Exclusives, Trauma

A Time to ACT — Antidote, CPR/AED, Tourniquet

Over time, threats to society have changed.1 In order to mitigate negative consequences and maximize opportunity, society must develop programs designed to adapt to change.

The first five minutes of a life-threatening emergency are critical. Citizens must be trained to act in these moments. Unfortunately, the percentage of citizens trained to provide first aid on an annual basis remains in the single digits.2

This article will explain the reasons behind the low percentages of citizens being trained and utilized to address critical emergencies in their community, as well as detail a revised first-aid program that was developed based on these findings and current leading threats to modern society. The ACT (i.e., Antidote, CPR/AED, Tourniquet) program provides an evidence-based approach that effectively and efficiently empowers a greater portion of the public to save a life.

In an effort to improve cardiac resuscitation results and address multiple other emergency response needs, South County Fire Deputy Chief Shaughn Maxwell, EMT-P, and Medical Director Rich Campbell, MD, along with assistance from department staff, researched currently available citizen emergency response programs on the effectiveness of the programs and derivations that have been proven effective. Maxwell and Campbell subsequently authored a new program and curriculum to address he needs of both their agency and their community of South Snohomish County, Washington.

The ACT program consists of a one-hour hands-on course that teaches three vital first-aid skills:

  • Antidote for suspected opiate overdose with hands-on naloxone delivery via training aid and naloxone simulator;
  • CPR/AED delivery with hands-on training; and
  • Tourniquet application and wound packing to stop bleeding.

The ACT program is based on evidence-based research, supported by over 30 academic references. The program is:

  • An educational outreach program focused on lifesaving interventions;
  • Focused on interventions for conditions that cause death within minutes;
  • Taught in a brief (60-minute) time period, with minimal equipment; and
  • Designed for rapid deployment and scaling; it has a train-the-trainer component, allowing for greater reach and community penetration.

The overall goal of the ACT program is to change outreach training courses to practical application and empower every community member to “ACT” against three leading threats to society:

  • Improving administration of naloxone for suspected opioid overdose victims prior to the arrival of first responders;
  • Increasing bystander CPR: The department had always offered CPR classes to the public but found that training only 16 to 20 individuals in an eight-hour class to be insufficient to meet the need for mass training and response by community members to life-threatening emergencies. Bystander CPR before ACT program initiation was only 58% of Utstein criteria cases;  and
  • Stopping life-threating bleeding.

The department’s aggressive goal is to train 6,000 citizens in the first year and assist program participants in procuring ACT kits from EMS vendors. To date 4,000 citizens have been trained in schools and at community events.

ACT First-Aid: An Evidence-Based Proposal

The world is changing at an accelerating pace. It’s often stated that change is hard. However, failing to change can also be dangerous. Many people are deluged with a constant flow of information.

This constant volume makes it challenging to distinguish the important from the unimportant. Humans and organizations struggle to maintain currency and adapt to the many changes facing modern society. This rapid change is being driven by globalization and rapid dissemination of information.3

One area of change relates to emerging and evolving threats to society. Society must be prepared to act against current and developing threats. Citizens who are prepared to act will save lives. However, few citizens are trained to act on an annual basis.2 Threats to modern society can be mitigated through the reinvention of first-aid outreach; one that effectively and efficiently empowers the greatest number of people to save a life.

Prominent Threats & Unprepared Citizens

Three prominent life-threatening challenges to modern society include 1) cardiac arrest; 2) opiate overdose; and 3) uncontrolled hemorrhage. The increasing prevalence of these threats are related to cardiac disease, the opioid epidemic, and increased terror attacks. The sequela following these three situations has the potential to cause death in minutes; however, rapid, simple citizen intervention has been proven to be lifesaving.

According to The National Center for Health Statistics, drug poisoning is a leading cause of mortality in the United States.4 Historically, America viewed terror as an issue afflicting other parts of the world. However, following the attacks of September 11, 2001, views in regard to the threat of terrorism have shifted in America.5 Concurrently, active-shooter events are on the rise in the United States.6 Finally, sudden cardiac arrest is a leading cause of death in the United States.7

Currently, citizen first-aid and CPR courses are four to eight hours in length and include many important, however, non-lifesaving interventions. Training in these non-critical interventions consumes valuable time and energy during a first-aid course.

