Abstract
Each year, approximately 60,000 people in the United States die from internal or external hemorrhaging. In some cases, it may take only 5 minutes for blood loss to take a life. Stop the Bleed and Until Help Arrives campaigns encourage the public to be active bystanders. 1 Stop the Bleed training provides the knowledge and tools needed to assist in a hemorrhage emergency until professional help is available, while Until Help Arrives training outlines simple steps to provide immediate aid during the crucial early stages of an emergency before first responders arrive.2,3
The Medical Reserve Corps (MRC) is a national network of local volunteer units who engage their local communities to strengthen public health, reduce vulnerability, build resilience, and improve preparedness, response, and recovery capabilities; these units can play a critical role in delivering this training to communities. 4 Currently, there are 860 MRC units with 180,858 volunteers across the nation. 5 MRC units improve preparedness by assessing community needs, responding to emergencies, and educating the public, an activity that has become especially important as mass violence becomes more prevalent.
This article explores how 2 MRC units—one in South Carolina and the other in Rhode Island—are taking a lead role in providing active bystander training to equip the people in their communities with life-saving skills that will increase community resilience in disasters and emergencies.
Pee Dee Public Health Reserve Corps
The Pee Dee Public Health Reserve Corps (PHRC) unit was originally formed in February 2007 to support the mission of public health in South Carolina communities. The unit has more than 100 volunteers, many of whom are nurses, physicians, or emergency medical technicians (EMTs). In addition to supporting emergency response during hurricanes, floods, and other disasters, Pee Dee PHRC volunteers also provide training for the community, including Stop the Bleed and You Are the Help Until Help Arrives.
The Stop the Bleed campaign was launched by the White House in October 2015 as a national awareness campaign and call to action. The campaign aims to build national resilience by encouraging bystanders to become trained, equipped, and empowered to stop life-threatening bleeding following everyday emergencies and man-made and natural disasters. Advances made by military medicine and research in hemorrhage control during the wars in Afghanistan and Iraq have informed the work of this initiative. 6
The decision to offer Stop the Bleed and Until Help Arrives training to communities was supported by 2 factors. First, the routine mortality numbers collected by the state health department each day demonstrated that death by accidents or unintentional injury is the leading cause of death for people ages 1 to 44 years in South Carolina. Additionally, homicides and suicide are consistently in the top 5 leading causes of death in the same age ranges. 7 The second factor had to do with the recurrence of high-profile events, such as the shooting in Charleston, SC, in which an active shooter killed 9 parishioners at the Mother Emmanuel Church on June 17, 2015.
These compelling occurrences and statistics made us ask ourselves: “How can we help reduce the impact of these events?” Part of the answer was to equip the public with knowledge and skills that they can use to effectively assist people as soon as possible during an emergency. This includes teaching them critical actions, such as prevention of blood loss and maintenance of an airway, and encouraging people to become “active bystanders.”
Two of the training tools that may help people who experience these types of events are Stop the Bleed (https://www.bleedingcontrol.org) and Until Help Arrives (https://community.fema.gov/until-help-arrives). These courses can give people the skills and confidence needed to respond and the opportunity to reduce deaths.
Preparing the Training: Challenges and Considerations
From the beginning, there were many issues to solve in the challenge of getting the training courses out to the public. For example, we needed training equipment and instructors to provide the courses. We wanted the training and equipment to have broad availability and geographic dispersion beyond the footprint of our unit. We also wanted to collaborate with community partners and give our nonlicensed volunteers the opportunity to participate.
First, we sought and were awarded a grant by NACCHO to purchase the training supplies needed, including mannequin legs, tourniquets, hemostatic bandages, gloves, and other necessities. The kits were strategically placed in each public health region across the state. In order to stretch the equipment dollars from the grant, we also bought PVC pipes and pool noodles that were used to manufacture some inexpensive mannequin training legs. Having these training aids, in addition to the more expensive and commercially produced legs, gave us more capacity to provide equipment across the state.
Second, we recruited and trained MRC volunteers statewide to provide the courses for community groups. The strategy was to “plant the seeds” across every corner of South Carolina, starting a “grassroots” educational training initiative.
Third, we needed the training to have maximum flexibility for different kinds of groups and varying levels of interest. So, we needed a curriculum with multiple information delivery options.
Finally, in addition to recruiting MRC volunteer instructors, we also recruited partners who were interested in providing the courses to their own employees, members, and target audiences. This allowed us to increase the number of instructors providing courses. We also provided our training equipment on request to groups that had instructors but lacked the funds to purchase their own training equipment.
