From hurricanes isolating segments of the population to the dynamic terrorist events in Paris and San Bernardino, the threats to our society are both complex and often overwhelm local resources. Because of their storied success, there is a widely held regard for the availability and professionalism of our emergency medical services, and deservedly so. Accordingly, most of the financial resources dedicated to disaster preparedness and counterterrorism are primarily focused on improving our uniformed response.
Yet the unspoken secret of EMS is that there is a systemwide overreliance on the existing EMS structure. Too often this reliance means our communities prepare based on the assumption that medical care will be readily available. As recent events continue to prove, this is not always the case, and it suggests our current response paradigm may need improvement.1 Now is the time to educate and empower everyone to be able to bridge this gap and provide emergency care. Perhaps Amanda Ripley says it best in her book The Unthinkable: “Regular people are the most important people at a disaster scene, every time.”
Trauma is the leading cause of death from birth to nearly age 50, but there has yet to be a concerted effort to improve outcomes from traumatic injury within this population.2 Under the best circumstances, medical response takes anywhere from 7–11 minutes on average during non-surge operations, and departments around the country are self-identifying their own inability to meet NFPA 1710 standards.3,4 Given this reality, there have been outstanding efforts highlighting the science of civilian survivability, particularly from hemorrhage. The Committee for Tactical Emergency Casualty Care (C-TECC) has made great strides synchronizing civilian-based prehospital guidelines for medical providers across the world. Subsequently the Hartford Consensus, convened following the Sandy Hook massacre, has effectively pushed the need for improving hemorrhage control within communities.5 Following on the success of these groups, the federal government has attempted to make recommendations for civilian actions (DHS active shooter pamphlet) and recruit the community with the “Stop the Bleed” program.6,7
While these efforts are critically important, what has been missing until now is a unifying solution to meet these new mandates. Recent publication of the First Care Provider white paper (http://firstcareprovider.org/#white-paper) has provided a foundation for this effort, combining the currently supported TECC guidelines with systemic lessons learned from a fully operationalized public education model.8 In this paper we share a brief insight into the success of a reproducible model for organizations constrained by limited resources.
The First Care Provider Concept
Organizations and agencies across the world now conduct regular active-shooter exercises. While many of these programs teach familiarization with the DHS-recommended “run, hide, fight” approach, the “first care provider” concept creates an all-hazard approach to situations where life may be compromised yet medical care is unavailable.9 This was the next critical step in the trauma chain of survival, considering that current trauma education programs are not designed for a civilian audience. Further, the situational response and prioritization of care differs dramatically from civilian medical programs (first aid, CPR) but adheres to the consensus guidelines recommended by C-TECC. Finally, the universality of the first care model makes it an appropriate subject to be included as a part of all ongoing safety programs and new-employee orientations, or as a stand-alone course.
Some of the most impressive outcomes were achieved in Westminster, CA, through a community-led effort to improve resiliency. As a small city (pop. 90,000) with limited resources, Westminster’s pilot project was launched through a public-private endeavor to improve preparation for mass-casualty disasters, including acts of terrorism, violence and natural disasters. In partnership with FirstCareProvider.org, the community sought to reach areas of community interface that have substantial public use or risk for traumatic injury but are often completely reliant on the 9-1-1 system (such as schools, city hall, city maintenance, non-sworn police personnel and local businesses). Following an active-shooter curriculum administered by the Westminster Police Department, the First Care Provider model was introduced to create a communitywide network of trauma-trained individuals capable of providing lifesaving interventions to trauma and potentially augmenting the capabilities of first responders.10
This model proved the key to success. Acting Chief of Police Daniel Schoonmaker summarized the program by saying, “Some treatments are covered in other courses currently offered to the public, but there is no bystander-led trauma system that combines both action and treatment, particularly in the time from onset to response.” Therefore, the supporting literature, prioritization of care and nuances of public education that make up this system are markedly different from other programs. While “Stop the Bleed” supports one of the major tenets of the civilian TECC guidelines and the Hartford Consensus, public access to hemostatic devices without educational outreach may not sufficiently address the needs of our communities.
First Care Provider Outcomes
This concern was evident during the Westminster exercise. “I felt myself panic,” says Patricia Singer, one of the volunteers who braved the study without prior preparation. This hesitancy was one of the primary barriers the First Care Provider model sought to overcome. Its evolution over the past several years and ongoing contact with our communities have extracted several lessons particular to public trauma education.
