Introduction
The United States has had an increasing amount of mass casualties secondary to gun violence. One event that shaped the future of trauma response was the Sandy Hook Elementary school shooting. This event prompted leaders to reform education on hemorrhage control by creating Stop the Bleed.1 Stop the Bleed is a program that teaches basic hemorrhage control by educating participants on the use of tourniquets, wound packing, and direct pressure while providing access to basic medical supplies for control of hemorrhage. This program was started by a group of physicians recruited through the American College of Surgeons to enact a solution to the problem that the United States faced: increasing fatalities due to hemorrhage.2 This program has been taught to many people from diverse educational backgrounds resulting in 1.5 million people learning how to effectively manage hemorrhage control.3
The Stop the Bleed program consists of an introductory video on the importance of hemorrhage control in a variety of situations. It uses examples of people that have had limbs saved after a traumatic event due to proper tourniquet placement. An instructor then teaches using model limbs how to properly place a tourniquet and date it for EMS. It teaches the indications on when to place tourniquets and the importance of timely management of hemorrhage. The program details how to differentiate from a wound that should be packed versus a wound that would respond to a tourniquet. The instructor teaches participants how to pack and dress wounds to stop hemorrhage from penetrating trauma.1
The literature shows many studies that have implemented the Stop the Bleed program at the community level and for first responders. There have also been studies that have been conducted in medical schools. These studies have analyzed the effectiveness of the program in teaching hemorrhage control and analyzed the role of medical students as future instructors of the Stop the Bleed program. However, there is not a systematic review that analyzes all the studies conducted utilizing medical students as participants. A systematic review could help illuminate the need for a hemorrhage control instruction program like Stop the Bleed in medical student education.
Methods
PubMed, JAMA, and Google Scholar were independently searched, using search criteria. The search criteria consisted of phrases such as “Stop the Bleed,” “Stop the Bleed in Medical Students,” “Stop the Bleed Training,” and “Medical School Stop the Bleed.” Relevant articles were then analyzed based on the populated results. Inclusion criteria included articles that utilized the Stop the Bleed program in training medical students in the United States of America. Exclusion criteria included studies that included other occupations in addition to medical students or were not performed through an accredited U.S. medical school. Table 1 depicts the process in which the studies were chosen for review.
As the figure shows, there were initially 29 studies screened with 22 excluded based on initial review of the abstract and methods. 9 studies were read and evaluated on inclusion/exclusion criteria. One of these studies was omitted as it solely focused on medical students as instructors of the Stop the Bleed program and not as participants. This left 6 studies meeting inclusion criteria and all were included in the systematic review.
In each study the following measures were defined: number of participants, pre-survey completion, post-survey completion, percentage of students who showed an increase in confidence of applying the appropriate hemorrhage control technique, percentage of students who felt confident that they could teach hemorrhage control skills to others, the percentage of students that said it would be helpful in clinical rotations, and the percentage of students who would recommend the course to other medical students.
Results
Each study that implemented the Stop the Bleed program assessed confidence at utilizing the teachings of the program in a situation where there was massive hemorrhage. All the studies assessed this using anonymous pre and post program surveys. Each study used a different survey method. Some used a 5-point scale in which the participant rated their confidence in each skill level, some had multiple question scenario surveys in which they rated their confidence in applying bleeding techniques, and some implemented knowledge quizzes. Some of the surveys assessed students’ perceptions on the importance of hemorrhage training and the potential of utilizing it in healthcare settings. One particular study assessed the students’ skills and graded them on proper tourniquet placement in addition to a follow up survey after the conclusion of the program.
Research Designs
Each study included in the systematic review is listed below with a description of the individual characteristics of what categories were assessed and by which means data was collected.
[Chernock et al.]4 This study incorporated the Stop the Bleed training into their surgery clerkship curriculum. Pre and post program surveys were done in which students rated their confidence in performing techniques and their perception on the importance of this training for other physicians and healthcare professionals.
[Fridling et al.]5 This article taught the STB program to entering first year medical students. Pre and post program surveys assessed effectiveness of teaching and comfortability with the skills. Refresher courses were later provided during years two and three, however, there were no additional follow-up surveys.
[Gowen et al.]6 In this article, the study assessed first year medical students by use of pre and post surveys. There were two post-program surveys, one at the conclusion of the study and the other 6 months after the study. This study assessed whether the participant could apply the bleeding control skills, the number of people who believed they could save a life, and whether the participant would recommend the course to another. The 6-month assessment survey investigated whether students used skills on live patients and whether the skills utilized were successful.
[Levy-Carrick et al.]2 Researchers in this study surveyed medical students before, during, and after completion of the Stop the Bleed program and associated lectures. Through these surveys, students self-reported increases in role clarity of when they should and should not utilize hemorrhage skills, their confidence levels in utilizing the skills learned, and their ability to act in a situation that would require their newly acquired skills.
[Marsh et al.]3 Results of this study were tabulated using a pre and post survey in which third year medical students had to rate their confidence in performing bleeding control techniques, training others in the techniques that they learned, and their thoughts on integrating the Stop the Bleed program into their medical school’s curriculum.