The time and complexity of these courses may represent a barrier to training. A very small portion of the general public attends a CPR course on an annual basis. Additionally, underrepresented and underserved populations receive CPR training at tragically low levels.2

 Time is a multifactorial issue in regard to this topic. Professional emergency responders rarely arrive in less than five minutes following an emergency.8 Time is also a barrier with respect to training a large percentage of the population. Citizens aren’t inclined to attend an eight hour first-aid or CPR course.

Courses should focus on the difference-makers in order to reduce the amount of time commitment required to obtain training.

Reinventing First Aid

Nearly every person in every area of the United States is susceptible to the direct or indirect impact of these threats. Today, every person in the community must be prepared to act. There must be a full-scale reinvention of first-aid and CPR training.

Re-crafting citizen training into an efficient model will leverage the ability for communities to train a higher percentage of the population. Citizen first-aid training must move from training courses to training communities.9

Increasing the overall uptake of citizen emergency medical training is only partially sufficient. It’s important for EMS systems to develop mechanisms that specifically reach the underrepresented and underserved portions of the population. The training must be condensed into an efficient and effective course that focuses on critical lifesaving interventions. These focused citizen interventions will preserve life until professional responders arrive.

As referenced earlier, the world is in a constant state of change and history has shown that change requires adaptation in order to assure survival. It should be our objective to create a community that’s adapted to modern threats.

Threat-adapted communities could be compared to non-threat-adapted communities. A community adapted to modern threats will enhance the safety of the community; and experience leveraged opportunities to save lives when tragedy strikes.9

The Birth of First Aid

Healthcare has also not been immune to these changes. Therefore, all areas of healthcare must study the changes that may influence the delivery of healthcare. Leaders must consider where systems require adaptation in order to optimize the delivery of care. One area of healthcare that may be minimized or forgotten is the care provided by citizens prior to them or their loved ones entering the healthcare system.

Over 100 years ago, this layperson intervention was called pre-medical treatment or first treatment. Today, the term to describe medical care provided by citizens and the military is called first aid.10

A higher portion of the public can be prepared to act against the threats to modern society by identifying the leading causes of time-sensitive preventable death, developing simplified and efficient layperson training and identifying barriers to effective outreach.

The article, “First-aid at the workplace-past, current and future,” identifies a need in healthcare and how innovative leaders should respond to this gap. It’s challenging to statistically measure morbidity and mortality rates on battlefields hundreds or thousands of years ago. Empirically, it’s known that people were dying on the battlefield and in the workplace. Early medical practitioners understood simple interventions could save lives.10

The article describes how over the course of time, methods were developed to reduce morbidity and mortality outside of the hospital. The first populations served were the military; followed by rail, mine and police workers. This article recommends that a higher ratio of workers should be trained in first aid.10

Changing Causes of Death

The leading causes of death have shifted over the last century. Over one hundred years ago infectious and parasitic diseases were a leading cause of death.1 In 2015, heart disease is now the overall leading cause of death.11

These quantitative studies of the population demonstrate that the leading causes of morbidity and mortality can change over time. Healthcare leaders should maintain a high level of situational awareness in consideration of these changes.11 In modern society there are three leading and evolving threats to life. In some circumstances, simple and rapid intervention can prevent death.

Heart disease: The 2015 National Center for Health Statistics (NCHS) report indicates, out of 2,712,630 deaths in the U.S., heart disease accounted for 633,842 of these lost lives.11 Understanding that cardiac disease is a leading cause of death should guide the focus of public prevention and intervention outreach efforts.

Opioid overdose: The opioid epidemic that’s plaguing the U.S. remains a topic of intense research. The specific breakdown of which opiates are predominantly responsible for the lethal overdoses remains elusive. Opioids—mainly synthetic opioids other than methadone—are currently the main driver of drug overdose deaths. The CDC reports that 70,237 drug overdose deaths occurred in the United States in 2017. The age-adjusted rate of overdose deaths increased significantly by 9.6% from 2016 (19.8 per 100,000) to 2017 (21.7 per 100,000).

Long-term solutions will require additional research, surveillance and understanding. Irrespective of the type, opioid overdose is a leading cause of death.12 It’s extremely important that, until a long-term solution is established; simple life-saving measures should be taught to all citizens.

Active shooter events/scenes of violence: Active shooter events, also called scenes of violence, have been increasing in frequency and lethality since the 1960s in the U.S. A study of ideological active shooter events identified 324 events from 1960 to 2012. Shooters motivated by ideological reasons represented over 70% of shooters. Ideologically motivated attacks were associated with higher levels of sophistication and lethality.13

Although motivations behind the active shooter events are being identified, incidents continue to increase. Until effective prevention efforts are identified and validated, society must implement measures that are proven to reduce loss of life.

