America is Bleeding, and Congress is Trying to Stop It

With 16 physicians in Congress, America has taken great steps toward putting healthcare providers in a position to address our nation’s most pressing healthcare issues. We have all heard about the most prevalent causes of death in America such as heart disease and cancer, but trauma is actually the leading cause of death for Americans aged 1-44. Whether it’s a car accident, a fall, or even gun violence, trauma kills over 200,000 people per year in the US alone. The figures abroad are in the millions. Every year, trauma-related injuries cost the US almost $700 million. Many of these deaths are caused by massive blood loss, and around 20% could be prevented. With millions of dollars and thousands of lives to be saved, Congressman and physician Dr. Brad Wenstrup (R-OH) and Congressman Alcee Hastings (D-FL) have introduced bipartisan legislation, the Prevent Blood Loss with Emergency Equipment Devices Act of 2019 (H.R.2550), also known as the Prevent BLEEDing Act, which would require blood loss equipment such as tourniquets (a device tightly wrapped around an arm or a leg to stop bleeding) and clotting bandages in public spaces like libraries, schools, and malls.

I sat down with the Chairman of National Stop the Bleed Month Andrew D. Fisher, a fellow Aggie, to talk about this bill and other ways we can improve trauma care in the United States. As a Major in the US Army, Andrew Fisher’s military and civilian experience is extensive. He has completed over 500 missions with a total of 30 months deployment in Iraq and Afghanistan as a physician assistant, and he is a recipient of the Purple Heart. Fisher’s military prowess led him to be named the 2018 U.S. Army Hero of Military Medicine. Now, at the age of 46, Fisher has over 40 publications in peer-reviewed medical journals and is in his last year of medical school at Texas A&M College of Medicine.

Many Americans know how to perform CPR, but Fisher points out that after receiving CPR, only around 10% of patients survive to the time of discharge. However, Fisher says that in the case of massive blood loss, the application of a tourniquet yields a higher survival rate. His previous unit in the US Army brought prehospital mortality from blood loss down to zero after proper blood loss training was given. So far, tens of thousands of people have been trained in bleeding control through National Stop the Bleed Month, and all the training has been completed for free and supported by the American College of Surgeons. Furthermore, traditional CPR/AED courses should add basics about bleeding control. A Texas study found that the mortality rate after a severe vascular injury to the arms or legs was 8% without the application of a tourniquet immediately after injury. However, the mortality rate drops down to 3% for patients who receive a tourniquet. Learning how to use a tourniquet could be vital in a deadly situation.

My own uncle passed away six years ago in a bus accident, and his life could have been saved through the use of a tourniquet. His arm was severely injured in the accident, and he was bleeding out. In a perfect situation, a tourniquet would have been available on the public bus. In this case, a bystander would have wrapped his arm above the site of bleeding, and the tourniquet could have stopped blood from leaving the major artery in his arm. Even where a tourniquet is not available, any type of band, scarf, or long piece of fabric can be used to tightly wrap the arm or leg above the site of bleeding.

When I asked Andrew Fisher about the Prevent BLEEDing Act, he said that he appreciates Congress’s efforts, but noted that the federal government is “a little late to the game.” Fisher pointed out that a few states, such as Georgia, have taken matters into their own hands by equipping every Georgia public school with bleeding control kits. Actions by the slow-footed federal government may not be the most desirable; however, the ratification of this bill would greatly advance bleeding-control education, provide a federal mandate for the availability of blood loss supplies in public spaces, and situate blood-loss prevention as a nationally recognized issue.

Mass shootings in public spaces, such as the Las Vegas Shooting in which 58 people were killed and 851 were injured, have become more common. Bullets can cause major bleeding in an extremity, and death can occur in minutes, which is why time is essential. After the horrific shooting at Sandy Hook Elementary School in which 20 children and 6 adults were killed, the Hartford Consensus was created to improve the response to mass casualty and active shooter events. The Hartford Consensus calls for bleeding control bags to be present in places such as schools. And although it’s debated whether or not teachers should be armed, there are no apparent downsides to having teachers learn basic bleeding control techniques in the case of an emergency.

Fisher emphasizes that one is unlikely to be a victim of a terrorist attack or a school shooting; however, the chance of being in a car accident is much greater. This is where the vitality of emergency medical technicians (EMTs)  and paramedics comes into play. These emergency responders are the first experts to the scene, and their actions frequently determine the life and death of a patient. One of the most common injuries from a major car accident is internal bleeding, which cannot be stopped through the basic application of a tourniquet. However, a procedure called REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) can be done by inflating a balloon in the aorta to temporarily stop blood loss. Currently, only trauma-related physicians are able to perform this procedure. However, Fisher along with countless others in the field of pre-hospital medicine, are calling for the training of paramedics to perform the procedure in a life or death situation. Fisher, a former paramedic, says that it is a challenging skill, but it may save more lives after traumatic injury. In addition to REBOA, Fisher believes that all paramedics should be trained on the administration of ketamine as a pain-reliever. Trauma related injuries can cause excruciating pain that warrants care, which is why first responders must be trained to administer safe pain-relievers to severely injured patients. Only half of paramedics report learning about ketamine during their training; however, ketamine has been vetted through research and has been shown to be a powerful and safe tool for pain relief in the pre-hospital setting. Fisher also believes that EMT standards should drastically increase to broaden their understanding of anatomy and pathophysiology, noting that professional hairdressers have to complete over 1000 hours for their program while based on national averages, EMTs only have to complete a total of 120-160 hours. Overall, furthering the knowledge and clinical skills of our medical responders has the potential to better stabilize patients before they reach the hospital and ultimately save lives.

Thousands of bills flow through our legislative bodies, and the majority of the bills signed into law are sponsored by Republicans and Democrats. The Prevent BLEEDing Act, which would appropriate $10 million to making blood loss supplies more accessible in public spaces, has already gained bipartisan support, and this bill along with other improvements in emergency medicine would have a positive impact on trauma care in the United States.

Sources:

Buckland DM, Crowe RP, Cash RE, et al. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehospital and Disaster Medicine. 2017;33(1):23-28. doi:10.1017/s1049023x17007142.

Civilian Prehospital Tourniquet Use is Associated with Improved Survival in Patients with Peripheral Vascular Injury. Teixeira, Pedro G.R.Vu, Megan et al.Journal of the American College of Surgeons, Volume 226, Issue 5, 769 – 776.e1

DiMaggio C, Ayoung-Chee P, Shinseki M, et al. Traumatic injury in the United States: In-patient epidemiology 2000-2011. Injury. 2016;47(7):1393–1403. doi:10.1016/j.injury.2016.04.002

Hastings and Wenstrup Introduce the Bipartisan Prevent BLEEDing Act of 2019. U.S. Congressman Alcee L. Hastings. https://alceehastings.house.gov

Hax SD, Davis K, Stone B, Bledsoe B, Hodnick R. Ketamine’s Versatility Makes it a Powerful Tool for EMS. Journal of Emergency Medical Services. https://www.jems.com/articles/print/volume-42/issue-2/features/ketamine-s-versatility-makes-it-a-powerful-tool-for-ems.html. Published February 1, 2017.

Stop the Bleed – Georgia – Georgia Trauma Foundation.

Zero Preventable Deaths After Injury. Washington (DC): National Academies Press (US); 2016 Sep 12. 1, Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK390332/

https://firstcareprovider.org/blog/tk-how-to