Most civilians support wider access to training and equipment to stop severe bleeding in victims of mass casualty events

Preventing a severe bleeding death in victims who have a survivable injury has been the focus of work of the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass Casualty and Active Shooters Events, convened by the American College of Surgeons. The committee's deliberations are known as the "Hartford Consensus" because the group has met three out of four times in Hartford, Conn.

The Hartford Consensus advocates that "no one should die from uncontrolled bleeding."

In addition to training law enforcement officers in bleeding control and instantly providing them with equipment to do so, emergency medical service personnel also need quicker access to the wounded. However, another key element calls for using civilian bystanders as immediate responders who perform external bleeding control for victims at the point of wounding before the arrival of professional responders. This element from the Hartford Consensus is at the core of the "Stop the Bleed" campaign by the Department of Homeland Security through the National Security Council.

"We know that to save life and limb, you need to stop the bleeding very early. Within five to 10 minutes or victims can lose their lives," explained Lenworth M. Jacobs, Jr., MD, FACS, Chairman of the Hartford Consensus, and Director of the Trauma Institute at Hartford Hospital.

"However, until now, there has been no clear indication of how well trained the general public is in bleeding control and how willing they might be to participate as immediate responders until professionals arrive on the scene," he said.

To find out, Dr. Jacobs secured the services of Langer Research Associates (New York City) on behalf of the Hartford Consensus to conduct a national telephone survey among the general public on several bleeding control issues. Specifically, Dr. Jacobs explained, the poll was developed to gauge public perceptions and identify potential motivators of their willingness to control bleeding in the wounded, including what techniques they would use, their willingness to be trained, and their level of support for placing bleeding control equipment in public places.

The 15 primary question telephone survey was designed to initially ask respondents if they had ever taken first aid training, and if so, how long ago the training took place, and did it include bleeding control instruction.

Respondents were next asked about their willingness to provide aid to bleeding victims in two different scenarios: a car crash scenario and a mass shooting one. Respondents were also asked about their interest in taking a bleeding control class, and their support for requiring bleeding control kits in public places.

Field work for the survey was conducted by the market and research firm SSRS (Media, Penn.) from November 6-11, 2015, ending just two days before the terrorist attacks in Paris. Telephone interviews, lasting eight minutes on average, were conducted with 1,051 individuals, 528 via cellphones and 523 via landline.

In terms of identifying what civilians already know about first aid, almost half of all respondents (47 percent) answered that they had received first aid training during some point in their lives. Of that number, 13 percent had first aid trained in the past two years, while 52 percent had first aid trained more than five years ago.

Of the respondents who had received first aid training at some time, 72 percent responded that the training included instruction on how to control severe bleeding, with 90 percent (941) confirming that they were physically able to provide first aid to injured people.

Respondents in the age group 50- to 64-years old reported the highest percentage (57 percent) of first aid training; the lowest percentage (37 percent) was reported in the age group of 18- to 29 year olds.

Within the context of the two scenarios presented to respondents for providing first aid to the injured, authors reported that:

• Of the 941 respondents able to provide first aid, 98 percent indicated they'd be "very likely" or "somewhat likely" to attempt bleeding control in a family member (scenario presented was severe bleeding from a leg wound). Within this subgroup, 62 percent indicated they would apply pressure or compression to the wound; 36 percent would apply a tourniquet; 6 percent would cover or wrap the wound in a bandage; while 2 percent would elevate the injured leg.
• When presented with a scenario of trying to stop severe bleeding in a car crash victim unknown to respondents, 92 percent of a random half sample of respondents indicated they'd be very likely (61 percent) or somewhat likely (31 percent) to enact bleeding control.
• In a mass shooting scenario, 75 percent of the other random half sample responded that they would attempt to give first aid if it seemed safe to act; 16 percent responded that they'd stay and wait to see what happens; and 8 percent said they'd leave the area. In terms of assisting if the situation seemed safe, 94 percent responded that they'd be very likely (62 percent) or somewhat likely (32 percent) to try to stop bleeding in an unknown person.

The authors further report that many survey respondents did indicate having a "major or somewhat of a concern" about several issues related to trying to stop severe bleeding in someone they didn't know. Specifically, respondents expressed concern over the sight of a blood (30 percent); concern with the risk of becoming contaminated with a disease (61 percent); concern for personal safety (43 percent); concern about causing a victim additional pain or injury (65 percent); and concern for being responsible for a bad outcome (61 percent). Within the context of a rendering assistance during the shooting scenario, 71 percent expressed concern about "putting themselves in physical danger from additional violence."

Despite these concerns, 82 percent of those physically able to provide first aid would be "very interested" or "somewhat interested" in locally attending a two-hour bleeding control course, with 39 percent confirming "they would definitely take the class if it fit their schedule."

The authors also noted strong public approval (91 percent of all surveyed) for training and equipping police officers for severe bleeding control to act as soon as possible before the arrival of EMS personnel, with 65 percent also supporting "faster access of EMS to victims in areas that may not be totally secure."

In terms of publicly placing bleeding control kits (containing gloves, tourniquets, compression dressings), 93 percent of those interviewed supported the proposal, with 70 percent expressing strong support, and 23 percent saying they somewhat supported it. Within this support group, 62 percent said, "kits should be encouraged but not required."

"It takes internal fortitude to want to get involved as immediate responders. We were overwhelmed to learn that the public is prepared to accept this responsibility. Keeping in mind that survey responses were collected before other terrorist incidents in Paris, Brussels, and Pakistan, we speculate that at this point, public support might be even stronger for civilians and police officers to enact bleeding control measures," Dr. Jacobs said.

"Moving forward, we plan use these new insights to develop a training program for the public, not health care professionals, so civilians can learn how to act as immediate responders. We want to steer interested people toward getting the right training, and to understand when victims are experiencing the signs of massive bleeding so they can 'stop the bleed' and save lives," he concluded.