And, until society can prevent these attacks, all citizens should be trained to reduce morbidity and mortality during or immediately following an event.13

Underprepared Citizens & Simple Interventions

In the U.S., nearly a thousand people a day experience sudden out of hospital cardiac arrest (OHCA). The immediate treatment for cardiac arrest is CPR. Comprehensive CPR training programs have been taught to the public since the 1970s. However, overall survival rates remain largely unchanged over the past three decades.2

CPR training rates are tragically low among citizens in the U.S. The overall median rate of citizens trained annually in CPR is less than 3%. One survey revealed that most respondents hadn’t received CPR training in over 10 years. Importantly, communities with high levels of poverty or minority populations displayed extremely low levels of citizen CPR training.2

Counties with larger minority populations were inversely proportional to the percentage of people trained in CPR. The odds ratio of a county having low levels of training increased over 1.06 for every five point percentage increase in the minority population, specifically blacks and Hispanics.

The study, Cardiopulmonary Resuscitation Training Rates in the United States, clearly identifies a population that’s unprepared to respond to one of the leading causes of death. Importantly, the study highlights that minority and low-income individuals are least likely to receive CPR training or treatment in the event of OHCA. Current training models are proving inadequate in respect to preparing all citizens to act.2

Simplified CPR Training

The Heart and Stroke Foundation of Canada argues that obtaining basic first-aid and CPR training should be a fundamental duty of every citizen. It’s challenging to quantify the benefits of citizen first aid; however, CPR is known to enhance cardiac arrest survival. The serious challenge is in relation to how to train a high percentage of the population. In the Canadian Medical Association Journal, experts posit that training may be excessively long and complex.14

Current training programs are excellent, but they may be a barrier to training a large number of citizens. Citizen training should be as simple and brief as possible; as long as effectiveness and quality are not compromised. The most important goal is to train as many citizens as possible. Brief, focused citizen training will leverage the goal of reaching a higher number of citizens.14

The four-hour traditional CPR course has been identified as a barrier against training large portions of the population. A controlled randomized study evaluated two CPR training delivery models. Researchers randomly assigned 285 adults to undergo either the classical or abbreviated CPR training.15

Participants were evaluated immediately after training and two months post-training for retention of key CPR skills. These components included calling 9-1-1, checking for responsiveness, performing ventilations and compressions. The results revealed equivocal skill retention at two months when comparing the participants who received 30 minutes of training vs. four hours of training.15

Training in CPR, a known lifesaving intervention, should be brief and effective in order to maximize outreach and save lives. Since this previously noted study was conducted, citizen CPR has been further simplified by streamlining the check for responsiveness and eliminating ventilations. This modified version of CPR is known as “compression-only CPR” and may allow for further reduction in the length of the course.

The effectiveness of compression-only CPR was demonstrated in a study conducted in Japan. The study reviewed 55,014 bystander-witnessed cardiac arrests. Among the cases reviewed, 22.1% received compression-only CPR and 19.7% received standard CPR. Patients who received compression-only or conventional CPR within 15 minutes of collapse exhibited similar survival rates. Conventional CPR did result in a more favorable neurological outcome when resuscitations were over 15 minutes.16

This study demonstrates the effectiveness of hands-only CPR and allows for the further abbreviation of the training as compared to the classical program. The study indicated compression-only CPR resulted in equivocal effectiveness concerning shorter duration resuscitations.16

In many regions of the U.S., first responders arrive in under 15 minutes. Healthcare providers in the U.S. are trained to include ventilations during CPR; this may serve as a mitigating factor in extended resuscitations.17

Bystander Opioid Overdose Training

Death from opioid overdose is a public health crisis. In Massachusetts, death from opioid overdose increased sixfold from 1990 to 2006.18 Death from an opioid overdose can occur within minutes to hours. However, an effective and safe antidote can quickly reverse an overdose and save a life.