Implementing the Training: Collaboration and Creativity
Most instructors were in a medical discipline and focused on teaching Stop the Bleed. This 1-hour course has an instructor-student ratio of 1 to 8 and focuses on controlling of bleeding with pressure, packing a wound, and applying a tourniquet. Teaching larger groups was going to be challenging, so the PHRC considered alternative solutions that would allow an expanded reach without sacrificing learning and comprehension.
One of the most creative and collaborative examples of delivering this course to a large group occurred in the Charleston County School District, which has thousands of employees. A physician with the Medical University of South Carolina was recorded teaching the Stop the Bleed course, and the recording was then placed on the school district's e-learning system, to be available for staff to view at their convenience. Medical Reserve Corps volunteers, in collaboration with area hospital trauma units, emergency medical services (EMS), and fire departments, conducted skills assessment sessions so that school staff could demonstrate the practical skills and receive a certificate of completion. One of these assessment sessions resulted in approximately 600 people being trained in 1 day.
For nonlicensed volunteers, we encouraged the use of Until Help Arrives, which can be taught by anyone with strong first aid skills. This course has multiple course delivery options and more generous instructor-to-student ratios. One of our youth volunteers who belongs to HOSA, a nonprofit, student-led organization of future health professionals, taught the Until Help Arrives curriculum to 138 students in a high school focused on arts, sciences, and technology. The volunteer stated that “the students really enjoyed the class and learned skills they could use to save a life in an emergency.” This empowers students and enables them to lead more resilient lives throughout their career and beyond.
We also developed a handout using the Until Help Arrives curriculum for distribution at health fairs or other venues. Additionally, demonstrations of specific skills were added as appropriate. For example, mannequin legs were used to demonstrate control of bleeding, and a child's doll was used to simulate placing a person in the recovery position. The Until Help Arrives and Stop the Bleed websites were listed on the handout, and people were encouraged to find a class to learn the skills. One of the best-attended events using the Until Help Arrives handout and demonstrations was held in the Upstate Health Region in a local shopping mall. The event was just prior to Halloween, so having a mannequin leg with simulated bleeding worked well for drawing attention.
Making South Carolina More Resilient
The project goals for the grant mentioned here included a target to train at least 32 instructors and teach at least 1,200 people. We doubled the number of trained instructors to 65 and trained 1,366 people trained during the grant period. We were also pleased to find that our efforts helped push South Carolina into the top 10 states with the most Stop the Bleed instructors. 8 Also helping to push us to the top of that list was a parallel grant-funded effort by the healthcare coalitions in the state (http://bparati.com/southcarolinahealthcarepreparedness) to place bleeding control kits in all public schools and provide Stop the Bleed training to all school nurses. All public health MRC units in South Carolina reported satisfaction with this project and had positive feedback from the volunteers involved. We will continue to provide the training to community groups as we consider adding new goals for the coming years.
Rhode Island Disaster Medical Assistance Team
The Rhode Island Disaster Medical Assistance Team's Medical Reserve Corps (RIDMAT/MRC) is a state-based 501(c)(3) nonprofit organization whose mission is to recruit, train, mobilize, manage, and equip a volunteer response corps to enhance state and local capabilities. RIDMAT/MRC is active in preparing for and responding to the public health and emergency response needs of Rhode Island and its communities.
Organized in 2003, with 1,700 registered volunteers, RIDMAT/MRC works to reduce the vulnerability of Rhode Island and its communities to disaster risk through community public health activities, the promotion of personal and community preparedness, and enhanced response capabilities. RIDMAT/MRC aims to provide support to public health initiatives across the state to improve the health and wellness of Rhode Island residents, ultimately reducing the vulnerability of the population to disaster risk and improving overall response efforts through high-level community training programs like NOPE-RI (Naloxone and Overdose Prevention Education) and Operation Stop the Bleed.
RIDMAT/MRC also provides training to its members in the form of field hospital events. The goal of these events is to train medical health professional volunteers to prepare for and respond to public health and emergency response disasters by providing hospital-level care to participants and spectators. RIDMAT/MRC's participation at these events alleviates surge on local emergency medical services and area hospitals and familiarizes volunteers with the processes and equipment that are used in a public health emergency or disaster event.
Equipping Communities with Life-Saving Skills
During the past decade, active assailant and shooter incidents have dramatically increased worldwide, becoming a very serious public health epidemic. These incidents not only have a direct impact on families, but they also have devastating consequences for the nation, our communities, and first responders. No matter how quickly professional emergency responders arrive, bystanders will always be first on the scene. A person who is bleeding can die from blood loss within 5 minutes; therefore, it is important to quickly “stop the bleed.” Those nearest to someone with life-threatening injuries are best positioned to provide first care.
