Page 136 - JSOM Winter 2017

Civil society is facing attacks with explosives, by active shoot- deaths in this kind of incidents, namely, extremity and junc-
ers, or by small groups of terrorists in which the same injury tional massive hemorrhage (treated with a tourniquet and/or
mechanisms occur. As a study of terrorist attacks that occurred hemostatic bandage), airway problems, and penetrating chest
between 1970 and 2013 found that no continent, except Ant- wounds (treated with a vented chest seal), to emphasize the im-
arctica, has been free of incidents in which terrorist elements portance of hypothermia prevention in the traumatic patient.
have not been implicated. A recent example is the Paris at-
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tacks, from which a series of lessons was drawn by the Emer- Another goal has been the training of prehospital and hospital
gency Medical Assistance Service, such as the need for more personnel in casualty management in this type of incident, seek-
tourniquets in the prehospital environment. 5 ing to speak a common language among all echelons of care.

These threats have led the different nations to consider de- Methods
veloping policies to deal with these situations at the opera-
tional and healthcare levels. An example of these policies is the A web page (http://www.mactac.org.es/) was created, incorpo-
Stop the Bleed campaign carried out by the US Department of rating, in addition to the Moodle platform (Moodle Project,
Homeland Security and the Office of the President in 2015, https://moodle.org/), free teaching materials such as videos
in which the early control of exsanguinating bleeding in vic- and “Guía para el Manejo de Heridos en Incidentes Intencio-
tims is enhanced. In addition, various meetings held by the nados con Múltiples Víctimas y Tiradores Activos” [Guide for
6,7
Hartford Consensus, chaired by the American College of Sur- the Handling of Wounded in Intentional Incidents With Mul-
geons, to increase survival in mass casualties and active shoot- tiple Victims and Active Shooters]. In addition, we facilitated
ers events have resulted in recommendations. These policies, the download of an Android smartphone application through
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in addition to influencing training, confer great importance to Google Play (Google, https://play.google.com) with the same
easy access to tourniquets and hemostatic agents by all citi- name, designed by Medical Simulator (http://www.medical-
zens, not only by medical or police personnel, emphasizing simulator.com/), which allows continuous education and, with
the philosophy of “chain of survival,” until then known for the correct training, could facilitate decision-making.
cardiopulmonary resuscitation. 2
Subsequently, a 7-hour training intervention called “Evita una
In addition, the use of the tourniquet and hemostatic bandages muerte, está en tus manos” [Avoid a Death; It’s in Your Hands]
was already contemplated in different civil protocols and in (Figure 1) was carried out between January and May 2017 at
recommendations such as the European Resuscitation Council the University Hospital 12 de Octubre and at the University
of 2015 Guidelines. 9 Hospital Fundación Jiménez Díaz in Madrid, Spain.

To achieve bleeding control effectively by applying a tourniquet
and to avoid the onset of hypovolemic shock or death, train-
ing is needed that emphasizes quick and and correct tourniquet
placement. Reducing the placement time will minimize the risk
of exsanguination that can lead to hypovolemic shock or death.
As findings of a Maryland study of individuals without medical Figure 1 Program logo.
training or previous military experience show, simply provid-
ing written information with the placement instructions of a
Combat Application Tourniquet (CAT Resources Inc., http://
combattourniquet.com/) made its application effective 44.14%
of the time, compared with 20.41% among participants who
did not receive any information. Another study on tourni-
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quets and hemostatic gauze use in the prehospital environment The program consisted of lectures and workshops conducted
concluded that to achieve and maximize adequate effectiveness by experts in the fight against terrorism and by health pro-
in the management of these tools, training is vital. That study fessionals, all trained in National Association of Emergency
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consisted of training through a computer program and then Medical Technicians Tactical Combat Casualty Care. The
hands-on practical training, started 1 month before implemen- instructor-to-student ratio was 1:6. The program was led by a
tation in June 2009. In the following 6 months, tests on the coordinator, medical director, and instructors.
maintenance of the skills showed 98.5% of participants (326 of
331) retained their proficiency. Therefore, if a simple instruc- The initial part of the classroom phase comprised 90-minute
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tion sheet achieves almost double the application effectiveness, expository (theoretical) sessions, separated into two blocks:
with adequate training, the results should be even better. introduction and assessment and management. To evaluate the
students’ progress, feedback was sought from them through
For this to happen, it is necessary to train the citizen as first questions about their previous experiences and their knowl-
responder or “immediate responder” (note: the first responder edge of the topic.
legal term does not exist in Spain; therefore, in this article,
we have used the latter term to refer to all persons without The second part of the classroom phase, which had the great-
regulated health training who may be involved in the initial est teaching load, comprised four practical workshops (45
moments of an incident). Therefore, the main objective of the minutes for each rotation) held simultaneously, and during
training in wound management in terrorist and active shoot- which techniques were demonstrated. The instructor ex-
ers attacks has been to train the student as the immediate plained the technique over 5 to 10 minutes and then the stu-
responder in self-protection measures and in the evaluation dents did performed the technique one by one until they could
and management of the most common causes of preventable do it correctly.

134 | JSOM Volume 17, Edition 4/Winter 2017