In order to combat this epidemic, the Boston Public Health Commission developed a curriculum to train bystanders in overdose prevention and antidote administration. During a 15-minute course, non-medical providers taught bystanders how to identify and reverse opiate related overdoses. Over the course of 15 months, 374 people underwent training. During this same period 74 overdoses were successfully reversed. The program reported minimal complications. This study indicates that bystanders can be efficiently trained in opiate overdose recognition and reversal.18

Another study demonstrated that the layperson can be effectively trained to intervene in the setting of opioid overdose. The study was conducted to assess overdose and antidote administration knowledge among current and former opioid users. The study compared knowledge among opioid abusers who did or did not receive overdose recognition and response training.19

Opioid overdose recognition training varied among sites and locations. All programs were brief and included didactic and interactive components to the training. The results revealed that the non-medically trained individuals displayed comparable opioid overdose knowledge in comparison to the medical experts and indicates that lay people can be trained to respond to an opioid overdose following a brief training course.19

Bystander Hemorrhage Control Training

In consideration of the rising incidence of active shooter events, all citizens should be trained in hemorrhage control. Hemorrhage control techniques can be taught quickly and effectively to the untrained citizen.

Hemorrhage control courses are excellent; however, instructor requirements and the time required to attend the course may represent barriers.20 Hemorrhage control courses should be delivered via a model that’s both efficient and effective.

Delivering courses that require minimal time commitment will maximize the number of citizens who are trained in hemorrhage control techniques. The Uniformed Services University demonstrated that untrained citizens can be rapidly trained in the use of tourniquets for hemorrhage control. The study randomized 194 volunteer participants to either apply a tourniquet with or without just-in-time instructions.21

For this study, selected participants received just-in-time training in the form of an instruction card. The control group didn’t receive an instruction card. Both groups were briefed on a mass casualty scenario and provided with a tourniquet to apply. The group that received the instruction card applied the tourniquet correctly more than double the rate of the control group; 44.14% vs. 20.41%, respectively.21

The just-in-time training group took an average of two minutes to apply the tourniquet, 48 seconds longer than the control group. Finally, 84% of all participants indicated they’d be willing to apply a tourniquet in a real-life situation.

The entire evolution and survey took 15 minutes.21 This study demonstrates that hemorrhage control techniques can be rapidly acquired and enhanced using simple instructional methods.

Barriers to First-Aid Outreach & Intervention

In this fast-paced society, it’s challenging for people to see important signals through the noise. The internet, social media and mobile phones create a constant flow of information and distraction. Arguably, the world has shifted from not enough information, to an overabundance of information. There’s also a fear of missing out on information.22

This can make it challenging for government and other public advocacy groups to call the public’s attention to important issues. Additionally, in this highly connected world, some groups are missed or isolated. It’s the responsibility of government to assure all groups experience equal access to healthcare, including first-aid and CPR training.

CPR training rates are low in the U.S. and the reasons are poorly understood. Historically, end of course surveys has been one of the few ways to assess student perceptions of CPR courses. These surveys provide limited insight. Researchers have used Twitter as a novel way to better understand the perceptions and barriers to CPR training.23

Researchers evaluated 1,000 tweets. The results indicated that the majority of the tweets in regard to CPR training were negative 53% versus 47% positive. Specifically, the aspects of curriculum, time of day and duration of course received the highest levels of negative tweets.

Because CPR is a known lifesaving intervention; known barriers to CPR training should be mitigated in order to increase uptake. CPR and first-aid courses should be abbreviated and offered at optimal times and locations.23

Reaching the elderly: The senior population is at risk for cardiac arrest; however, the elderly aren’t as likely to receive CPR. People under age 35 who suffer cardiac arrest have been found to be nearly twice as likely to receive CPR as individuals over age 75.

Although greater age is associated with lower survival following cardiac arrest; seniors who are successfully resuscitated had equal or better quality of life compared to the general population.24

The elderly population is also less confident, less trained and less likely to perform CPR. Targeted elder CPR training represents an untapped opportunity to train a greater portion of the public. Elderly outreach should impress upon seniors that they are capable of CPR; and that it’s a worthwhile endeavor to perform.24

Transportation: Transportation has been identified in the literature as a barrier to adequate and ongoing healthcare. One systematic literature review revealed that millions of Americans couldn’t access adequate health care due to transportation issues. The barrier of transportation has the highest impact on special and vulnerable populations. Health access can impact health outcomes.25

A study that assessed rates of CPR training in the U.S. revealed special populations beyond the elderly also have very low uptake of CPR training.2

First-aid training is generally offered at centralized locations similar to other forms of healthcare delivery. It’s likely that transportation barriers represent an impediment to the healthcare with respect to first-aid and CPR training.

