Stopping the bleed in Texas: The importance of surgeons and health care professionals as advocates

The most common cause of preventable death following traumatic injury is uncontrolled bleeding. The American College of Surgeons (ACS) Stop the Bleed^® (STB) course is designed to teach the nonmedical lay public the essentials of bleeding control. The course uses a simple ABC approach that anyone can apply. The goal of the Stop the Bleed program is to turn bystanders into immediate first responders. This article summarizes the history and goals of the program, and it explains how the North and South Texas Chapters of the ACS worked together to get legislation passed to ensure that Texas middle school and high school students and teachers would have access to lifesaving bleeding control kits.

The beginnings

Following the tragic mass shooting at Sandy Hook Elementary School, Newtown, CT, December 14, 2012, Lenworth M. Jacobs, Jr., MD, MPH, FACS, shepherded a small group of multidisciplinary professionals to meet to find a solution to this public health problem. This group was drawn from multiple federal agencies and civilian organizations. They came together with the goal of developing effective strategies to save lives following mass casualty events. The work of this group became known as the Hartford Consensus. The first meeting of the Hartford Consensus team took place April 2, 2013, and the group continued to meet through 2016. In 2016, the ACS Committee on Trauma and the National Association of Emergency Medical Technicians (NAEMT) developed and piloted a bleeding control course based on the lessons learned from the U.S. military on the battlefield. Following these initial first steps, Stop the Bleed training has become an international movement, and although born as a response to a horrific school shooting, we know the principles of immediate bleeding control are most often applicable to injuries and wounds that occur every day in communities around the globe.

The core premise of the Stop the Bleed initiative is that public education and access to some basic equipment will enable individuals and teams of laypeople to act in the event of any traumatic occurrence that produces uncontrolled bleeding. Since its formal launch as an ACS course in 2017, more than 1 million people in more than 100 countries have learned the fundamentals of bleeding control. The number of people trained to provide this lifesaving care is growing exponentially.

Stop the Bleed education and training has been shown to be effective in teaching the public reliable and simple techniques to control bleeding before emergency medical services (EMS) professionals have time to arrive on the scene. For seriously bleeding patients, this intervention is the difference between life and death. STB education increases the lay public’s resilience and confidence, and enhances their interest in improving their local EMS and trauma system. The ACS Stop the Bleed course saves lives and empowers partnerships between health care professionals and their communities. This course also is valuable for surgeons, physicians, nurses, and paramedics, as it provides a forum for a meaningful dialog with their neighbors, communities, other health care professionals, and policymakers.

Chapters work to bring the program to Texas

From the beginning of the Stop the Bleed program, surgeons in Texas recognized the importance of bringing it to the state. The North and South Texas Chapters of the ACS made it an advocacy priority to enact the ACS model legislation for Stop the Bleed training and bleeding control kits in public schools in Texas. In 2016, at the Texas Chapter Lobby Day, supported by a grant from the ACS, a group of Texas surgeons prioritized our legislative agenda for the upcoming 2017 legislative session (the Texas legislature meets every other year for 140 days). Although other issues important to surgeons and their patients, such as scope of practice and Maintenance of Certification (MOC) legislation, remained high priorities, none united the group as much as a desire to require education about bleeding control in the schools in our state. During the 2017 session, we brought Stop the Bleed kits to our legislators, mentioning the need for the program, but placing emphasis on lobbying for more difficult topics. Compared with many of our legislative asks, the Stop the Bleed program was an easy sell. Teaching the proper use of tourniquets and hemostatic gauze was a lot more compelling than complaining about the inadequate compensation health care professionals receive from state insurance programs.

At the 2018 Texas ACS Lobby Day last fall, we determined that emphasizing Stop the Bleed legislation would be one of the chapters’ foremost priorities in the upcoming 2019 Texas legislative session. The Texas Regional Advisory Councils, which had actively promulgated STB courses in their regions, also recognized that Stop the Bleed training was a critical and necessary skill for the lay public. These grassroots efforts merged into a concerted effort to support STB education, training, and equipment for Texas schools.

With a defined agenda, the teams went to work. The teams were grateful for the vision and leadership of Rep. Barbara Gervin-Hawkins (D-Bexar County) who filed a Stop the Bleed bill, H.B. 496, December 10, 2018, prior to the opening of the legislative session. Representative Gervin-Hawkins and her staff worked with Jordan Ghawi, MPA, LP (co-author of this article), from the Southwest Texas Regional Advisory Council (STRAC) to draft additional language in the bill. In consultation with Ricardo D. Martinez, MD, FACS (co-author of this article), companion bill S.B. 2087 was filed by Sen. Juan “Chuy” Hinojosa (D-20) in the Senate. After 79 actions, nine votes, seven amendments, and multiple testimonies, H.B. 496 worked its way through both chambers and Gov. Greg Abbott (R) signed it into law June 15, 2019.

H.B. 496 requires all Texas public and charter school personnel to participate in Stop the Bleed training and to offer training to students in grades seven and higher, and mandates that schools install bleeding control kits. How was this achieved? Through advocacy supported by the ACS, with the help of Christopher L. Johnson, State Affairs Associate, ACS Division of Advocacy & Health Policy, the North and South Texas Chapters of the ACS and STRAC, led by the co-authors of this article, came together to rally in support of the bill as it passed through the complex and challenging process of becoming a law. ACS Fellows testified in support of the respective bills in committee hearings in both chambers. Robert O. Carpenter, MD, and Mr. Ghawi waited for eight hours to provide testimony before the House Public Education Committee on April 16, and Elizabeth Scherer, MD, MPH, FACS, testified in the Senate Education Committee on May 16, both in support of H.B. 496. J. Patrick Walker, MD, FACS, testified in support of S.B. 2087 in the Senate Education Committee on April 30.

