Bringing a Battlefield Lesson Home

In the summer of 2013, John Hunt and Wells Weymouth, medical students at a nearby university, were heading to the exit of a Sam's Club in Gaithersburg, Maryland, when an automobile burst through the wall of the store and slammed into two shoppers 20 feet away. While stunned bystanders frantically dialed 9-1-1, the young men swung into action. Rapidly assessing the situation, they determined that one victim was relatively stable. The other, a 76-year-old man, was not. The force of the crash had nearly torn his right leg off near the knee, severing his femoral artery. If prompt action was not taken, he would bleed to death. “Both recently completed their first year of medical school at the Uniformed Services University of the Health Sciences in Bethesda, which trains members of the U.S. military. Students at the school receive trauma training to prepare them for what they could later encounter on a battlefield. Hunt and Weymouth were no different, learning in their first year how to use a tourniquet, for example. [They] took off their belts, tightening them around the man's thigh. But they couldn't stop the bleeding. ‘Give me your belts,’ Weymouth said to several shoppers nearby. They did. Weymouth and Hunt tightened three more belts around Chavez's thigh. The bleeding stopped. Weymouth spoke to Chavez in Spanish. “It's going to be okay,” he said. “We're medics. We're medics.”1 Prehospital emergency care is based on the premise that swift and decisive action at the scene and en route to the hospital can make the difference between life and death. The classic example is out-of-hospital-cardiac-arrest (OHCA), a condition that is almost invariably fatal if proper treatment isn't initiated within 4 to 8 minutes of collapse.2 Another example is massive bleeding from life-threatening trauma. Modern emergency medical services (EMS) systems were developed to get trained rescuers to a victim's side within minutes of a call for help. But sometimes, “within minutes” isn't soon enough. The only way care can be delivered more quickly is through the actions of bystanders. Studies have determined, for example, that provision of bystander cardiopulmonary resuscitation (CPR) more than doubles an OHCA victim's odds of survival.3 To boost rates of bystander CPR, communities have sponsored mass trainings; implemented dispatcher-assisted CPR; promoted video self-instruction CPR; and, more recently, embraced the “hands-only” technique to make CPR easier to learn, easier to retain, and easier to perform.4 A similar evolution of care has occurred with prehospital defibrillation. Once, physicians and paramedics had to undergo lengthy training in the recognition of cardiac arrhythmias to safely operate a manual defibrillator. Then, introduction of automated external defibrillators (AEDs) enabled first-responding firefighters, police officers, and even bystanders to defibrillate patients in cardiac arrest.5 Today, to facilitate public access defibrillation, AEDs are placed in countless public settings.6 Perhaps it's time for a similar evolution in prehospital trauma care. The U.S. military's recent experience in Iraq and Afghanistan may be instructive. After military researchers determined that as many as one-quarter of combat casualties were dying from potentially survivable injuries, the services implemented a collection of evidence-based clinical practice guidelines to reduce preventable battlefield deaths.7 The resulting program, Tactical Combat Casualty Care (TCCC), achieved remarkable results.8-10 Key elements of the program include rapid application of tourniquets to control life-threatening extremity hemorrhage11 and use of hemostatic dressings for bleeding that cannot be treated with tourniquets. The use of tourniquets in combat was so effective, they are being adopted by a growing number of civilian EMS units in the United States.12 In a few instances, lay rescuers have used the technique as well. After two improvised explosive devices were detonated near the finish line of the 2013 Boston Marathon, runners and other bystanders tore off their shirts to use as tourniquets or to apply direct pressure to control bleeding. The urge to help in mass casualty situations is so powerful; it makes sense to provide bystanders with sufficient training and equipment to do a credible job. The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events (also known as the “Hartford Consensus”) recently called for the “seamless integration of a hemorrhage control intervention” that “starts with the actions of the uninjured public or minimally injured victims and extends to the first responding law enforcement officers, then to EMS/Fire/Rescue personnel, and ultimately to definitive trauma care.”1 Before the Hartford Consensus' vision can be put into action, it will be important to confirm that teaching laypeople to apply tourniquets is both feasible and safe. The pilot study by Goolsby and colleagues14 in this issue of Academic Emergency Medicine is an important first step toward that goal. Critics may scoff at the observation that fewer than half of bystanders properly applied tourniquets after receiving “just-in-time” (JiT) instruction. Others will worry that improper tourniquet placement might increase bleeding or worsen a victim's injuries. Some will question the cost-effectiveness of predeploying tourniquets, because the odds that any particular setting will be the scene of a mass shooting or bombing are low. Advocates will respond that the study by Goolsby et al. shows that with a JiT card, every other bystander might properly apply a tourniquet versus one in five without it. If aspiring volunteers received a brief training, or watched a short online video15 that demonstrated proper technique, the success rate might be higher still. Goolsby's team used an all-black, military-issue Combat Application Tourniquet (C-A-T). A “civilian” version could be color-coded to facilitate use. And just as any CPR is better than no CPR, a partially applied tourniquet is probably better than no tourniquet at all.16 Finally, it's worth noting that despite the rarity of fires and other incidents, public buildings and private businesses are amply supplied with fire extinguishers, sprinkler systems, and other life-saving equipment. A new AED can cost $1,000 to $1,700 or more. The retail price of a C-A-T is less than $30. Interest in tourniquets is growing. In addition to the Hartford Consensus, the White House National Security Staff is actively examining this issue. The Institute of Medicine recently convened a consensus committee on “the Military Trauma Care's Learning Health System and its Translation to the Civilian Sector.” Should public access tourniquets be considered the trauma equivalent to bystander CPR and public-access defibrillation? After all, the odds that a teen or young adult will sustain life-threatening trauma are far greater than his or her odds of collapsing from out-of-hospital cardiac arrest. In an increasingly volatile world, the risk of mass shootings and terrorist attacks on U.S. soil could grow. Teaching bystanders, particularly young adults, to be citizen lifesavers could increase the number of helpful hands at future incidents. It might also foster self-confidence, resilience, and a stronger sense of citizenship. It is time to find out.