I found myself in the privileged position recently of participating in the National Stop the Bleed Research Consensus Conference, at the table with an extraordinarily committed and compassionate group of thought leaders exploring the role, challenges and implications of this crucial initiative. My perspective as a consultation-liaison psychiatrist interested in trauma-informed care was aptly described as “a different lens,” though my colleagues appeared to require no convincing of its relevance.
When we talk about trauma, we should always couple that with recognition of resilience. The Stop the Bleed campaign provides an exceptional case-study in this effort. Borne from the depths of national despair following the Sandy Hook Elementary School massacre in 2012, an initiative extended from clinicians across the country to the White House, continuing to gain traction through efforts that couple leadership commitment with community-based mobilization. An aspirational goal of zero-preventable deaths by empowering civilians to become immediate responders to life-threatening bleeds reflected then, as it does now, a pragmatic desire to take prompt action toward secondary prevention while the more ponderous primary prevention advocacy for gun control works its way through the political system. Does thinking about increasing civilian first response skills, from CPR to bleeding control, run the risk of prompting panic or can it be a springboard for valuable discussions about how we can respond in different kinds of crises? How do we build resilience?
Resilience is an umbrella term encompassing many attributes that help us withstand, or rapidly recover, cognitively and emotionally after a stressor – to “bend, not break.” These attributes are manifold and include having a sense of humor, improvisation, and creativity. There are three salient factors worth considering in the context of clinical practice in general, and hemorrhage control training in particular: role clarity, self-efficacy, and empowerment.
The first is role clarity: #thisisourlane. In any first response training, it is crucial that participants understand clearly their role as an immediate responder. With role clarity comes an opportunity to recognize when and how one’s skills can be applied – or cannot be applied. This presents an opportunity to consider, while in a safe place and being instructed by someone with credibility, that there may be times when our skills may not prevent a bad outcome. And this framework of “best effort-variable outcome” presented in the context of a skills-building exercise has the potential to mitigate the cascade that can occur from a sense of responsibility to guilt or shame in the face of potentially ineffective intervention – whether a hemorrhage or other potentially life-threatening context. Another opportunity for a national – indeed, global – discussion about what and when lifesaving skills can be universally taught, and how coming up with such a “first-aid core curriculum” could provide a means of cultivating a sense of shared humanity and civic responsibility.
Another central component of resilience is self-efficacy, which refers to an individual (or community’s) belief in a capacity to apply skills to produce a desired outcome. This is a modifiable psychological trait. It can be learned, taught, modeled, mentored and nurtured. This is at the heart of hemorrhage control training: how do we ensure that individuals leave the training with a sense of mastery of the skill to stop potentially life-threatening bleeding? It will likely improve the odds of response if a relevant situation occurs, and of increased interest in first aid skills in general. And this is a social skill, a counterweight to the anonymity of social media. The skills training itself can contribute to team-building; with high penetration, moreover, it offers “herd immunity” to improve the odds that someone in a crowd will know how to respond. The message is clear. In the face of a major injury – whether secondary to an active shooter, a car accident, or a playground mishap – anyone with some basic knowledge can play a supportive, and even life-saving, role.
The third aspect of resilience to consider in this context is empowerment: the process (and it is a process) of becoming stronger and more confident in our ability to make an impact in our roles. We can easily feel overwhelmed or helpless in the face of the magnitude of communal violence and individual suffering, or even the prospect of it. While distress may be unavoidable, the ability to retain a sense of agency and purpose, of collaboration with colleagues, classmates or other bystanders, and of connectivity with supports means that while PTSD is a risk, post-traumatic growth is also a possibility.
So let’s think about this possibility of hemorrhage control training as an opportunity for primary prevention through stress inoculation: introducing the possibility of exposure to trauma as a way to mitigate impact of that exposure if it occurs (in addition to the live-saving impact of the bleeding control skill itself). We need to couple first response training with messaging that recognizes the stressful context of the intervention and explores strategies that might prophylax against progression to pathology.
The sense of meaning and relevance will be different depending on where training is conducted, and there is a lot to learn about how to ensure adaptation of trainings to culture and context. In communities where exposure to violence is the experience of a majority, training may be not only relevant but effectively contextualized in an explicitly trauma-informed framework. A trauma-informed approach recognizes the high rates of exposure to adverse events across populations, and the ways that this impacts not only health trajectories, but also how individuals experience health care engagement itself. Stakeholder involvement is integral to program success.
As a country, we are currently faced with crucial questions of identity and civic responsibility. As clinicians, in the face of ever-encroaching administrative demands, role-clarity can be eroded, impacting our sense of self-efficacy in patient care, and empowerment as professionals. A first response program like Stop The Bleed offers an opportunity to consider this framework as it applies to individual and community resilience, where first aid skills are a concrete way of acknowledging shared responsibility for each member of society, neighbor or stranger.
Nomi Levy-Carrick is a psychiatrist.
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