Bleeding Control Protections Within US Good Samaritan Laws.

INTRODUCTION: In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. METHODS: This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. RESULTS: Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. CONCLUSION: Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.

Recommendations for Placement of Bleeding Control Kits in Public Spaces-A Simulation Study.

OBJECTIVE: Bleeding control measures performed by members of the public can prevent trauma deaths. Equipping public spaces with bleeding control kits facilitates these actions. We modeled a mass casualty incident to investigate the effects of public bleeding control kit location strategies. METHODS: We developed a computer simulation of a bomb exploding in a shopping mall. We used evidence and expert opinion to populate the model with parameters such as the number of casualties, the public's willingness to aid, and injury characteristics. Four alternative placement strategies of public bleeding control kits in the shopping mall were tested: co-located with automated external defibrillators (AEDs) separated by 90-second walking intervals, dispersed throughout the mall at 10 locations, located adjacent to 1 exit, located adjacent to 2 exits. RESULTS: Placing bleeding control kits at 2 locations co-located with AEDs resulted in the most victims surviving (18.2), followed by 10 kits dispersed evenly throughout the mall (18.0). One or 2 kit locations placed at the mall's main exits resulted in the fewest surviving victims (15.9 and 16.1, respectively). CONCLUSIONS: Co-locating bleeding control kits with AEDs at 90-second walking intervals results in the best casualty outcomes in a modeled mass casualty incident in a shopping mall.

Learner's Stop the Bleed Outcomes Between Lay Instructor and Emergency Medical Services (EMS)-Trained Instructor Groups.

BACKGROUND: One of the most utilized Stop the Bleed courses, the "Bleeding Control Basic (BCon) course v. 1.0," requires instructors to have a specific healthcare license or pre-hospital credential (e.g., physician or paramedic) or specific emergency medical services (EMS) instructor certification and have completed the BCon provider course. This requirement provides a level of expertise in instructors but limits the potential workforce for sharing life-saving knowledge and skills. Other Stop the Bleed courses, such as the American Red Cross First Aid for Severe Trauma (FAST) course, do not have this requirement. This raises questions pertaining to the learners' outcomes between those facilitated by instructors with and without healthcare licenses or credentials. METHODS: Learners' outcomes for applying a tourniquet (skill), knowledge (cognitive), and Intention to Aid (attitude for behavior) were compared between those taught by lay instructors and EMS-trained (emergency medical technician or paramedic) instructors. All were trained as new instructors in the FAST program. RESULTS: For the study's primary outcome, all of the learners (n=135) properly applied a tourniquet to a simulated leg injury at the end of the training based on video evidence (skill). Learners in the EMS-trained instructor groups (n=84, mean age 25.5 years, 68% female), who were older and had more education, scored significantly higher on knowledge of tourniquet use on the Stop the Bleed Educational Assessment Tool (SBEAT) (mean=90.0 vs. 83.9 on a scale of 0-100, p=0.001) with a small effect size than the lay instructor group (n=51, mean age 16.6 years, 88% female). There was no statistical difference in attitude toward helping behaviors in a bleeding emergency between the two groups on the Intention to Aid (I2A) survey. IMPLICATIONS: Lay instructors and EMS-trained instructors performed comparably in facilitating a widely available Red Cross Stop the Bleed course. Lay experience with tourniquets should not disqualify individuals from being a Stop the Bleed instructor. Using a standard curriculum with instructor development offers a way for people with and without an EMS background to teach life-saving competencies effectively.

Blood Vessel Occlusion by the Layperson Audiovisual Assist Tourniquet (LAVA TQ) Compared to the Combat Application Tourniquet: Randomized Controlled Trial.

