Challenges with Stop the Bleed and training civilians in wound packing

Is a paramedic or police officer allowed to teach the public a medically controlled act that they do themselves regularly in their job? What about a first aid instructor?

The short answer is: No, not unless a medical professional has explicitly authorized them to do so. The long answer is very complicated, important, and unfortunately ‘maybe’.

This topic has several interacting parts which need to be laid out to explain. For context and bias, it is our opinion that the public should be trained in wound packing techniques but there are some concerns which put said training in a legal grey area.

This means that in some jurisdictions, during an emergency, there is effectively no legal difference between:

• Using an epi-pen (auto injector) on someone to assist with an allergic reaction.

• Injecting a diabetic with insulin.

• Packing a wound for a severe bleed.

• Cutting someone’s throat to create a surgical airway.

• Decompressing the chest cavity of a casualty with a needle.

• Doing a direct person-to-person blood transfusion in the field.

• Any other medically controlled act that is considered necessary in an emergency.

Further, there is no explicit guidance on who is allowed to train in these things and to what degree. No list exists qualifying which medical acts on this list have exemptions, to what degree, and how they should be handled outside of medical professionals who are directly authorized to do them.

This issue is extremely complex and nuanced compared to most topics previously explored in these articles so it has been broken down into different parts below. The ordering of these sections has been done purposefully to help contextualize the situation. These sections are in order:

• Brief history on Stop the Bleed

• Skills Associated with Stop the Bleed

• A note on how wound packing is taught

• The Challenge (Background)

• The Challenge (The Grey Area)

• Solutions

The main solutions that are proposed at the end are essentially asking for a decision to be made and for more clarity. It is possible that the solution could be a single line being added to an existing regulation or could utilize policies for other things that already exist.

This should not require ‘reinventing the wheel’ or novel solutions.

Brief History on Stop the Bleed

In 2012 there was a mass-shooting at Sandy Hook Elementary School in Newton, Connecticut, United States.

Fast forward to 2015, the American College of Surgeons created the Stop the Bleed public awareness campaign in direct response to this 2012 mass-shooting.

The main finding which motivated this was that while the injuries of the deceased were severe, autopsies revealed that if their significant bleeding had been addressed immediately more victims may have survived.

Due to the types of wounds involved in this case, the bleeding control in the field would have likely required wound packing.

Skills Associated with Stop the Bleed

Stop the Bleed training is an advanced wound care skillset. Here is a rough breakdown of its components:

Emergency scene management – present in any first aid related situation.

Wound care (severe bleeding) – This is the initial basics component present in first aid courses: dressings and bandages, direct pressure, rest.

Tourniquets – This is where things start getting more advanced. Tourniquets are optional in first aid, specialized programs like combat medicine and wilderness first aid will commonly have them.

Wound Packing – Involves inserting material into the body to apply pressure to a deep wound internally. Generally, only present in medical training and Stop the Bleed courses.

A note on how wound packing is taught

Wound packing is normally taught as a progression following the same order as the skills listed above.

For brevity multiple subcomponents will be combined into larger steps to provide the general picture. With the step specific to wound packing, more detail will be provided. For the wound packing progression for laypeople it generally goes like this:

Step 1: Identify in Emergency Scene Management that there is a severe bleed.

Step 2: (If there is a severe bleed) Use direct pressure and rest as per regular first aid in an attempt to control the bleed.

Step 3: (If step 2 is insufficient) Apply a tourniquet above the wound to restrict blood flow to the wound. This will increase risk of damaging the area below the wound, but is done in the interest of preserving the casualty’s life.

Step 4: (If step 3 is insufficient) Remove the bandage and dressing applied in step 2. Proceed to insert gauze and ‘pack’ the wound internally. Large amounts of gauze should be used. Even for what appear to be small wounds, the pocket may be much deeper than expected.

Assuming roller gauze is used: Start at one end of the wound and (fairly aggressively) cram the end of the gauze using one’s fingers into the base of the wound. It is very possible and even likely that the surface of the wound will be torn and opened further in this process, this may be an unfortunate necessity.

Going from end-to-end continue packing gauze into the wound until no more can fit. One will likely need to go back and repeatedly press down and compact the gauze being packed to cram more in. With many wounds it is very possible that an entire roller gauze or multiple rolls will be used to pack a single wound.

If possible, leave a small end of the roller gauze outside of the wound so that medical staff at the hospital can more easily remove the wound-pack when they need to. If multiple gauze rolls are used, this may mean multiple ends being left outside.

