Responding to the Criticism of Stop the Bleed Training

The Department of Homeland Security is pushing a new public awareness program called ‘Stop the Bleed’ which is trying to train as many citizens as possible in basic bleeding control techniques. This is partially in response to the mass shootings we’ve been having. A lot of the casualties from these events are the result of blood loss. Many lives could have potentially been saved if the victim’s bleeding had been controlled earlier. In the first minutes of an active shooter situation, the police will be entirely concerned with neutralizing the shooters. It will likely be five to ten minutes (at least) after the initial police response before medical personnel move in to start treating victims. For many this will be too late. If more people were trained in bleeding control, they could potentially save their own lives or that of those around them.

The criticism of these programs is always the same. That training like this ‘is turning our schools into war zones’, that this is ‘normalizing mass shootings’, or that this will somehow preclude whatever your preferred action on gun control is because we’ve ‘accepted mass shootings as part of life.’ Frankly, I don’t understand this view. When I say I don’t understand, I mean I have difficulty comprehending how any adult can seriously hold this view. But it’s clear that that is more about the limits of my own imagination or capacity for empathy since many serious people do seem to genuinely hold that view, so let me explain myself.

I do this (emergency preparedness and emergency training) professionally. I run CPR and bleeding control courses at work on a semi-regular basis. I participate in creating emergency plans and procedures. In the event of a crisis or emergency, I would be part of the response. My department is tasked broadly with preparing the organization for an emergency.

The fundamental reality of my field is that we cannot eliminate all risk to everyone at all times. It’s simply not possible. We cannot offer complete protection or complete safety. Public safety typically has extremely constrained resources & budgets, especially when, like me, you are one operational department in a large organization. I serve approximately 19,000 students, faculty, and staff across more than two dozen campuses. My colleagues and I have to decide how best to allocate departmental resources in order to maximize safety and preparedness.

Armed guards (instead of unarmed) are a regular suggestion, even from the political right, in lieu of something like active shooter training or stop the bleed training. So, let’s dig into that. In Manhattan, the going rate for an armed guard is $24 an hour. I teach bleeding control courses, they take about an hour, and if I’m giving away tourniquets to the participants, the cost is around $25 per student. For those who are ahead of me, one-year of 24/7 coverage from one armed guard at one campus would cost $105k. If we had a $105k excess budget (we don’t but a guy can dream) which of these would provide a larger benefit to my organization and the population I serve?

  1. Employing one armed guard at one campus for one year
  2. My department training an average of 12 people a day for a full calendar year (4,380 people) in basic bleeding control and hands-only CPR, and giving them all a tourniquet

Which of those would provide the largest net-positive? I know which one I would go for. We train 4,380 people, say the training sticks with 60% (2,628 people), who will hopefully be with our organization for years to come. Those 2,628 will also be out walking around, living their lives, with that lifesaving training in their heads. It seems like a no-brainer compared to sinking $100k into a single point of armed security for one year.

This is obviously bar-napkin math, but you begin to see why people who do what I do often pursue what to the public may seem like counterintuitive aims. “Why are we spending all this money on training when we could invest it in armed guards to keep people safe?”. Mass-training programs, like the now decades-long push to teach the public CPR, provide a lot of benefits compared to the relatively modest investment required.

The connected criticism, which comes especially frequently when this training is done at schools, is about not burdening ‘children’ with such things, about it triggering anxiety. As a physician said to me on twitter criticizing bleeding control training being given to high school students: “A child should never have to worry about trying to save another child. A child should never be in that situation in the first place.”

Leaving aside the question of if high school students are “children”, I agree with the impulse. It is important not to unnecessarily terrorize people, especially children, with things (like mass shootings or cardiac arrests) which are very unlikely. I should differentiate between “mass shooter training” and bleeding control training. Mass shooter training (if a shooter comes into the school this is what we’ll do) is something which I do not believe we should be doing with young school children. It effectively terrorizes children over something that is extraordinarily unlikely, creating a fear that need not exist. It’d be like doing home invasion drills with your children, why would you want to put that thought in their heads before they are old enough to process the probability of ever being a victim of a home invasion?