INTRODUCTION: While windlass-rod style tourniquets stop bleeding in limbs when used by skilled responders, they are less successful in the hands of the untrained or not recently trained public. To improve usability, an academic-industry partnership developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ). The LAVA TQ is novel in design and technology and addresses known challenges in public tourniquet application. A previously published multisite, randomized controlled trial of 147 participants showed that the LAVA TQ is much easier for the lay public to use compared to the Combat Application Tourniquet (CAT). This study evaluates the LAVA TQ's ability to occlude blood flow in humans compared to the CAT. METHODS: This study was a prospective, blinded, randomized controlled trial to demonstrate the non-inferiority of the LAVA TQ to occlude blood flow when applied by expert users compared to the CAT. The study team enrolled participants in Bethesda, Maryland, in 2022. The primary outcome was the proportion of blood flow occlusion by each tourniquet. The secondary outcome was surface application pressure for each device. RESULTS: The LAVA TQ and CAT occluded blood flow in all limbs (21 LAVA TQ, 100%; 21 CAT, 100%). The LAVA TQ was applied at a mean pressure of 366 millimeters of mercury (mm Hg) (SD 20 mm Hg), and the CAT at a mean pressure of 386 mm Hg (SD 63 mm Hg) (P = 0.14). CONCLUSION: The novel LAVA TQ is non-inferior to the traditional windlass-rod CAT in occluding blood flow in human legs. The application pressure of LAVA TQ is similar to that used in the CAT. The findings of this study, coupled with LAVA TQ's demonstrated superior usability, make the LAVA TQ an acceptable alternative limb tourniquet.

The Impact of Operation Bushmaster on Medical Student Decision-making in a High-Stress, Operational Environment.

INTRODUCTION: Operation Bushmaster is a high-fidelity military medical field practicum for fourth-year medical students at the Uniformed Services University. During Operation Bushmaster, students treat live-actor and mannequin-based simulated patients in wartime scenarios throughout the five-day practicum. This study explored the impact of participating in Operation Bushmaster on students' decision-making in a high-stress, operational environment, a crucial aspect of their future role as military medical officers. MATERIALS AND METHODS: A panel of emergency medicine physician experts used a modified Delphi technique to develop a rubric to evaluate the participants' decision-making abilities under stress. The participants' decision-making was assessed before and after participating in either Operation Bushmaster (control group) or completing asynchronous coursework (experimental group). A paired-samples t-test was conducted to detect any differences between the means of the participants' pre- and posttest scores. This study was approved by the Institutional Review Board at Uniformed Services University #21-13079. RESULTS: A significant difference was detected in the pre- and posttest scores of students who attended Operation Bushmaster (P < .001), while there was no significant difference in the pre- and posttest scores of students who completed online, asynchronous coursework (P = .554). CONCLUSION: Participating in Operation Bushmaster significantly improved the control group participants' medical decision-making under stress. The results of this study confirm the effectiveness of high-fidelity simulation-based education for teaching decision-making skills to military medical students.

Military Medical Provider Perspectives During the New York COVID-19 Response.

INTRODUCTION: The response to the coronavirus disease 2019 pandemic in New York City (NYC) included unprecedented support from the DoD-a response limited primarily to medical and public health response on domestic soil with intact infrastructure. This study seeks to identify the common perspectives, experiences, and challenges of DoD personnel participating in this historic response. MATERIALS AND METHODS: This is a phenomenological qualitative study of 16 military health care providers who deployed to NYC in March 2020. This study was approved by the Institutional Review Board at the USU (No. DBS.2020.123). All participants served on either the United States Naval Ship Comfort or at the Javits Center. We conducted semi-structured interviews exploring the participants' experiences while deployed to NYC. These interview scripts were then independently coded by five research team members. RESULTS: We identified four common themes and 12 subthemes from the participants' responses. The themes (subthemes) were lack of preparation (unfamiliar mission and inadequate resources); confusion about integration with civilian health care (widespread, dynamic situation, and NYC overwhelmed), communication challenges (overall, misunderstanding and miscommunication resulting in tension, and patient handoffs); and adaptation and success (general, military-civilian liaison service, positive experience, and military support necessity). CONCLUSIONS: This study provides unique insight into the DoD's initial response to the coronavirus disease 2019 pandemic in NYC. Using this experiential feedback from the DoD's pandemic responders could aid planners in improving the rapidity, effectiveness, and safety of military and civilian health care system integrations that may arise in the future.

Mass Shootings in America: Consensus Recommendations for Healthcare Response.

