The Research Agenda for Stop the Bleed: Beyond Focused Empiricism in Prehospital Hemorrhage Control | Emergency Medicine | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Views 1,530
Citations 0
Invited Commentary
Emergency Medicine
July 6, 2020

The Research Agenda for Stop the Bleed: Beyond Focused Empiricism in Prehospital Hemorrhage Control

Author Affiliations
  • 1Department of Surgery, Indiana University, Indianapolis
  • 2Department of Surgery, Stanford University, Stanford, California
JAMA Netw Open. 2020;3(7):e209465. doi:10.1001/jamanetworkopen.2020.9465

We live in times when public health challenges have become a looming presence in daily life. Although infectious disease is currently foremost in public awareness, we are reminded that many other threats remain. In the United States, trauma continues to be the leading cause of mortality for people younger than 45 years. Mass casualty shooting events are one of the most visible manifestations of the toll of firearm violence. In JAMA Network Open, Goralnick et al1 present their comprehensive vision for research into the efficacy and effectiveness of prehospital hemorrhage control by civilian lay responders.

In response to the Sandy Hook Elementary School shooting of 2012, the American College of Surgeons convened the Hartford Consensus Conference, a meeting of experts from the medical, emergency medical services, fire and rescue, law enforcement, and military communities to improve survival of such events. It was noted at the time that these events were uncommon but horrific. Building on the success of Tactical Combat Casualty Care in the US military, principles of hemorrhage control were adopted for broad civilian application, resulting in the Bleeding Control Course. A concerted effort by this broad coalition has resulted in a claim of more than 1 million civilians trained worldwide in principles of hemorrhage control under the umbrella of “Stop the Bleed.”2

In a 2016 JAMA commentary, Berwick et al3 praised this innovation born of necessity: “That urgency was inconsistent with reliance on slow and costly clinical trials to inform improvements in trauma care practices.”3 Instead, the Military Health System “embrace[d] a culture of continuous performance improvement and a more agile approach to advancing combat casualty care.”3 The authors hold up military medicine as putting the learning health framework into practice even before the Institute of Medicine described it. The results speak for themselves, with only 9.3% of wounded service members dying of their injuries compared to 23% during the Vietnam war.

More recently however, it has been noted that there may not be a broad applicability of these skills. One recent study4 cited a 4.6% incidence of firearm injuries that would have benefitted from the application of a tourniquet. To counter this, others cite benefits to empowering bystanders.5 To address the knowledge gaps involved in the Stop the Bleed program, Goralnick and collaborators1 assembled a panel of experts representing surgery, military medicine, emergency medicine, and implementation experts. They explicitly attempted to look broadly, not only on the individual medical intervention, but also on its broader psychological and social implications.

Facing a future with multiple looming threats and clear economic constraints, it is more important than ever to evaluate the effectiveness of these large-scale health initiatives. By their broad, well-considered evaluation, Goralnick et al1 have shown a way forward in evaluating the implications of this prehospital intervention and creating a framework for a truly learning trauma care system.

Back to top
Article Information

Published: July 6, 2020. doi:10.1001/jamanetworkopen.2020.9465

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Lu SW et al. JAMA Network Open.

Corresponding Author: Stephen W. Lu, MD, Department of Surgery, Indiana University, 1604 N Capitol Ave, Suite B251, Indianapolis, IN 46202 (

Conflict of Interest Disclosures: None reported.

Goralnick  E, Ezeibe  C, Chaudhary  MA,  et al; Stop the Bleed National Research Agenda Consensus Conference Working Group.  Defining a research agenda for layperson prehospital hemorrhage control: a consensus statement.   JAMA Netw Open. 2020;3(7):e209393. doi:10.1001/jamanetworkopen.2020.9393Google Scholar
Stop the Bleed. Home Page. Accessed April 21, 2020.
Berwick  DM, Downey  AS, Cornett  EA.  A national trauma care system to achieve zero preventable deaths after injury: recommendations from a National Academies of Sciences, Engineering, and Medicine report.   JAMA. 2016;316(9):927-928. doi:10.1001/jama.2016.8524 PubMedGoogle ScholarCrossref
Hsu  Y-T, Chang  DC, Perez  NP,  et al.  Civilian firearm-related injuries: how often is a tourniquet beneficial?   Ann Surg. 2020;271(2):e12-e13. doi:10.1097/SLA.0000000000003622 PubMedGoogle ScholarCrossref
Ross  EM, Redman  TT, Mapp  JG,  et al.  Stop the Bleed: the effect of hemorrhage control education on laypersons’ willingness to respond during a traumatic medical emergency.   Prehosp Disaster Med. 2018;33(2):127-132. doi:10.1017/S1049023X18000055 PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words