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Amid so many shootings, a movement to make tourniquet training as common as CPR

It’s been almost a decade since a Connecticut trauma surgeon viewed the carnage following the Sandy Hook shooting and helped launch an effort to bring battlefield medicine to everyday trauma care.

(CN) — One day in March 2018, Kathy Gregory, a nurse at a northern Georgia elementary school, was speaking with the principal outside her clinic.

“I just remember seeing a teacher running towards me, and the look on her face just was sheer terror,” Gregory said. “And all I could hear her saying was, ‘There’s blood everywhere.’”

A student had taken a short fall from playground equipment onto another student. The fall broke a bone in her arm, tearing an artery.

What happened next was the culmination of an effort that had begun years before. Military doctors embraced tourniquets, once a tool viewed with suspicion, as a way to keep wounded soldiers alive during the wars in Iraq and Afghanistan, and an Obama-era White House initiative — the Stop the Bleed program — sought to get them into the hands of civilians.

In an interview, Gregory, a nurse of nine years at the time of the incident, said nursing school addressed tourniquets theoretically. If you need one, Gregory remembered her instructors saying, improvise with a belt or an electrical cord.

But Cumming Elementary School, where she worked, had taken part of a state program to place bleeding control kits in Georgia schools. Weeks earlier, a group of nurses had taken a two-hour course at a local fire department and Gregory had spent the following weeks showing teachers how to use a trainer tourniquet; she practiced dozens of times.

On that day, the 13 bleeding control kits and their orange-colored tourniquets — which the school planned to hang in the halls, near the playground, by the front offices — sat in an unopened cardboard box on top of Gregory’s medicine cabinet.

Leaving her medical bag, Gregory grabbed one of the kits and sprinted in flip-flops to the playground.

Twenty minutes later, an ambulance was carrying the student to the hospital. Without the tourniquet, it would have been 20 minutes too late. The paramedic who shook Gregory’s hand said as much, as did a trauma surgeon in an email.

Proponents who say Stop the Bleed tenets should be taught right up there with techniques such as the Heimlich maneuver cite statistics such as from the Coalition for National Trauma Research that say physical injury is the leading cause of death for people ages 1 to 46.

Elizabeth Atkins, executive director of Georgia Trauma Commission, compared the efforts to teach bleeding control as the “modern-day version of CPR.”

In 2017 the commission ran the program to place bleeding control kits in Georgia schools. About two years later, the commission began to place bleeding-control kits in the state’s school buses.

It’s not just Georgia. Indiana has a law on its books mandating schools stock bleeding kits, although an Indiana Department of Education spokesperson said schools are not required to report on their status with the program to the state. A Texas law also directs schools to stock units for bleeding control.

In Cape Cod, the Atlantic White Shark Conservatory hosts Stop the Bleed classes. In a 2018 press release, the group said while shark bites are rare, the highest number of Great White Sharks lurk off the coast of the cape in September and October, when no lifeguards scan the waters from the shore.

More recently, the American College of Surgeons produced a bleeding control training video in Ukrainian.

These days, Gregory keeps a bleeding control kit in her car, in case she comes across a car collision.

The Stop the Bleed campaign began as an initiative launched by the Obama White House in October 2015. It said widespread knowledge of bleeding control was needed because an individual with severe bleeding could bleed out within five minutes — long before the sirens of emergency personnel could be heard coming in the distance.

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But the impetus for the project began three years before, in the aftermath of the Sandy Hook shooting.

Lenworth Jacobs, director of the Stop the Bleed program at the American College of Surgeons and surgery professor at the University of Connecticut, spent four decades as a trauma surgeon at Hartford Hospital after he relocated to the area to start the trauma center.

Often the hospital would be placed on alert, its air medical service crew standing ready to helicopter in the critically wounded, but would then be told to stand down when an incident turned out to be not as serious.

On Dec. 14, 2012, the hospital learned there was a major incident at Sandy Hook Elementary School in Newtown, Connecticut. Staff prepared to treat the wounded. But no wounded came and the hospital was told to stand down.

“The original thought was it was a firecracker, just not a problem here. But it turned out that obviously was not the case,” Jacobs said.

The reality: a score of first-grade students and six educators dead. In the aftermath, Jacobs, as chair of the Connecticut State Trauma Committee, reviewed the injuries with the state medical examiner.

“Even though I’d seen a lot of things before, children and a lot of children is very, very different,” Jacobs said. “And coming out of that, I just thought you can’t have this kind of thing going on in a civilized society. So we have to do something — we being everybody — has to do something about this.”

Jacobs, then a member of the American College of Surgeons board of regents, called for a committee to examine the response to mass casualty incidents like Sandy Hook and the 2013 Boston Marathon bombing.

While the committee’s compendium noted that most of the injuries at Sandy Hook were “immediately lethal” and a tourniquet would not have helped the majority of victims, the Hartford Consensus identified two areas for improvement. The first was an increased coordination between police, fire and emergency services, who all descend on a mass casualty incident with different goals and command structures, which can lead to confusion, Jacobs said.

While police officers in the past would wait for emergency services to come in with medical care, they are now learning bleeding-control techniques and carrying tourniquets, Jacobs said.

“Most police units now carry kits just like the military. So you know, it’s on their belt or in their police car or something, and they’re being trained to use it,” Jacobs said.