But to teach someone a skill is not to terrorize them. Teaching someone a skill, showing them how to fix something, is empowering. Every child (and certainly every adult) should know how to use a tourniquet and do CPR from the point they’re physically strong enough to do those skills. It’s not ‘normalizing’ violence or injury, it is empowering people to be masters of their own fate.

The conflict here is between normative and descriptive ways of engaging with the world. “There should be no mass shootings” is a normative claim, “but there are mass shootings” is a descriptive one. We must, at this level, engage with the world on a descriptive basis. We must engage with the world as it is, not as we wish it to be. This is what people in my field do. We are given limited resources and an impossible goal. We take honest stock of the world as it exists, and work backward towards what we can do to make a positive impact in it.

I do not have the luxury of saying in response to mass shootings “well there shouldn’t be shootings” or “we should ban guns” or any such macro-level political ‘solutions.’ I am tasked with doing something productive for the population I serve in the face of this risk. Calls for mental health funding, red flag laws, media reform, or various flavors of gun control are all well and good but are part of a separate discussion. Those long-term systemic policy discussions are not going to help the victim of a shooting who’s bleeding out on the ground while the police are searching for the shooter. But bystander or self-intervention to stop the bleeding could.

This is empowering. We live in a political environment where millions of Americans feel impotent and helpless to be able to effect change around these systemic problems. But this is something you, or anyone, can do to have a positive effect on the world. Anyone can learn to use a tourniquet or pack a wound from YouTube videos (if you’re in NYC I’ll be more than happy to teach you how in person over lunch). This is something everyone can do today to mitigate the tragedy of mass shootings and violence or injury of all kinds. Regardless of what our politicians do or don’t do, all of us citizens can grab this bull by the horns and say “I am going to learn how to do this, and I may someday save a life with this knowledge, I am going to take this step to reduce the amount of tragedy in the world.”

The final criticism, which often comes from professionals, is that we can’t expect “lay people” or “civilians” to do these things, let alone do them correctly. They, rightly, point out that out of people who learn CPR, only a percentage of them will actually perform CPR if the time comes, and only a small percentage of that group will do it correctly. This is true, but it is all the more reason to give better training to more people to increase the numbers of people who know these skills, choose to do them when needed, and do them correctly.

Even professionals fumble and make mistakes, or freeze entirely, especially the first time they do something in the field. This is why medical training consists of repeated simulation practice and then graduated, supervised, practice in real life. Further, it’s worth noting a lot of physicians and medical professionals are spectacularly bad at skills they rarely or never use in their practice. A dermatologist, despite his MD, is not going to necessarily be any better at using a tourniquet than a janitor who went through a stop the bleed seminar. A veteran nurse who works in a pediatrician’s office is not necessarily going to be any better at CPR than one of the college students I trained this fall.

Mark Bennett said succinctly in a discussion on twitter “If we are certain we will attack, we may attack. If we think we will run, we will certainly run.” It is not about getting 100% of the training to stick with 100% of the people. This is about increasing the probability that if I find myself bleeding out on the floor of Penn Station during rush hour there will be someone in the crowd who knows how to control bleeding and jumps into action. The fact of the matter is there will not always be a professional present. There will not always be an EMT or a Police Officer there when you need them. Sometimes, it will be up to you, the person going about their day who is all of a sudden tossed into chaos. Massive bleeding and cardiac arrest are two situations were seconds count, and the victim won’t have minutes to wait for an EMS response.

If professionals like me go into this exercise thinking “regular people will never do this”, then regular people certainly will not. If we breed helplessness, and tell people there’s nothing they can do, just wait for help, then helplessness is what we’ll get. However,if we go into this thinking “this is a skill regular people can master and will use in an emergency, and save lives” then there is a chance they will, and that, is a chance I am willing to take.

You can find this post cross-posted on my LinkedIn

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