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In the past year, gun violence in America has become widely recognized as a . According to the , there were a record 690 mass shootings (defined as an incident in which four or more individuals sustain a firearm injury) in the U.S. in 2021 -- double the incidence from 2018. This year, the U.S. has had separate mass shootings to date. In a of acute care hospital shootings between 2012 and 2016, one study found that 88 shootings occurred in 86 hospitals, resulting in 121 firearm-related casualties. Gun violence is our new reality.

As the incidence of gun violence in our nation rises, American healthcare workers have become increasingly likely to witness a shooting event, including in our own workplaces. We need to be better prepared for these types of situations.

At The Permanente Medical Group in Northern California, for example, we provide active shooter training for our 10,000 physicians and 40,000 staff -- helping healthcare workers learn what to expect during an active shooter event and how they can protect themselves by following the principles of "run, hide, fight." As part of this active shooter preparedness, we are also scaling up voluntary training for care outside the walls of the hospital. This covers when and how healthcare workers can safely render hemorrhage control until the scene is secured and transport to definitive care can occur.

The notion that bystanders can save lives through control of traumatic hemorrhage is a concept that has slowly taken hold over the past decade. This idea is predicated on the development of "immediate responders," and it's a straightforward concept. Among trauma patients, hemorrhage is the most common cause of . In , patients who underwent tourniquet placement in the field had a mortality rate 4.5x lower (3% versus 14%) than patients who didn't receive that treatment until arriving at a trauma medical center. Hemorrhage control in the form of direct pressure, wound packing, or tourniquet placement can mean the difference between life and death for an individual with a gunshot wound and life-threatening hemorrhage.

Without rapid treatment, major arterial hemorrhage in an extremity can lead to exsanguination and death in . Given the average national EMS response time of approximately , why not offer training so bystanders -- including healthcare workers and the general public -- can help victims with on-the-ground hemorrhage control until paramedics arrive? Could mortality in the field be improved by borrowing from the same concept that underlies layperson training in CPR and automatic defibrillators?

These were a surgeon's questions after the 2012 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut. The same surgeon convened a panel of national experts to evaluate the response to such events -- and the group emerged with that became the backbone of the .

The program's premise is to train as many people as possible in the principles of stepwise traumatic hemorrhage control to create a corps of immediate responders. Since its debut, STOP THE BLEED has been widely endorsed by many medical and federal agencies, including the American College of Surgeons, the American College of Emergency Physicians, the Federal Emergency Management Agency, the FBI, and the Department of Defense.

As healthcare workers and as members of our communities, it's time for us to become trained in traumatic hemorrhage control. Whether a shooting occurs at the grocery store or in a medical facility, we should understand how to serve as immediate responders. This requires training. Like the lay public, it's important that healthcare workers receive accurate, evidence-based training on how to safely intervene in life-threatening hemorrhage. Fortunately, multiple courses in hemorrhage control have been developed: they are mostly free and widely accessible (The STOP THE BLEED website contains a ).

The training is designed for individuals with a wide range of medical backgrounds, and is appropriate for those with extensive prior training in hemorrhage control and those with little to none. During a training session, participants engage in a didactic course about the management of traumatic hemorrhage, followed by skills stations where they learn how to control hemorrhage via direct pressure, packing a wound, or application of a tourniquet.

By the end of the course, participants understand how to identify life-threatening hemorrhage and how to use stepwise interventions to control that hemorrhage. A hemorrhage control course also addresses important factors such as maintaining personal safety, notifying 911, and infection prevention measures. Afterward, participants may purchase vetted hemorrhage control kits and tourniquets if they wish to do so. Healthcare workers can become trainers themselves upon completing a hemorrhage control training session.

The past few years have presented many public health challenges for American communities that have, in turn, demanded the development of new strategies to address them. The troubling rise of gun violence calls for enhanced active shooter education and preparedness on the part of American healthcare workers. The reality is that knowledge and training in traumatic hemorrhage control have become every bit as necessary as understanding CPR or how to operate an automatic defibrillator.

As a physician, a director of emergency preparedness, and a member of my community, I encourage healthcare organizations and workers to make hemorrhage control training a top priority.

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