Stop the Bleed in Long Island, New York: A “Must” Need Born from the Blood of Innocents—Where We Are and Where We Are Going.
Fahd Ali, MD, and D’Andrea Joseph, MD
Department of Surgery
The Trauma Center at NYU Winthrop Hospital, Mineola, New York
Born out of the Sandy Hook tragedy, the Hartford Consensus was formed as a response to achieve the goal of decreasing bleeding from injury. The primary tenant of the consensus was that no one should die of bleeding that could be controlled. The ability to achieve this important goal rested on these key concepts: (1) EMS must be able to get the victims sooner and work with law enforcement to do so, (2) police and other law enforcement must be trained in the use of packing and tourniquets for hemorrhage control, and (3) a new category of responder, “the civilian citizen,” could be trained to start rendering immediate aid to the injured. *1*
In October 2015, the White House endorsed the Stop the Bleed campaign with the goal of bringing lessons learned from our military experience to the “lay public” and turning them into a large population of immediate responders during mass casualty incidents. *2, 2A*
While many associate Long Island with the glamour of the Hamptons and its beaches, it is one of the most densely populated regions in the country. Nassau county, the home of the NYU-Winthrop, an ACS verified Level-1 trauma center, is just west of New York City and has been in immediate proximity to several major mass-casualty events: Sandy Hook, the West Side Highway (motor vehicle MCI, October 2017), the Port Authority (bombing, December 2017); Chelsea, NYC (bombing, September 2016); and who can forget the World Trade Center (September 2011—NYU-Winthrop stands less than 20 miles away from the 9/11 memorial park). Of import is the 1993 Long Island Rail Road shooting that left 6 dead and 19 injured—it occurred less than 1.5 miles away from the hospital.
Experience in the battlefield has refocused the ability to maximize patient survival immediately after injury. The concept of balanced resuscitation using the 1:1:1 ratio of plasma, RBC, and platelets has contributed to the decrease in mortality rates and resulted in the widespread implementation of standardized, massive transfusion protocols. *3* Eliminating the need for transfusion would, however, be the most ideal.
Tourniquets were described as early as 1674, when Guy Chauliac used them to limit blood loss during battlefield amputations. During the US Civil War, combatants carried bandanas and a stick to use as a windlass. Unfortunately, during World War I, tourniquets became much maligned for leading to poor outcomes and limb injury—a belief that was reinforced by many during World War II.
With a mature graded medical care delivery system during the recent Middle East conflicts, Kragh et al., demonstrated a marked positive-survival benefit with no amputation could be related to the use of tourniquets alone. Indeed, the use of tourniquets before the onset of shock strongly correlated with survival. *6, 7* (This finding also correlated with the fact that during 2001–2011, most deaths in the battlefield were the result of truncal or central nervous system injury.) With the proper use and deployment of tourniquets, the death rate from extremity hemorrhage dropped by 85 percent despite the fact that the extremities are a commonly injured site among combatants. *8*
We adopted the Stop the Bleed program at our institution after a trauma surgeon on staff, in response to an unfortunate boating incident where the victim bled to death, suggested the course. It was clear at that time that any education on bleeding control could be helpful to the people we served. It was not until the tragedy that occurred in Las Vegas, however, that we gained focus and expanded our reach. The principles of our program center on the core tenants of the 2016 Hartford Consensus:
1) That all law enforcement officers (and security) must be trained in the control of ongoing extremity bleeding, and
2) Civilian citizens can act as immediate responders. *1*
The reports from the Boston Marathon bombing showed that even in the presence of a heavy first-responder presence and deployment, most of the tourniquets that were applied to the 83.9 percent of exsanguinating extremity injuries were improvised, and many were not properly applied. *9, 10, 11*
To that end, we focused our initial rollout of first responders to include lifeguards, security officers, police officers, and fire fighters. We conducted classes at local utility companies, malls, sporting venues (like the Barclays Arena and Nassau Coliseum), and at law enforcement academies.
We also worked with security agencies commensurate with the Hartford data *1,* which demonstrated that previous training or exposure did not necessarily indicate a comfort level with the principles and techniques of stopping the bleed. This group would also be “high yield,” as they are the most likely to be exposed to stress scenarios where that first aid skill set would be most needed.
With our aggressive rollout of the highly beneficial Stop the Bleed program, we have successfully trained nearly 300 individuals in less than a year. Data from 74 law enforcement personnel who were trained and tested demonstrated marked improvement in applying the principles of Stop the Bleed, as well as statistically increased comfort levels with the process.
Dr. Lenworth Jacobs et al., have encouraged the use of practice drills and planning with first responders and pre-hospital providers. *12* Our hope is that as we continue to expand, with the addition of the general public AND hospital-based providers, the idea of Stop the Bleed will be as natural a response as the average citizen performing CPR on an unfortunate victim. This hope is the goal of the program itself.
The recent widely reported tragedy of the Parkland shooting demonstrates the need for ongoing education. While we continue to identify ways to decrease injury and violence, it is clear from our recent data that the correct training and equipment can be both lifesaving and empowering, and our institution, as an ACS verified Level-I trauma center, is committed to this cause.