After the wound has been packed, cover the wound as per step 2.

Remove the tourniquet and see if the wound bleeds through. If so, the wound may have been insufficiently packed and may need to be entirely repacked or crammed down further.

The Challenge (Background)

To better understand the challenge, one needs to be aware of two important concepts:

1. What a medically controlled act is.

2. The normal expectations and purpose of a first aid course

In general, a medically controlled act is something (an action, ‘act’) that is regulated in such a way that only medical professionals are supposed to do it. These sorts of regulations are generally taken very seriously. They also have many different components, here are some of the ones that will be particularly relevant:

• Who is considered a ‘medical professional’

• What actions are ‘controlled’

• Delegation

• Exemptions

  
  

In Ontario, Canada, medically controlled acts are under Section 27 of the RHPA, the Registered Health Professionals Act.

Who is and is not considered a registered health professional is outlined in this act.

It goes into specific fields of medicine but the short-version is that medical doctors and nurses are registered health professionals. An important distinction that will be relevant later, paramedics are not.

Wound packing is covered under Section 27 (2) 6. vii.

For a breakdown of the relevant parts of this section:

27 (2) A “controlled act” is any of the following done with respect to an individual

6. Putting an instrument, hand or finger,

vii. Into an artificial opening in the body. 

Delegation is the ability for a medical professional to ‘delegate’ or effectively ‘allow’ a non-medical professional to perform a medically controlled act.

For the context on this, the entirety of Section 27 (1) will illustrate:

27 (1) No person shall perform a controlled act set out in subsection (2) in the course of providing health care services to an individual unless,

(a) the person is a member authorized by a health profession Act to perform the controlled act; or

(b) the performance of the controlled act has been delegated to the person by a member described in clause (a).

So normally, an individual can only do something on the controlled act list if they are a medical professional or are delegated by one.

But then there are any relevant exemptions that apply to the Stop the Bleed scenario where wound packing would be utilized.

Section 29 (1) appropriately titled Exemptions and its associated subclause (a) is the particularly relevant clause:

29 (1) An act by a person is not a contravention of subsection 27 (1) if it is done in the course of,

(a) rendering first aid or temporary assistance in an emergency;

In-effect, this means that for the wound packing portion of Stop the Bleed to be adopted, either the medical industry needs to facilitate the training directly and individually delegate this act or this function needs to be fulfilled by the first aid industry.

Now, a general understanding of the expectations and purpose of a first aid course.

First aid courses are standardized mass-certification programs. Distilling them down to their most basic core functions they:

Teach a psychomotor skill 🡪 Assess competency 🡪 Issue certification

There are also knowledge and awareness elements, for wound packing this would be the difference of either:

a) Awareness – Telling the student wound packing exists and recommending they seek training from a medical professional. As an example: This is how naloxone was first handled by telling students to seek education from a pharmacist. This has since changed.

b) Knowledge – Teaching the student how to identify when wound packing is necessary. This would be done to then instruct them to seek a qualified individual to assist. They would likely also be encouraged to obtain further training so they could be said qualified individual. As an example: this is largely how insulin for diabetics is handled, first aiders are not to administer insulin but they are trained on how to identify that a casualty may need it (diabetic shock).

c) Skills – Formal Training in wound packing. As an example: how auto-injectors are currently trained for anaphylaxis.

These examples will be relevant again later.

At its core, first aid also has an underlying assumption. Anything the student is taught to do, they expect they are allowed to do within the context of ‘providing first aid’ unless explicitly instructed otherwise.

There is essentially no point in training a student in a skill within a first aid course unless the instructor is going to certify they are sufficiently competent in performing said act.

Here is another way to think about this in a question: If the entire purpose of the course is to train laypersons to perform the procedure on real patients, how is that materially different from training people to carry out a controlled act?

The Challenge (The Grey Area)

Ontario does not make a distinction between controlled acts. There is no further qualification around degrees of invasiveness, or really anything. It simply comes down to is the act “Controlled” or not and is it “First Aid” or not.

There is no list of controlled acts that qualify as “First Aid” and there is no guidance on exemptions. Medical institutions are historically fairly restrictive with invasive procedures in civilian first aid.

In Ontario there is effectively no legal distinction between:

Wound packing – Explained above.

Needle thoracostomy – Using a needle to decompress the chest cavity in a life-threatening tension pneumothorax.