Health literacy: It’s well documented that health literacy is tied to health outcomes. Educating a larger portion of the population in regard to the conditions of cardiac arrest, overdose and severe hemorrhage is a health literacy issue. A greater understanding of these issues will likely improve health outcomes. Health literacy is the ability for a person to acquire, understand and take action as it relates to healthcare decisions.26

Health literacy disparities are greatly influenced by demographic and socioeconomic factors. In one study, which provided a breakdown of influencing factors with respect to health literacy scores, women scored five points higher than men.26

Income correlated health literacy scores as well: for every $1,000 increase in income, literacy scores increased a quarter point. African Americans, foreign- and native-born Hispanic and Latinos scored significantly lower compared to white respondents with respect to health literacy.26

The authors of the study recommend that health literacy can be improved by creating enhanced engagement within multiple social constructs. The recommended components include improving self-efficacy, personal empowerment and civic engagement. These components are directly supported when citizens are taught first aid and CPR.26

First Aid as a Pathway to Peace

There’s violence across the world that’s devolving healthcare infrastructure. This is leaving the most vulnerable populations without emergency care when tragedy occurs. The World Health Organization advocates for the scaling of brief first-aid courses to untrained laypeople. This will empower people to respond to emergencies when professional help is unavailable.27

One article highlights additional benefits that can be obtained when delivering brief first-aid courses. The authors brought together four tribes in Sudan. Over the course of three days, 50 members of different tribes were taught a brief course in first aid. The lifesaving benefits of first-aid training are intuitive; the authors describe a secondary benefit. In the right context, there’s a significant opportunity to bring people together using these courses to build community.27

The U.S. isn’t immune to this violence; there’s value in using brief first-aid courses to empower citizens and build peace in American communities.

Complex Adaptive Systems Theory

Thousands of years ago, the ancient Greek philosopher Heraclitus posited that no two things are alike and that change is constant.28 The world is in a state of constant, interconnected and often invisible change. According to Rosling, most people have an incorrect and outdated view of the current world.29

Through the application of complex adaptive systems theory, citizen first aid can be re-created, designed for change and updated over time. Healthcare organizations must view themselves as complex adaptive systems; therefore, programs deployed around healthcare must include complex adaptive systems theory. To assure maximum impact; citizen first-aid outreach programs should be re-invented to align with modern society.30

The complex adaptive system theory takes into consideration that outreach systems must be created for constant change and interconnectedness with other systems and theories.

 Historically, first-aid outreach has generally been designed as a standard course with standardized curriculums, content and guidelines. The contents are often updated to match the current science; however, the overall program hasn’t changed significantly over time.30

Experts believe that first-aid development and deployment will be enhanced by integrating complex adaptive system theory into the course. This will allow the courses to be designed for constant adaptation to meet the needs of a changing society. The course content and time requirements can and should be designed for change.

Threats, science and society are in a state of constant change. Using complex adaptive system theory, first aid can be designed for constant change. Using this theory, first-aid outreach will no longer be designed as a static course; first-aid courses will be dynamic, agile and expected to change over time.

Complex adaptive systems theory can be used to assure citizen first aid is created with change in mind, designed for change; and, it’s understood the program will change with time. Applying this theory will assure citizens are properly prepared to meet new challenges as society evolves. A society with programs designed for change will be enabled to adapt to change.

In addition, the leading causes of preventable death and threats are changing. Large portions of the public should be trained to act against the threats to modern society. This can be accomplished by identifying the leading causes of preventable death, developing simplified layperson training and identifying barriers to effective outreach. These efforts will improve the health and safety of both individuals and communities.

ACT: Citizen First-Aid for Modern Society

Society is in a constant state of change in the U.S. and around the world. The impact of societal changes can be positive, negative and interconnected. Society must develop agile programs to rapidly adapt to evolving threats to society.

When citizens call 9-1-1, the fire department strives to expeditiously respond to the emergency. The modern fire service is designed to respond within minutes. However, the fire department will rarely arrive at the scene in less than five minutes. During this gap in time, citizens can be empowered to make a difference in patient outcomes.