BACKGROUND: In 2021, 702 people died in mass shooting incidents (MSIs) in the US. To define the best healthcare response to MSIs, the Uniformed Services University's National Center for Disaster Medicine and Public Health hosted a consensus conference of emergency medical services (EMS) clinicians, emergency medicine (EM) physicians, and surgeons who provided medical response to six of the nation's largest recent mass shootings. STUDY DESIGN: The study consisted of a 3-round modified Delphi process. A planning committee selected 6 MSI sites with the following criteria: the MSI occurred in 2016 or later, and must have resulted in at least 15 people killed and injured. The MSI sites were Orlando, FL, Las Vegas, NV, Sutherland Springs, TX, Parkland, FL, El Paso, TX, and Dayton, OH. Fifteen clinicians participated in the conference. All participants had EMS, EM, or surgery expertise and responded to 1 of the 6 MSIs. The first round consisted of a 2-part survey. The second and third rounds consisted of site-specific presentations followed by specialty-specific discussion groups to generate consensus recommendations. RESULTS: The 3 specialty-specific groups created 8 consensus recommendations in common. These 8 recommendations addressed readiness training, public education, triage, communication, patient tracking, medical records, family reunification, and mental health services for responders. There were an additional 11 recommendations created in common between 2 subgroups, either EMS and EM (2), EM and surgery (7), or EMS and surgery (2). CONCLUSIONS: There are multiple common recommendations identified by EMS, EM, and surgery clinicians who responded to recent MSIs. Clinicians, emergency planners, and others involved in preparing and executing a response to a future mass shooting event may benefit from considering these consensus lessons learned.

The Untrained Public's Ability to Apply the Layperson Audiovisual Assist Tourniquet vs a Combat Application Tourniquet: A Randomized Controlled Trial.

BACKGROUND: Although the Stop the Bleed campaign's impact is encouraging, gaps remain. These gaps include rapid skill decay, a lack of easy-to-use tourniquets for the untrained public, and training barriers that prevent scalability. A team of academic and industry partners developed the Layperson Audiovisual Assist Tourniquet (LAVA TQ)-the first audiovisual-enabled tourniquet for public use. LAVA TQ addresses known tourniquet application challenges and is novel in its design and technology. STUDY DESIGN: This study is a prospective, randomized, superiority trial comparing the ability of the untrained public to apply LAVA TQ to a simulated leg vs their ability to apply a Combat Application Tourniquet (CAT). The study team enrolled participants in Boston, MA; Frederick, MD; and Linköping, Sweden in 2022. The primary outcome was the proportion of successful applications of each tourniquet. Secondary outcomes included: mean time to application, placement position, reasons for failed application, and comfort with the devices. RESULTS: Participants applied the novel LAVA TQ successfully 93% (n = 66 of 71) of the time compared with 22% (n = 16 of 73) success applying CAT (relative risk 4.24 [95% CI 2.74 to 6.57]; p < 0.001). Participants applied LAVA TQ faster (74.1 seconds) than CAT (126 seconds ; p < 0.001) and experienced a greater gain in comfort using LAVA TQ than CAT. CONCLUSIONS: The untrained public is 4 times more likely to apply LAVA TQ correctly than CAT. The public also applies LAVA TQ faster than CAT and has more favorable opinions about its usability. LAVA TQ's highly intuitive design and built-in audiovisual guidance solve known problems of layperson education and skill retention and could improve public bleeding control.

Military Response to Medical Crises-Consensus Recommendations for Military-Civilian Transitions of Care.

OBJECTIVE: The threat that New York faced in 2020, as the COVID-19 pandemic unfolded, prompted an unprecedented response. The US military deployed active-duty medical professionals and equipment to NYC in a first of its kind response to a "medical" domestic disaster. Transitions of care for patients surfaced as a key challenge. Uniformed Services University and the Icahn School of Medicine at Mount Sinai hosted a consensus conference of civilian and military healthcare professionals to identify care transition best practices for future military-civilian responses. METHODS: We performed individual interviews followed by a modified Delphi technique during a two-day virtual conference. Patient transitions of care emerged as a key theme from pre-conference interviews. Twelve participants attended the two-day virtual conference and generated best practice recommendations from an iterative process. RESULTS: Participants identified 19 recommendations in 10 "sub-themes" related to patient transitions of care: needs assessment and capability analysis; unified command; equipment; patient handoffs; role of in-person facilitation; dynamic updates; patient selection; patient tracking; daily operations; and resource typing. CONCLUSIONS: The COVID-19 pandemic resulted in an unprecedented military response. This study created 19 consensus recommendations for care transitions between military and civilian healthcare assets that may be useful in future military-civilian medical engagements.

A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs.

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

The Impact of Medical School on Military Physicians' Readiness for their First Deployment.