[Sainbayar et al.]7 This study assessed first year osteopathic students and had them complete a pre and post program survey in which they rated their confidence levels in applying the different interventions taught during the program. During this study, participants were randomly assigned to two study groups. Throughout a 12-week intervention period, both groups watched a Stop the Bleed review video or a “distractor video” after 4 weeks had passed since the initial training program. After the 12 weeks ended, the post-program survey was given.
[Schroll et al.]8 Medical students of years one through four volunteered to participate in this study and took part in pre and post program surveys that allowed them to rate the 6 major skill levels taught throughout the Stop the Bleed program. This study also allowed instructors to assess the skill level of the participants after completing the program and evaluated if the students would make proficient instructors.
Assessment of the Stop the Bleed Program
The table below depicts the following criteria by study: number of participants, pre-survey completion, post-survey completion, percentage of students who showed an increase in confidence of applying the appropriate hemorrhage control technique, percentage of students who felt confident that they could teach hemorrhage control skills to others, the percentage of students that said it would be helpful in clinical rotations, and the percentage of students who would recommend the course to other medical students.
While the studies included a different number of participants, each tabulated their results by percentages of categories assessed in the pre and post surveys. The studies that did not include percentages of participants indicated the confidence interval and p-values. All categories yielded statistically significant results in each study. The varying use of research design that each article used while demonstrating similar results further indicates the efficacy of the program and the indication that it should be implemented in medical school curricula.
Discussion
Limitations of Included Studies
Throughout review of these studies, a common limitation among most of the studies was that the implementation was not longitudinally incorporated into the curriculum. While the pilot program study was completed, students in the following classes were not given the opportunity to participate. Follow up studies could be completed at each individual institution demonstrating the effectiveness of medical students as instructors in the community. There was a study that did incorporate the program into their medical school curriculum. The limitation of this study was that they did not survey participants on whether they had to utilize the training that the program provided outside of a healthcare setting.
Clinical Implications
The results of this systematic review show that medical students have improved knowledge and confidence in hemorrhage control after taking part in Stop the Bleed training. This program can help aid students on their clinical rotations and throughout their career as physicians by implementing early response tactics to prevent complications of massive hemorrhage. It also would allow for a greater number of potential instructors for communities at large. Studies have already shown that medical students serve as sufficient instructors once having completed the Stop the Bleed program.5 This would allow for numerous training programs in which citizens without healthcare training could have the opportunity to learn how to properly respond to events in which quick and efficient hemorrhage control could save lives.
Accessibility and Challenges of Stop the Bleed Program
One of the biggest challenges of the Stop the Bleed program is the accessibility to kits that the program provides. These kits can be purchased and distributed to participants during the training program. Basic tourniquets cost about $30 while a standard training kit can be upwards of $80. An instructor kit included other materials such as model limbs for participants to practice tourniquet application and wound packing, these materials cost upwards of $1000.2 These costs could be challenging for medical schools as implementation of this program would cause annual costs for standard kits. Further implementation of this program using medical students as instructors could incur greater costs and potentially offset public interest.
Implications for Medical Education
Basic hemorrhage control is not taught in most medical school curriculums. BLS and CPR are necessary requirements that students must have prior to entering clinical rotations. Most medical schools offer vaccination training so that students can assist in local clinics. However, basic hemorrhage control and necessary materials are not provided to students. This systematic review shows that this is beneficial in medical student education and improves confidence levels and knowledge of how to efficiently prevent hemorrhage. The skills that this program teaches would not only be beneficial during clinical rotations, but throughout the student’s future career as a practicing physician.
Recommendations for Future Research
The implementation of this program in medical school curricula whether it be a single occurrence or something that occurs annually has proven to be effective in education surrounding basic hemorrhage protocol. Further research should be conducted on the need for implementation of these skills during medical school clinical rotations or outside of the healthcare setting. Future studies could be conducted on schools that have implemented this program and on their students as instructors in the community. Lastly, a cost benefit analysis for individualized institutions could be conducted on the unique cost for instituting this program and recommendations to provide funding in the curriculum if this program were to be utilized longitudinally.
Conclusion
Stop the Bleed is a nationally recognized program that has helped provide valuable life-saving skills to individuals in healthcare and outside of healthcare. It allows for those who have participated in the program to educate others, with a common goal of increasing the number of people trained to control massive hemorrhage. It provides readily accessible materials that can be easily stored and utilized. The hemorrhage prevention techniques taught by this program have also helped prepare medical students for what they might encounter on clinical rotations and throughout their career as physicians. With other life support programs being a requirement in medical school curriculums, this program also serves a similar purpose. Teaching basic life-saving skills that everyone, especially future physicians should know. Incorporating a hemorrhage control program like Stop the Bleed has increased medical student confidence in treating massive hemorrhage and has enabled them to feel as if they could teach others what they have learned. If medical schools were to incorporate this program into their curriculum, not only would it make our physicians better equipped in emergent situations, but it would allow the civilians that they have provided training to be more prepared to help control massive hemorrhage quickly and effectively.