Operation Stop the Bleed—Rhode Island (OSTB-RI) encourages bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives. We can make a positive difference in the outcomes of these incidents by training civilians to initiate bleeding control measures and educating them on how to react when faced with a situation that requires action to save a life. By increasing the number of trained civilians actively involved in rapid bleeding control, we will save lives.
From inception, the goal of OSTB-RI was to use the Stop the Bleed campaign to establish a short and concise Rhode Island–based curriculum that teaches simple and effective life-saving skills to individuals with clinical training and those in nonclinical professions of all different ages, education levels, and proficiency levels. The programming helps participants recognize life-threatening bleeding and when and how to apply firm, steady pressure to stop it, while also ensuring participants understand when to use a tourniquet and how to create makeshift tourniquets.
Maximizing Reach to Strengthen Resilience
OSTB-RI is a collaborative effort with state partners aimed at better leveraging RIDMAT/MRC's experience in training everyday citizens to take action. The program has activated teams of registered and trained MRC health professional volunteers to provide bleeding control education and rescue skills to citizens and organizations. Providing education in bleeding control, recognition, and response is a harm reduction intervention that has been demonstrated to saves lives and increase the capacity of bystanders to “be the help” until help arrives.
OSTB-RI ramped up training activities during 2018. Dedicated members delivered critical training that prepared bystanders to become equipped and empowered to help in a bleeding emergency before professional help arrives. Additionally, OSTB-RI received funding and began renovating the OSTB-RI Humvee to deliver training in new locations, such as at special community events, retail shopping center parking lots, sporting events, or any other high-traffic locations. The introduction of this mobile capability will make a significant impact on preparedness. Bringing the mobile training vehicle and team to a location will provide everyday citizens an opportunity to learn how to save a life with just 12 minutes of training.
Since its beginning, OSTB-RI has provided training to more than 2,870 individuals; held 2 law enforcement train-the-trainer courses, 3 municipal police academy classes, and a TF Green Airport Training session; and managed the purchase and distribution of 500 belt trauma kits to law enforcement agencies across the state. The program is well received and well supported and can and should be replicated by other communities.
Challenges do exist in fulfilling all of the training requests that are received. The demand for the training has nearly stretched the organizational capacity, as organizations and partners come to understand potential threats and the increased need for training employees and citizens. RIDMAT/MRC continues to offer train-the-trainer courses to its unit and encourages members to become trainers. However, with limited budgets and reliance on a volunteer-led course, not all requests are met as quickly as they are received. RIDMAT/MRC continues to look to expand the programming and ensure a sustainable future for OSTB-RI.
Partnering for Community Preparedness: NACCHO and the MRC
As the voice of and advocate for the nation's nearly 3,000 local health departments, the National Association of County and City Health Officials (NACCHO) is committed to improving the health of communities. The importance of preparedness, response, and resilience to community health cannot be understated, which is why NACCHO has supported the MRC's work for more than a decade.
In today's threat environment, where active shooter incidents and domestic terrorism are on the rise, everyday people must be prepared to serve as active bystanders. Operating in support of a health system that's underfunded and overwhelmed, MRC units are critical resources that build capacity for community members—including those unaffiliated with a unit—to take life-saving action during emergencies and disasters, including in mass casualty incidents. That's why the efforts of the MRC units in this article are so important: Their work to prepare communities for the worst has real power to save lives and protect health, which is what health security is all about.
Roughly two-thirds of MRC units are housed at local health departments, but NACCHO encourages all MRC units to work closely with their local health departments to build stronger and more productive alliances. With local health department members rooted in cities, counties, and local jurisdictions across the United States, NACCHO will continue to support MRC's aim to promote a network of common capabilities that support local and multi-jurisdictional preparedness and response activities. It is a matter of when, not if, MRC units will be called on to offer support to public health, healthcare, and emergency medical service systems, and NACCHO embraces the opportunity to work with the Office of the Assistant Secretary for Preparedness and Response (ASPR) to help MRC units prepare for and conduct this important work.
Footnotes
Acknowledgments
Special thanks to Deborah Beasley, State Volunteer Coordinator (SC), who helped make this project happen; Joanne Hobbick, Upstate PHRC Unit Coordinator, who produced many of the homemade mannequin legs with the help of her husband and PHRC volunteer, Tony; Stefanie Roy, Lowcountry PHRC Unit Coordinator, who has been a tireless advocate for providing classes in the community; Scott Phillips, Midlands PHRC Unit Coordinator, who helped cut the PVC pipes for the mannequin legs; Mark Hendrix, Pee Dee Public Health Preparedness Director, whose vision started us down this path years ago; and all of the volunteers and partners across the state who provide these courses to our community.