INTRODUCTION: Military physicians receive their undergraduate medical training primarily by either attending civilian medical school, through the Armed Forces Health Professions Scholarship Program (HPSP), or by attending the Uniformed Services University (USU), a federal medical school with a military unique curriculum. The purpose of this study was to explore the perceptions of graduates from these two educational pathways regarding the impact of their medical school training on their readiness for their first deployment. MATERIALS AND METHODS: We conducted 18 semi-structured interviews with military physicians who attended civilian medical schools and USU and who had deployed within the past 2 years. The participants also completed emailed follow-up questions. The interviews were recorded and transcribed. The research team coded the interviews, extracted meaning units, and identified themes that emerged from the data. RESULTS: The following themes emerged from the data: (1) medical readiness; (2) operational readiness; (3) command interactions; and (4) role as a military physician. All of the participants perceived themselves to be prepared medically. However, the USU graduates were more confident in their ability to navigate the operational aspects of deployment. In addition, they described their ability to naturally build positive working relationships with their commanding officers and navigate their combined roles as both a physician and military officer. CONCLUSIONS: These perceptions of both the civilian medical graduates and USU graduates provide important insight to the military medical education community regarding the ways in which civilian medical schools and USU prepare students for their first deployment. This insight will help to identify any training gaps that should be filled in order to ensure that military physicians are ready for deployment.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Provider Fatigue During Direct Manual Compression for Life-Threatening Bleeding.

Introduction Trauma is a leading cause of death throughout the world, with hemorrhage being responsible for more than 35% of pre-hospital trauma deaths and more than 40% of deaths within the first 24 hours after injury. Despite first aid having a demonstrable effect on mortality from trauma, relatively little research has compared the best methods for bleeding control in the prehospital first aid setting. The most common first-line therapy for external bleeding control in the pre-hospital first aid setting is direct manual compression (DMC). However, a prior study demonstrated that the primary cause of failure in a simulated model of life-threatening bleeding was the inability to maintain adequate direct pressure for three minutes. In this study, we evaluated the effect of fatigue on DMC for the duration of a typical urban emergency medical services (EMS) response time. Methods We conducted a prospective observational trial of 33 participants, 18 years of age or older to measure the pressure generated on a model of life-threatening bleeding over an eight-minute period using a "CPR posture" for applying pressure. The primary analyses were longitudinal two-level multilevel models (MLM) with repeated measures of outcome (i.e., CPR posture pressure) nesting within participants. The demographic factors of gender, age, and weight were included as moderators in the analyses and each was analyzed independently. Results The participants' average age was 31 (SD = 11) and the average weight was 161 pounds (SD = 31). The sample consisted of 18 female participants (54.5%) and 15 male participants (45.5%). Applied DMC pressure declined over time, more sharply initially from the beginning to approximately 250 seconds, at which point the decrease in pressure was gradual. Of the demographic factors, gender was associated with a difference in cardiopulmonary resuscitation (CPR) posture pressure over time. Conclusion Rescuers should be aware that fatigue may occur and may affect the quality of direct manual compression for control of life-threatening bleeding. Further research is needed to define the external pressures needed to control life-threatening bleeding and the extent that rescuer fatigue affects this pressure.

Emergency physician risk of occupational mortality: A scoping review.

BACKGROUND: Occupational hazards for emergency physicians are widely known, but the risk of work-related mortality is not clear. The COVID-19 pandemic generated new concerns about the risk of occupational mortality, particularly in the setting of inadequate personal protective equipment. The perception of increased risk generated ethical concerns regarding emergency physicians' duty to treat and employers' duty to protect their employees. We performed this scoping review to define prepandemic emergency physician occupational mortality. METHODS: We performed a scoping review of peer-reviewed publications from PubMed, EMBASE, and Cochrane databases in September 2020. RESULTS: Of the 747 unique articles identified in the 3 databases, 1 article met inclusion criteria and was included in the final analysis. CONCLUSION: The baseline risk of occupational mortality for emergency physicians is not established in the scientific literature. Further study is needed to quantify risk, as this information would be useful to shape policy and ethical considerations.

Appropriate Tourniquet Types in the Pediatric Population: A Systematic Review.

