ACS, the Committee on Trauma, and the Hartford Consensus

BleedingControl.org

Stop the Bleed Save a Life

Turning Bystanders into First Responders

The New Yorker (@NewYorker) recently published a long feature about Stop the Bleed and the rise in Intentional Mass Casualty Events. The piece, by Paige Williams (@Williams_Paige), contained previously unpublished accounts of the mass shooting at Tree of Life, a synagogue in Pittsburgh, and a mass stabbing at a high school. Here is an excerpt, with the author's permission, followed by a link to the full piece, "Under the Gun," which appeared in the magazine's April 8, 2019, issue.

One icy morning in mid-January, Matthew Neal, a trauma surgeon and a research scientist at the University of Pittsburgh Medical Center, got in his car and drove twenty-six miles north of the city. He arrived at Mars Area High School, where more than two hundred employees of the public-school district were filing into the auditorium, for a mandatory Stop the Bleed seminar. They wore puffy coats and snow boots, and carried Starbucks cups and thermoses that were still warm.

Neal, who is thirty-eight, is tall and lean, with a resonant voice. People call him Macky. He has his own laboratory, which recently received a grant partly funded by the Department of Defense to study treatments for types of bleeding that don’t respond to compression, such as certain belly wounds. One night, when I joined his family for dinner, he told me, “My whole focus is blood.”

He stood at the front of the auditorium with Raquel Forsythe, another U.P.M.C. trauma surgeon, who wore a voluminous red scarf and had her hair in a high bun. They used a laptop to project a presentation onto a screen. One slide read, “Why do I need this training?” The answers included “mass shootings,” “motor-vehicle crashes,” “home injuries,” and “bombings.”

The stabbings at Franklin Regional Senior High had occurred in the wake of other horrific attacks in the Pittsburgh area, including shootings at an L.A. Fitness franchise and a psychiatric clinic. The city’s trauma specialists reviewed these tragedies, but, Neal told me, they often ended a case analysis “feeling a bit empty.” No matter how nimble first responders are, Neal is prone to say, “I can’t do anything if the patient’s dead.”

In October, 2015, the American College of Surgeons launched a national Stop the Bleed campaign. The White House backed it. President Barack Obama declared that national disaster preparedness was a “shared responsibility” between citizens and the government, and Vice-President Joe Biden described Stop the Bleed as a “call to action” for anyone “in a position to help.” Cities at high risk for gun violence, including St. Louis and Baltimore, welcomed the program. Laurie Punch, a trauma surgeon and a leader of St. Louis’s Stop the Bleed efforts, has said that trainers “want people to discover that they’re not just victims—that they can actually save a life.”

The Orlando Fire Department was modernizing its first-responder protocol when, in June, 2016, a gunman shot up the Pulse night club, killing forty-nine people and injuring fifty-three. Trauma specialists based at George Washington University Hospital, in Washington, D.C., found that four of the victims might have survived if they had received “basic E.M.S. care” within ten minutes and had been transported to a trauma hospital within an hour. (None of those who died had received tourniquets or other bleeding-control interventions.) Two days after the Pulse shooting, the American Medical Association voted to adopt a new policy aimed at training the general public in bleeding control.

In Pittsburgh, Andrew Peitzman, U.P.M.C.’s chief of surgery, urged the hospital system to embrace Stop the Bleed. Seminars were soon held throughout the region, with a special emphasis on training law-enforcement officers. U.P.M.C. announced that it would donate more than a million dollars to provide such supplies as tourniquets and hemostatic gauze to every public school, and to put “a tourniquet on the belt of every law-enforcement officer in western Pennsylvania.” By the start of this year, nearly forty thousand people in western Pennsylvania had been trained, and bleeding-control kits had been handed out to some five hundred public schools in the area—more than anywhere else in the country.

Stop the Bleed uses a “ripple” approach: volunteers train people, who, in turn, train others. At the Mars Area High School seminar, Neal and Forsythe were the volunteers, along with a group of Cranberry Township paramedics and U.P.M.C. flight nurses. The team also included a more unusual participant: Neal’s nine-year-old son, Cameron, who often helps his father teach workshops. He was standing with the other volunteers in a red-and-blue striped shirt, khaki cargo pants, and glasses. Before Christmas, Cameron’s third-grade teacher had assigned how-to presentations; recommended topics included how to bake cookies or make a paper airplane. Although Cameron has various areas of expertise—Legos, kung fu—he chose to demonstrate Stop the Bleed.

The standard presentation contains graphic images: an enormous leg gash, a nearly severed foot. Macky Neal warns audiences that the photographs may be upsetting, and trainees sometimes look away or leave. The queasiness is understandable. Blood is supposed to remain inside the body, and it can be sickening to see it released, especially in large quantities. Blood is slippery and messy, and it has a strong metallic smell. Under certain circumstances, it may transmit disease. In traumatic injuries, blood may be mixed with body tissue and teeth and bone. Neal, the son of a Pennsylvania State Police commander, believes that showing people images of severe injuries, if done sensitively, can reduce their unease in a crisis later, just as the use of dummies in C.P.R. training helps people overcome the discomfort of performing chest compressions and mouth-to-mouth resuscitation during a cardiac arrest.

