First Care Providers: Extending the Chain of Trauma Survival (Part 1 of 2)

Joshua Bobko

Joshua Bobko , MD, FAAEM

Director, First Care Provider

Published January 26, 2016

Let's pretend a major earthquake has just partially destroyed your home. Your 10-year-old daughter was struck by falling debris. She's unconscious, gasping for breath and bleeding profusely from a cut on her leg.

With the city in chaos, it could take emergency medical services (EMS) hours to reach you. Fortunately, there are a few simple actions you can take that will drastically increase your daughter's chances of survival. This is true even if you lack medical training and advanced equipment.

Envisioning scenarios like this one, communities are embracing the concept of the First Care Provider (FCP). FCPs are medical laypeople who have been trained in basic techniques to manage traumatic injury. They can provide lifesaving interventions in the critical moments following an accident. And in a mass casualty, they can act as "force multipliers," working with professional first responders to save more lives.

This two-part series will examine this trend in detail. Today in part 1, I'll cover the rationale for changing our current trauma response paradigm. And in part 2, we'll look at an evidence-based training program for FCPs.

"Regular people are the most important people at a disaster scene, every time."
Amanda Ripley, author, The Unthinkable: Who Survives When Disaster Strikes — And Why

Before the Ambulance

As an emergency and disaster medicine physician, it's my privilege to serve on several state and national operational medicine committees. One of our jobs is to formulate mass casualty response guidelines for law enforcement and EMS.

Traditionally, much of this work has focused on speeding resources and first responders to the scene of the incident. But does this go far enough? Consider that:
  • Following the 1999 shooting at Columbine High School, the campus was locked down for several hours, and ambulance crews had no access to the victims inside. During this time, two high school students kept an adult victim (their coach) alive for three hours.
  • The 2013 Boston Marathon Bombing was perhaps a "best case scenario" for terrorism response. The city was already on alert during this high-profile event, with multiple EMS units on standby. However, experts believe that bystander assistance in the minutes following the explosions significantly reduced death and disability among the victims.
  • A man injured in the 2013 Los Angeles International Airport shooting likely saved his own life by applying an improvised tourniquet to his leg.

These examples highlight an important truth: following a traumatic incident, bystanders can be a crucial link in the "chain of survival." However, our system has done little to empower people immediately responding to a trauma. As a result, witnesses who desire to render aid often stand by helplessly — at great cost to both the injured and the bystander's own emotional health.

EMS Has Limits

The United States is fortunate to have one of the world's best EMS services. However, even in a best-case scenario, an ambulance still takes more than four minutes to reach the scene once dispatched. That's long enough for a patient to die of blood loss or experience the beginnings of brain injury due to hypoxia.

Nor can we always count on this idealized response time. Orange County, Calif., with a population of over 3 million, staffs around 200 paramedics per 48 hour shift. These medics are spread throughout 23 cities. As a resident, it's scary to think how thin those first responders would be spread in the event of a mass casualty.

And unfortunately, we live in an age where mass public violence is becoming both more frequent and more deadly. Such incidents often result in lockdowns that prevent EMS personnel from reaching the victims quickly. (While this will hopefully change in the future as our tactical responses evolve, it's very much the reality today.)

In such cases, bystander intervention can mean the difference between life on one hand, and death and disability on the other.

Fortunately, our country has at least two successful blueprints for empowering ordinary citizens to become FCPs.

Precedents for Change

During the Global War on Terror (GWOT), military experts determined that 24 to 28 percent of military combat deaths were possibly “preventable.” This information led to the creation of a "point of injury" system designed to reduce preventable deaths to nearly zero. This system placed particular emphasis on tourniquet use and control of massive bleeding, and has successfully reduced combat mortality rates from approximately 17 percent during the Vietnam War to about 8 percent today.

Using the vast amount of trauma data obtained from the GWOT, the Committee for Tactical Combat Casualty Care (C-TECC) was created to translate applicable practices from the battlefield to the civilian environment. They subsequently adopted guidelines for law enforcement, fire and EMS based on the evolving threat of global terrorism.

As these events now become commonplace in our communities, our approach must once again evolve. Faced with a growing threat of violence and limitations on professional first responders, our logical next step is to empower ordinary citizens to provide point-of-injury care.

Our country also has a successful history of empowering civilians as First Care Providers. As early as the 1950s, experts recognized that in the event of sudden cardiac arrest, early cardiopulmonary resuscitation (CPR) by bystanders could increase survival rates several times over. Today, the American Heart Association estimates that 30 percent of Americans (including many children as young as 10) have been trained in CPR.

Shifting Our Focus

The above examples represent successes we can build on. Unfortunately, we've made little progress in applying these lessons to civilian trauma care.

This oversight is far from trivial. Trauma is the No. 1 cause of death among people ages 1 to 44. Statistically, children and teens are far more likely to experience an injury at school than sudden cardiac arrest. But while almost every school is equipped with an automated external defibrillator (AED), very few have basic trauma kits available.

The Obama White House recently set out to change this with its "Stop the Bleed" campaign. One of its goals is to deploy "bleeding control kits" to public places (in the same manner as AEDs). While valuable, these actions probably don't go far enough. Without proper training, it's unlikely that bystanders will attempt to apply a tourniquet.

We can change that. In my next post, I'll share an evidence-supported model for empowering bystanders to act as First Care Providers in traumatic emergencies.

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[Image credit: "Ski Hill Rd. Crash" by Jason Bain licensed under CC BY 2.0]

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