Trauma is the leading cause of mortality in those aged 1-19, with hemorrhage accounting for up to 40% of all trauma deaths. Manufactured tourniquets are recommended for the control of life-threatening extremity hemorrhage in adults but their use in the pediatric population requires further investigation. We performed a systematic review to evaluate the most appropriate tourniquet design for use in the pediatric population. A literature search of Embase and the Cochran databases of trials and systematic reviews on October 1, 2020 identified 454 unique references, of which 15 were included for full-text screening. Two single-arm observational studies with a high risk of bias evaluated the use of windlass tourniquets in the pediatric population (73 patients, age 2-16 years). The certainty of the evidence was very low. In both studies, conducted on uninjured extremities, the use of a manufactured windlass tourniquet, specifically the Combat Application Tourniquet (C-A-T®) Generation 7, led to the cessation of Doppler detected pulses in 71/71 (100%) of upper extremities and 69/73 (94.5%) of lower extremities. Of the four failures, one participant withdrew due to pain and three tourniquet applications failed to occlude pulses after three turns of the windlass. No controls were used for comparison. In conclusion, two observational studies demonstrated that windlass tourniquets were able to abolish distal pulses in children as young as two years of age and with a minimum limb circumference of 13 cm. These preliminary findings may be helpful for organizations in the creation of guidelines for the management of life-threatening extremity bleeding in children.

Tourniquet Use in Animal Attacks: An Analysis of News Media Reports.

Background Animal attacks pose a significant public health problem in the United States. Non-venomous animals are the leading cause of mortality in these attacks, and extremity injuries leading to hemorrhage are a common pattern. The Stop the Bleed campaign advocates for public training in bleeding control tactics and public access to bleeding control kits. Controlling life-threatening bleeding, as promoted by the Stop the Bleed campaign, may be a method to reduce preventable death in these attacks. Methodology We searched the Nexus Uni database, which compiles international news media articles, to collect newspaper articles in the United States between 2010 and 2019 that referenced animal attacks on humans in which a tourniquet was applied. We screened articles to assess for inclusion criteria and isolated a single report for each attack. Results A total of 50 individual attacks met the inclusion criteria and were included for data collection. Overall, 92% (n = 46) of the victims survived the attacks, and the average victim age was 33. California was the most common location of the attacks (n = 12, 24%), sharks caused the most attacks (n = 26, 52%), and victims most often sustained isolated extremity injuries (n = 24, 48% for arm and n = 24, 48% for leg). Laypeople applied the most tourniquets (n = 29, 58%), and appliers most frequently used improvised tourniquets (n = 30, 60%). Conclusions While mortality in this series was low, there are hundreds of fatalities from non-venomous animal attacks each year. Equipping and training the at-risk public to stop bleeding may save additional lives. Future Stop the Bleed efforts should improve access to public hemorrhage control equipment and expand educational outreach to people engaged in high-risk activities with animals.

The FAST VIP (First Aid for Severe Trauma "Virtual" in-Person) Educational Study.

INTRODUCTION: Trauma is the leading cause of death for young Americans. Increased school violence, combined with an emphasis on early hemorrhage control, has boosted demand to treat injuries in schools. Meanwhile, coronavirus disease 2019 (COVID-19) has made educating the public about trauma more difficult. A federally funded high school education program in development, called First Aid for Severe Trauma™ (FAST™), will teach students to aid the severely injured. The program will be offered in instructor-led, web-based, and blended formats. We created a program to prepare high school teachers to become FAST instructors via "virtual" in-person (VIP) instruction. We used a webinar followed by VIP skills practice, using supplies shipped to participants' homes. To our knowledge, no prior studies have evaluated this type of mass, widely distributed, VIP education. METHODS: This study is a prospective, single-arm, educational cohort study. We enrolled a convenience sample of all high school teachers attending FAST sessions at the Health Occupations Students of America-Future Health Professionals International Leadership Conference. Half of the participants were randomized to complete the Stop the Bleed Education Assessment Tool (SBEAT) prior to the webinar, and the other completed it afterward; SBEAT is a validated tool to measure learning of bleeding competencies. We then performed 76 VIP video-training sessions from June-August 2020. The FAST instructors assessed each participant's ability to apply a tourniquet and direct pressure individually, then provided interactive group skills training, and finally re-evaluated each participant's performance post-training. RESULTS: A total of 190 (96%) participants successfully applied a tourniquet after VIP training, compared to 136 (68%) prior to training (P < 0.001). Participants significantly improved their ability to apply direct pressure: 116 (56%) pre-assessment vs 204 (100%) post-assessment (P < 0.001). The mean score for the SBEAT increased significantly from pre-training to post-training: 2.09 with a standard deviation (SD) of 0.97 to 2.55 post-training with a SD of 0.72 (P < 0.001). CONCLUSION: This study suggests that a webinar combined with VIP training is effective for teaching tourniquet and direct-pressure application skills, as well as life-threatening bleeding knowledge. VIP education may be useful for creating resuscitative medicine instructors from distributed locations, and to reach learners who cannot attend classroom-based instruction.