Dr. Carpenter said, “I’ve had an interest in political advocacy for years. Attending the 2018 ACS Leadership & Advocacy Summit in Washington, DC, provided me with basic political tools, as well as the confidence to know that I could, in fact, make a difference, so I sought out opportunities to get more involved here at home. A day spent with my colleagues from around Texas pressing our agenda allowed me to see how much work was needed if nonproviders were going to understand the importance of acting on these issues. As the new Advocacy Chair for the South Texas Chapter of the ACS, I knew that H.B. 496 was of paramount interest to me as an educator, a surgeon, and as the father of two school-aged boys. When the call came out for members willing to testify before the House Public Education Committee, I jumped at the chance, canceled clinic, shifted my patients, and made the drive to Austin. The wait for our opportunity to testify was more than worth it. I truly believe we helped change the trajectory of this piece of legislation by directly addressing misconceptions the committee had about the bill’s intent and details of the training, as well as the required contents of the kits. The ACS made a difference for the children and teachers of Texas. I am so lucky to have been a part of it. In fact, I have started working with local private schools in central Texas to develop their own Stop the Bleed policies in line with this new public school standard.”

In moving testimony, Mr. Ghawi, a former firefighter/paramedic and present director of strategic initiatives for the STRAC–Trauma, urged Texas lawmakers to pass this bill, sharing that his 24-year-old sister was killed in the 2012 Aurora Theater mass shooting in Colorado.

After the hearings, the Texas House of Representatives passed the legislation, and though the bill sponsor amended it with non-ACS supported additions, such as inclusions of chest seals and other equipment in the bleeding control kit, it became the vehicle for the final bill. The Senate passed an ACS-supported amended bill. The differing bills then were sent to a conference committee to work out the differences between the House and Senate versions. Both chambers approved the reconciled version of H.B. 496 Sunday, May 26, just two days before Sine Die—the official adjournment of the Texas Legislature. What a race it was to get the bill passed as the legislature was closing.

Tips for others

The final passage and enactment of the law to require Stop the Bleed training and bleeding control kits in schools was the culmination of a multiyear strategy of education, outreach, and grassroots advocacy by the ACS Texas chapters. As noted previously, this effort began when the North and South Texas Chapters of the ACS met with Texas legislators during their Chapter Lobby Day in 2017, providing Stop the Bleed demonstrations in the Capitol Office Building and delivering bleeding control kits to targeted legislative offices.

The chapters took the next step to advance a bill by hosting a Lunch and Learn on Stop the Bleed training for state legislative staff in September 2018, as part of that year’s Lobby Day program. In Texas, it is common practice for advocacy groups to host Lunch and Learn events for legislative staff to educate them on public policy issues and planned legislation for the coming session. From that event, Senator Hinojosa, whose staff person attended the event, agreed to sponsor the ACS model Stop the Bleed bill, introduced as S.B. 2087.

It is vitally important that surgeons be involved with legislative efforts. Passage of this law did not start with one visit to the legislator’s office; it began with multiple visits with legislators and legislative staff at home and in the capitol before the session even started, which fostered relationships that proved integral to gaining support for the bill. It also involved building partnerships with other like-minded health care groups involved in the Texas trauma and emergency health care system, who would form a broad-based collaborative of surgeons, physicians, paramedics, and nurses.

This strategy can be replicated across the states. It begins with engaging in the advocacy process and participating in activities. Introduce yourself to your elected representative, support fundraisers, write letters, visit the legislative staff, and become a trusted expert on health care issues. All of these activities pave the way for successful passage of a bill—often a bill that does not even exist on a topic that you might not know about at the time you are forging a relationship. It is important to know your representative before the session starts and to be committed to building partnerships and consensus with other aligned health care organizations and professionals.

The efforts that began three years ago with Stop the Bleed also enabled us to talk to our legislators about scope of practice issues (stopping chiropractors from infringing on the practice of orthopaedic surgeons, stopping physical therapists from diagnosing orthopaedic injuries, stopping optometrists from practicing periorbital surgery, and so on) and the anti-MOC legislation that would have prevented local hospital medical staffs from even considering if a physician participated in MOC when credentialing a surgeon for hospital privileges. All of these issues failed to gain enough traction to get through the legislature this past session, but we can now begin planning for the next legislative session in 2021, building upon our relationships and successes from the 2019 legislative session.

The last slide in the ACS Stop the Bleed Course PowerPoint reads, “The only thing more tragic than a death…is a death that could have been prevented.” This message resonates with us. We believe no one should bleed to death from extremity or junctional hemorrhage. We hope efforts such as the one described in this article serve to empower and encourage surgeons, emergency physicians, paramedics, and nurses across the nation to engage with their local state legislators and legislatures to make the goals of the Stop the Bleed movement a reality.

Acknowledgment

This state legislative advocacy initiative was supported by the national ACS office with funding from the ACS Chapter Lobby Day Grant Program and staff support from the ACS State Affairs team, particularly Mr. Johnson.