Primarily, the images are intended to help attendees identify life-threatening bleeding. Many bystanders’ instinct is to cover up blood. But, as Forsythe put it, “to stop bleeding you need to see bleeding.”

Paramedics talk about getting patients “trauma naked”—moving aside any clothing and pinpointing the source of hemorrhage. The loss of a limb is automatically considered life-threatening. In other cases, there are warning signs: Is blood pooling around the victim? Is the wound spurting? Are bandages saturated? Bystanders should pay close attention to a victim who becomes suddenly irrational or loses consciousness, symptoms that suggest the onset of hemorrhagic shock. Explaining that “people can bleed to death in as little as five to eight minutes,” Forsythe told the audience, “It often takes E.M.S. that long to respond.”The location of a wound dictates treatment. For an arm or a leg, use a tourniquet. For a “junctional” injury—neck, armpit, groin—press against the wound or pack it with gauze. (Place the victim on a hard surface, to maximize pressure.) For a chest, belly, or head wound, the most helpful interventions, such as suction or a needle thoracostomy, require E.M.S. training, but applying pressure can help a patient hold on. Skeptics sometimes ask Neal whether administering emergency care will traumatize a young person, to which he responds, “It may be more traumatic to stand there and watch someone die.” The National Center for Disaster Medicine and Public Health recently received a FEMA grant to design a Stop the Bleed-style program for schools.

Neal’s son climbed onstage, to demonstrate how to address a severely bleeding wound. He knelt over an object that resembled a piece of smooth firewood. It was a training limb the size of an average male adult’s thigh, with the spongy consistency of flesh. A “wound” in the limb went all the way to the “bone.”

Cameron started by explaining manual pressure. He told the audience to place one hand on top of the other, interlocking the fingers for stability. “You’re gonna push as hard as you can, shrugging your shoulders,” for at least ten minutes, he said, or until help arrives. His father added, “This is not ‘one hand while you’re calling for help on your phone.’ When it’s your job to hold pressure, that is exclusively your job.”

The next subject was tourniquets. When a victim has a potentially fatal injury to an arm or a leg, Neal and Cameron explained, tourniquets should be applied right away and should be “high and tight.” Cinch the tourniquet just below the armpit or groin, they counselled, and “you will never be wrong.”

Cameron slipped a C-A-T onto the fake limb. As he cranked the windlass, Neal asked, “How do we know when to stop?” Cameron said, “When you don’t see any more blood coming out.” Once a tourniquet is on, it must be left on: only a medical professional should remove it. (Doctors advise against using improvised tourniquets—without a proper windlass, a belt or a tie won’t be tight enough.)

They moved on to wound packing. Forsythe told the crowd, “This is the part that gives some people the willies.” The hole in the fake limb simulated a gunshot or a stabbing injury. Cameron poked an index finger into it and said, “As you can see, it’s really deep.” He steadily thumbed length after length of gauze into the hole, and said, “You’re gonna stuff it in.” The audience laughed.

The wound held several feet of gauze. When no more fit, Cameron balled up the remaining material and used it to apply pressure on top. His father explained that, beneath the skin, a wound could be surprisingly large—it was important to “get gauze down in there, to occupy that space.” Packing a wound added pressure that impeded blood flow, and the kaolin in the gauze encouraged clotting. In a mass-casualty incident, using tourniquets and packing wounds could free up first responders to move on to other patients.

The audience had questions. Which should be used first with an extremity wound, a tourniquet or wound packing? A tourniquet. What if the patient fights you? Calmly but firmly explain what you’re doing, and acknowledge that the tourniquet may be painful. Forsythe noted, “Tourniquets hurt—a lot.” (Paramedics typically give victims pain medication.) What if you don’t have any hemostatic gauze? “If I needed to, right now, I could take off my scarf or my jacket and use that,” she said.

For the second half of the training, everyone trooped to the cafeteria and broke into groups. Each table held a fake limb and a Stop the Bleed kit. The basic kit, which is sold online by the American College of Surgeons, costs sixty-nine dollars. It contains a C-A-T, a compression bandage, protective gloves, hemostatic gauze, and a Sharpie, for writing “tourniquet,” and the time it was put on, in a highly visible location, such as across the patient’s forehead.

Neal and his son claimed a table near the cafeteria’s plate-glass windows, which overlooked a parking lot white with ice. Their students included a track-and-field coach, two custodians, an eighth-grade English teacher, a fifth-grade math teacher, and various administrators. One of the administrators watched the math teacher stuff gauze into the training limb, and said to Neal, “I mean, I understand that we need to stop the bleeding, but if you use your T-shirt to pack a wound—that’s not sterile!”

“You’re not gonna introduce a life-threatening infection,” Neal told her. “We can take care of that at the hospital, with antibiotics.” He added, “I don’t mean to be blunt, but let me worry about that problem.”

To read "Under the Gun," the full New Yorker story on Stop the Bleed and Intentional Mass Casualty Events, go to newyorker.com.

This excerpt has been reprinted with permission of the author, all rights reserved.