleed JEMS May 2019 | 23 STOP THE BLEED

extremely valuable and the delivery of References Centers for Disease Control and Prevention. Retrieved May 20, 2019, from www.cdc.gov/ this event to be very well thought-out and 1. American College of Surgeons. (2018.) injury/wisqars/overview/key_data.html. organized. Through future collaboration Stop the Bleed: 2018 progress report. 7. American College of Surgeons Committee on between the NHFD and the school district, Retrieved April 1, 2018, from www. bleedingcontrol.org/~/media/bleedingcontrol/ Trauma. (n.d.) BleedingControl.org. Retrieved training will be held for the remaining 43 files/2018_stb_progressreport.ashx. May 20, 2019, from www.bleedingcontrol.org. teachers as well as the support personnel 2. Levy-Carrick NC, McCarty JC, Chaudhary MA, 8. Ramly E, Bohnen JD, Fagenholz P, and paraprofessionals. Recertification of et al. Hemorrhage control training promotes et al. Creation of the first Hartford trained employees will also be discussed resilience-associated traits in medical Consensus compliant elementary at future meetings. students. J Surg Educ. 2019;76(1):77–82. school in the USA. Trauma Surg Acute Care Open. 2016;1(1):e000031. Stop the Bleed trainings have occurred 3. Goolsby C, Rouse E, Rojas L, et al. Post- previously in public schools but a single mortem evaluation of potentially survivable hemorrhagic death in a civilian population. training event for an entire school district Jeremy Fridling, BA, NRP, TP-C, is a medical student J Am Coll Surg. 2018;227(5):502–506. is a unique event.8 at the Frank H. Netter MD School of Medicine at And, although all members of the 4. Teixeira PGR, Brown CVR, Emigh B, et Quinnipiac University in North Haven (Conn.) and al. Civilian prehospital tourniquet use community may benefit from training in a former full-time firefighter/paramedic at the is associated with improved survival in Westminster (Md.) Fire Department. hemorrhage control techniques, training patients with peripheral vascular injury. J the group of individuals responsible for Am Coll Surg. 2018;226(5):769–776.e1. Scott Martus, MS, LP, is deputy chief of operations the community’s children should be a 5. Cronin R. (Feb. 27, 2018.) North Haven School for the North Haven (Conn.) Fire Department. top priority. District: District Profile and Performance Report David Shapiro, MD, MHCM, FACS, FCCM, is vice chair We hope that this article serves as both for School Year 2016–2017. Connecticut State Department of Education. Retrieved May 20, of surgery and chief quality officer at Saint Francis a proof of concept and a motivational 2019, from https://edsight.ct.gov/Output/ Hospital and Medical Center in Hartford, Conn. piece for fire and EMS departments across District/HighSchool/1010011_201617.pdf. the country to train their schoolteachers 6. National Center for Injury Prevention and Control. to stop the bleed and save precious lives. ✚ (May 8, 2017.) Key injury and violence data.

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ADVANCED PUBLIC ACCESS GRAB & GO BLEEDING CONTROL KIT INDIVIDUAL BLEEDING CONTROL KITS FROM H&H MEDICAL from North American Rescue provide proven lifesaving equipment that The Grab & Go Bleeding Control Kit puts everything you need to save empowers the general public to take action as immediate responders a life in one easy-to-use pouch. All the products needed to control in stopping life-threatening bleeding. Featuring the CAT Tourniquet severe bleeding, protect wounds, prevent hypothermia and shock, and highly effective hemostatic QuikClot® Bleeding Control Dressing, and keep someone who’s injured alive until help arrives. Each item these two intuitive, easy-to-use tools come packaged in a personal- in the kit is individually wrapped and protected to survive under any sized rugged nylon bag or clear vacuum-sealed pouch. Prepare conditions. Packed thin with every product visible, so it’s easy to slip anyone, anywhere, to save a life! into a backpack or briefcase, or bring into any workplace. North American Rescue® H&H Medical www.NARescue.com https://buyhandh.com/collections/hemorrhage/products/grab-go-bleeding-control-kit

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