One of those is that the reluctance to act is possible to overcome once the root cause of this reluctance is identified and an easily retainable model that integrates with existing emergency procedures is provided. The success of this approach was made evident by Berri Williams, a teacher who had completed FCP training almost two months prior to the exercise. “They taught us exactly what to care about first,” Williams says, “so we knew exactly what to look for.” This familiarization and recognition of the preventable causes of death can be imparted to the layperson and must be included in any civilian course.
Second, in the untrained population there is a tendency to congregate in times of emergency, and a hesitancy to take individual action. With a brief familiarization, First Care-trained members of the public demonstrate a notable willingness to operate independently, recognize critical injuries and properly allocate resources for maximal benefit. This type of outreach effort may actually encourage independent thinking in times of disaster. This becomes critical given that recent events (e.g., Tucson, Aurora, Boston) have shown that rapid evacuation to medical care can be as important as hemorrhage control.11 Therefore, bystander safety training, recognition of critical injury and rapid evacuation should be the key objectives in civilian training, with the preventable causes of death as a secondary objective.
Finally, one of the most notable observations was ironically captured by one of the participants who had the most medical education. “We are so used to having equipment to rely on that you don’t know what to do in a situation like that,“ says Hiram Diaz, a registered nurse. The reality is that there must be a mandate within our medical educational system to highlight this developing skill set and prepare providers to face the threats of terrorism, active-violence incidents and disaster medicine. There has been dramatic support preparing first responders, but there has not been a parallel effort to educate “first receivers.”
Recommendations and Future Direction
Reluctance to change is perhaps the most critical barrier that must be overcome for a successful community resiliency program. This will require leadership to move beyond a complete reliance on traditional 9-1-1 response and hesitance to introduce medical policy into the broader population. However, the evolving threats facing our society make it necessary to recognize the gap left by our current disaster planning assumptions and existing medical curricula. There are currently no common protocols for EMS services or law enforcement to provide medical care in what has become known as the “hot zone.”12,13
This is a crucial gap for those affected by crisis or conflict, for whom the “how to respond” decisions have already been made. The victims of trauma can neither wait for help nor consult others away from the incident. Therefore, the only care provided for the victims of those events will be self-aid and by the unharmed bystander. The First Care Provider concept was created specifically for the nonmedical civilian needing to provide care for those injured in trauma. It adheres to the latest medical guidelines and the recommendations of both Hartford and “Stop the Bleed.” The FCP model prioritizes decisions based on the expected resources available to the nonuniformed civilian population and dispels the common fear of how to recognize and appropriately treat critically injured victims.
In a time where limited budgets and reduced personnel make operating emergency response systems increasingly challenging, agencies must realistically consider return on their investment when it comes to public safety. A synchronized strategy for improving community resilience will include fire prevention, cardiac arrest and traumatic injury. As departments continue to face escalating expectations of service as well as soft mandates from multiple organizations, creating a first care provider network becomes a realistic and achievable goal with limited time investment.
1. Bobko JP, Kamin R. Changing the paradigm of emergency response: The need for first-care providers. J Bus Contin Emer Plan, 2015 Autumn; 9(1): 18–24.
8. Callaway D, Bobko JP, Shapiro G, Anderson K, Smith E, Sarani B. Building Community Resilience to Dynamic Mass Casualty Incidents: A Multi-Agency White Paper in Support of The First Care Provider. J Trauma Acute Care Surg, pending publication April 2016.
9. Fisher AD, Callaway DW, Robertson JN, Hardwick SA, Bobko JP, Kotwal RS. The Ranger First Responder Program and Tactical Emergency Casualty Care Implementation: A Whole-Community Approach to Reducing Mortality From Active Violent Incidents. J Spec Oper Med, 2015; 15: 46–53.
Joshua P. Bobko, MD, FAAEM, is a board-certified emergency physician and adjunct assistant professor of emergency medicine at Loma Linda University in California. He is a medical team manager for California USAR Task Force 5 and the medical drector for the Westminster (CA) Police Department. His company, Valiant Research, provides training and operational medical support for the Los Angeles FBI. Recognizing the gap in traditional EMS response, Bobko started the nonprofit FirstCareProvider.org with the goal of improving community resilience by expanding trauma education into our communities. He is on the Board of Directors for the Committee for Tactical Emergency Casualty Care.
William J. “Bill” Harris, NREMT-P, is a 20-year veteran of the U.S. Navy. His deployments include Iraq, Afghanistan, Kuwait and Africa, as well as serving in Iceland. He spent eight years serving beside U.S. Marines as a Fleet Marine Force corpsman, and seven years at the Naval Special Warfare Development Group. Since retirement in 2010 he has trained military members, law enforcement, firefighters and other government agency personnel in Tactical Combat Casualty Care (TCCC), Tactical Emergency Casualty Care (TECC) and active-shooter tactical response.