Is there a limit on the civilian scope of practice?
The expectation of civilians to respond to emergencies has expanded from care of close friends and family to caring for bystanders and stopping attackers
A single shooter killed 26 people and injured 19 at a church in Sutherland Springs, Texas Sunday morning. The killer exchanged gunfire with a bystander before being pursued by two bystanders. The high-speed pursuit ended when the killer lost control of his vehicle. The bystanders kept aim on the killer's vehicle until police arrived.
Their actions are commendable and heroic. They risked their lives to track the fleeing suspect and kept watch until law enforcement arrived. I am expecting we will learn of equally heroic first aid efforts inside the church as parishioners cared for shooting victims and other community members rushed to assist the wounded.
It's easy for me to have wide ranging, speculative thoughts about the men who have perpetrated recent mass killings – New York City bike path, a Las Vegas concert or a small-town Texas church. But the motives and intents of these mass killers don't change an emerging and clarifying trend in emergency response. In addition to caring for friends and family, we increasingly expect civilians to deliver lifesaving care for strangers and confront, pursue or monitor criminals.
Is there a civilian scope of practice for emergency care and response? And is that scope of practice changing?
Relief of a foreign-body airway obstruction with the Heimlich maneuver was one of the earliest first aid education efforts for the masses. The technique can be used in any setting, but the anecdotal and news reports I have heard most frequently involve a family member relieving an obstruction for someone they know.
Bystander CPR and AED use
Layperson CPR instruction was long aimed at the provision of CPR in the home until researchers recognized that out-of-hospital cardiac arrest was more common in public spaces. Bystander CPR is a noble and worthwhile endeavor that engages civilians in the tradition of the good Samaritan. Emergency responders have increasingly called on civilians to provide care through dispatcher-assisted CPR.
Smartphone apps and voice-activated devices now put CPR instructions and location of the nearest AED within reach of every American. The PulsePoint app pushes a cardiac arrest notification to nearby civilians who have opted into the program.
Severe bleeding control
Layperson control of severe bleeding is a logical outgrowth from the success of dispatcher-assisted CPR, ubiquitous AED deployment and just-in-time instructions from a dispatcher or a device. The "Stop the Bleed" public education campaign leverages the military research on tourniquet efficacy and the FBI research on mass killing events.
We've decided that because severe bleeding control is lifesaving, it has to begin before emergency responders arrive. The civilian scope of practice is widened to include this class of emergencies. Civilians are encouraged through public service announcements, expert advice and mass media to keep a tourniquet in their glove box. Marketing to parents, emergency responders and the general public advises that schools, churches and movie theaters should have a box, bag or tourniquet of bleeding control supplies.
Civilian's expanding scope of care
Was it enough for civilians to know the Heimlich? Do we also need them be able to use an AED and compress a patient's chest? Those asks, expansions of the scope of practice, don't seem unreasonable.
We are also asking baristas, librarians, cooks and Uber drivers to know how to recognize an opioid overdose and administer naloxone. The annual death toll from the opioid epidemic has exceeded all other causes of accidental, unintentional death for several years. So the knowledge and skill to deliver naloxone ought to be as common as the ability to give the Heimlich maneuver. Right?
The evolving two-part approach to active shooter response is to stop the killing and stop the dying. Jim Morrissey, a tactical paramedic and terrorism response coordinator wrote, "The primary mission for law enforcement is to stop the killing. Once that occurs, the mission for everyone, including law enforcement is to stop the dying."
Fight or attack
Personally, I am perplexed about how far we want the civilian scope of practice to expand. I like the idea that we all know how to "stop the dying." I'd encourage anyone to complete first aid training, know where to access supplies and consider keeping some supplies on hand.
Their decision likely saved lives, but it was not without risk and the public official praise is worth discussion among emergency responders. I am pondering the broader and long-term implications to emergency response and public safety as we increase our expectations of or expand the scope of practice for civilians.
Should "stop the killing" be the newest addition to the civilians' scope of practice?