Two soldiers with U.S. Army Medical Research and Development Command at Fort Detrick in Frederick, Maryland practice applying a tourniquet during a Stop the Bleed awareness event on May 19, 2022. (Photo courtesy Gloriann Martin/USAMRDC Public Affairs)

The second was a recommendation to broadly adopt some of the changes occurring in the military surrounding bleeding.

The public, Jacobs said, tends to be scared of bleeding. Many people’s mindset “is to be horrified and then call for help, and kind of observe or watch. And we need to change that: if you see something, do something,” Jacobs said.

Jacobs said the goal of the Stop the Bleed training is to empower people not to shrink back but to use their hands, perhaps holding gauze or just a shirt, to press hard on the source of bleeding. And if available and appropriate for the situation, use a tourniquet.

Tourniquets earned a bad rap in past military conflicts, Jacobs said, because wounded soldiers would often spend hours waiting for medical care. As the tourniquets sat, they cut off oxygen to their limbs, which often required amputation. These days, trips to the hospital are typically quicker.

Stephen Carroll, who teaches emergency medicine at the Drexel University College of Medicine, said when he took classes for his EMT Basic certification in 1999, he was taught that a tourniquet was a tool of last resort, that a first responder needed to do everything they could before tightening a band around a limb so tight it would cut off blood flow.

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But even before Sandy Hook, there was already a change in thinking. The success of tourniquets on the battlefields in Iraq and Afghanistan and the 2007 shooting at Virginia Tech started discussions within the EMS community about tourniquets.

“They got it down to a point in Iraq and Afghanistan, where you were making it a to a medical facility, if not a trauma center, within 45 minutes or an hour of point of injury,” Carroll said. “Having a tourniquet on for an hour is almost inconsequential. It hurts, don’t get me wrong; it’s not pleasant for the person, but it will help them survive.”

Soldiers outside the wire carried individual first-aid kits to use in case they became injured.

Carroll, who worked in a trauma center in Afghanistan in the U.S. Army, kept four tourniquets stashed on his body: one in the pocket near each of his limbs.

Stateside, bleeding injuries often come from kitchen knives, car collisions and chainsaws.

“The difference with the military is,” Carroll said, “in general, you’re dealing with much higher-caliber weapons and assault rifle injuries, which cause a lot more damage, and things that you would need a tourniquet for a lot more frequently, whereas with civilians we’re mostly dealing with handgun injuries and there’s not as much energy.”

Craig Goolsby, professor of military and emergency medicine at Uniformed Services University, said in the past, first-aid instruction has been effective in teaching individuals how to address sprained ankles, minor cuts and scrapes. The old training typically advised people to remain hands-off and call 911 for serious injuries.

Goolsby, who deployed to Iraq twice with the Air Force, was also the principal investigator developing an American Red Cross course called “First Aid for Severe Trauma,” which is targeted towards high school students and debuted in 2019.

According to the Red Cross, more than 2,500 people have taken its FAST training, a number Goolsby hopes to see snowball as students return to school in the fall.

Goolsby said teaching high schoolers bleeding control is a way to effectively teach the techniques across the country, as they are at a maturity level to deal with the subject of massive bleeding, they have not yet heard the earlier adages of eschewing tourniquets and they can carry the knowledge for the rest of their lives.

He said the training is needed so that people can know how to properly use a tourniquet, make sure it’s applied correctly and know when an injury is serious enough to warrant it.

“Many first-aid courses are starting to incorporate some of the stop the bleed techniques as well,” Goolsby said. “So I think what we’ll see in the coming years is … a significant shift towards teaching these skills more ubiquitously.”

Seven years after the White House’s initiative, Stop the Bleed training has been carried forward by such big names as the American Heart Association, the American College of Surgeons and the Red Cross.

The name itself, Stop the Bleed, is a trademark owned by the Department of Defense. The Combat Casualty Care Research Program (CCCRP) is the organization that considers whether to license the trademark to various groups; around the world, there are 462 Stop the Bleed affiliates.

“It is not a formal governmental program beyond the fact that it was a White House mandate several years ago, and the DoD maintains the trademark,” said Travis Polk, director of CCCRP. “But it’s very much a grassroots effort across all of those that believe in it. Most of the instructors are volunteers.”

Polk, who himself was a Stop the Bleed instructor, said when an entity seeks to use the Stop the Bleed trademark, CCCRP will evaluate to see if a qualified individual teaches the course and whether the training hews to published standards on, say, how to use a tourniquet appropriately.

Polk said that the pandemic has changed the way people experienced training, with some groups shifting away from in-person training in order to bring the training virtually. However, virtual trainings don’t benefit from the psychomotor skills that come from actually working with a tourniquet, he said.

Meanwhile, Jacobs said Stop the Bleed has trained 100,000 instructors across 134 countries, instructors who have trained about 2.1 million people worldwide. It is a mere fraction of the 200 million Jacobs wants to have trained.

While the effort to teach Stop the Bleed has been going on for a couple of years, the widespread teaching of CPR began in the early 1970s and it took time for it to grow nationwide, Jacobs said.

Some medical schools require students to learn Stop the Bleed techniques, Jacobs said, who will in turn teach others.

“That’s how we get from 2 million to 200 million,” Jacobs said. “It’s not linear. It’s gonna be exponential.”

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