Cricothyrotomy/Tracheotomy – Cutting the neck to create an emergency airway.

Field Amputations – Relevant for certain conditions like crush syndrome.

Direct Field Blood Transfusions – Donating blood directly from a live individual into another individual.

Administration of Insulin – Giving a casualty a medication that does not have an existing exemption.

Who is allowed to train in these techniques is also a grey area.

While many paramedics do wound packing regularly, they are not registered health professionals. Paramedics have to ask their supervising physician and/or base hospital if they are allowed to teach wound packing, often on a case-by-case basis.

The same applies to police, firefighters, and any other profession where they may be personally trained in wound packing, authorized to perform it, but are in a legal grey area where they are likely not allowed to teach it.

It is not as if all controlled acts are the same, precedents do exist for certain exemptions.

With inhalers for asthma and auto injectors for anaphylaxis, first-aid instructors used to tell students to “put their hand over the casualty’s hand and then press down on the medication” and only if the casualty was conscious so that the casualty was administering their own medication.

If that sounds asinine, yes, virtually everyone agrees. Inhalers now have a specific exemption under Good Samaritan legislation.

Auto-injectors are still in a similar grey-area to wound packing but some specific mention of them in Sabrina’s law and other Health and Safety legislation has separated them a bit.

They still do not have an explicit legal exemption like inhalers however, they remain in a first-aid grey area.

Some instructors are still hesitant to tell students to administer auto-injectors on casualties, opting to encourage the casualty do it themselves because the law has not caught up. This becomes complicated when the casualty is quadriplegic or is unconscious.

Naloxone has exemptions or at minimum clarifications provided both in the Ontario College of Social Workers and Social Service Workers, where it is stated that:

“The revisions to the Appendix on the administration of Naloxone clarifies that College registrants with the appropriate training can administer Naloxone without a formal delegation process.”

and Ontario government resources provided on “Naloxone in the workplace” where it is explicitly stated that: 

“Protection from liability available under the Good Samaritan Act, 2001 would generally apply to a worker who voluntarily administers naloxone at the workplace in an emergency in response to an opioid overdose.”

Solutions

The path forward on wound packing depends on what the government and the medical industry decide is appropriate for this particular controlled act.

Here are a few different solutions:

1. Explicitly broaden the delegation scope for this and/or explicitly clarify teaching eligibility.

Paramedics and police are often regularly trained in and delegated to do wound packing already. First-aid infrastructure already exists. If the intent is for some or all of these people to be able to teach this skill then why not make it explicitly allowed.

2. Give clear guidance on the limits of the awareness piece in first aid.

First Aid courses are starting to include or infer a reference to wound packing already, but they do not generally go into details on medical delegation. If the medical industry wants people to seek outside training on this like with the initial rollout of Naloxone then just include it as an awareness piece in first aid standards.

Awareness content can take around 30 seconds to teach, if instructors are given guidelines on how the medical industry wants this handled then they will follow them, the lack of guidelines on wound packing in particular creates undue confusion.

3. Full exemption: explicitly exempt wound packing as a controlled act that is explicitly acceptable in a first-aid emergency. Potentially, even explicitly add it to the list of teachable skills of licenced first-aid instructors. It could be an additional module for specific workplaces like a few others already are.

If the medical industry was amenable, they could go even further and just incorporate it into basic wound care as part of the severe bleeding portion, but given invasiveness this might be a bit far.

Importantly, this separates it from other procedures like needle thoracostomies.

Conclusion

In summary, the issue is this:

• Wound packing is a medically controlled act.

• Laypeople can’t do medically controlled acts unless delegated to.

• All medically controlled acts delegations are exempted in a first aid emergency.

• What medically controlled act is and is not considered first aid is not explicitly defined.

• This vacuum creates a sort of ‘all of it is okay or none of it is okay’ question.

Personal Opinion:

1. There is a significant push towards wound packing skills being taught to the public. 

2. A plethora of non-medical professionals currently exist that have expertise in these skills.

3. It is near unanimously agreed that it is in the public interest to make this skillset more widespread.

At a minimum it would be preferred to have explicit clarity on this. It is not obvious how wound packing is distinct from other invasive procedures like direct field blood transfusions that the medical industry clearly does not want non-medical professionals training people in.

Vezina is the CEO of Prepared Canada Corp. and is the author of Continuity 101. He can be reached at info@prepared.ca.