The current model of training citizen first aid is long and complex. The training program requires eight hours on a Saturday. This training is both excellent and comprehensive; however, the course includes many non-lifesaving interventions. Due to the length and location of these courses, they’re often viewed negatively.23 Under the current course model, an extremely small portion of the population receives training on an annual basis.2

First-aid training must evolve into a rapidly-deployable and adaptable program; designed to keep pace with societal change. A reinvented citizen first-aid program will focus on the key difference makers; this will reestablish the relevance of first aid in a rapidly changing world.28

This new approach to first aid training will only include training that is focused on lifesaving interventions; interventions that focus on conditions that are capable of causing death within minutes. They will be interventions that can be easily taught in a brief period of time with minimal equipment, and will empower a greater portion of the population to be prepared to act to save a life.

Adopted and implemented by South County Fire in Snohomish County, Washington, north of Seattle, the concept of an evolved, next-generation first-aid course was conceptualized as a solution to meet a constellation of challenges.

The new ACT citizen first-aid program is a brief low-barrier training program that focuses on the predominant threats to modern society; conditions where rapid citizen intervention can be lifesaving. These threats include overdose, cardiac arrest and severe hemorrhage. The goal of this new training is to be brief, simple, effective and supported by the literature.14 Each letter of “ACT” represents one of three key lifesaving interventions that will be taught in one hour. “A” stands for “antidote,” the 15-minute module will cover opioid overdose recognition and response. “C”stands for “CPR,” the 15-minute module that will cover cardiac arrest recognition and response. This module also includes automatic external defibrillator (AED) training. “T” stands for “tourniquet,” the 15-minute module that will cover severe hemorrhage control.31

The program is designed in a train-the-trainer model to involve citizens from the community, effect rapid scaling, and allow the program to reach a greater portion of the population in less time than with traditional, limited instructor programs. Each of the modules include an instructor-led practical evolution. The students will be taught to identify each of the conditions and effect countermeasures.32 The students will also be provided a checklist for use during the training and during actual events.

A Reason for Evidence-Based Change

The study referenced earlier provides insights in relation to the barriers of greater uptake of citizen first-aid. The ACT course specifically answers these challenges.

Time is a challenge and people surveyed had a negative impression with respect to the length of the class and time of day. However, the ACT course can be taught in one hour, and is designed to fit into a classroom period or workplace lunch break.

The traditional first-aid curriculum was also a noted negative component of the standard first-aid course. Although the study didn’t reveal specific reasons indicating why participants had a poor impression of the curriculum, in today’s society, it is likely citizens value courses that are concise and more sensitive to their time commitment.

 The goal of the ACT program is to train as many people as possible, in a shortened period of time and at times and locations more conducive to their busy schedules. It is theorized, based on other programs of this nature, that a course with a positive rating will likely attract more participants.23

The Canadian Medical Association has been advocating for a change to citizen first-aid; training that’s simplified and abbreviated in order to equip as many people as possible to save a life.14

Studies reveal that hemorrhage control and overdose interventions can be effectively taught to non-medically trained individuals in brief 15-minute courses.18,19,21

It has also been shown that CPR course length can be shortened as well and still produce equivocal skill retention as compared to a full length course.15

The World Health Organization has also identified first-aid courses as a possible peacebuilding activity. First-aid courses may be used to build relationships by bringing groups together; groups that normally do not spend time together. Community may develop when groups or individuals learn a new skill in a safe environment. This area of benefit may be measured through the methods of observation and surveys.27


Society will always be in a state of change. Programs that are designed to interact with society must, therefore, be designed for change. Programs that aren’t designed to change will eventually become obsolescent and ineffective.

First aid is fundamentally a mechanism for citizens and society to reduce morbidity and mortality. Citizen first-aid outreach is susceptible to both change and obsolescence. Society must maintain a constant state of situational awareness as it relates to changing threats.

Threats challenging modern society can be mitigated through the creation of agile outreach programs. Society can address these changing threats through the reinvention of first-aid outreach. Modern first-aid must be designed to effectively and efficiently empower the highest number of people to save lives.

An adaptable society is a prepared society; a community where everyone is prepared to save a life, a nation prepared to ACT.

South County Fire is working to build a resilient threat-adapted community. Today everyone must be trained to respond. We have realigned and refocused outreach to the challenges facing modern society. Three leading threats include the opioid epidemic, cardiac arrest and scenes of violence.

We designed a program that focuses on the difference makers and has substantially accelerated our ability to build a community prepared to ACT; prepared to save a life in those critical minutes before the first- responder arrival.

We have implemented an evidence-based course that trains citizens in one hour to ACT against threats that can cause death in minutes. Using three 15-minute modules, citizens are trained to intervene when faced with the leading threats to our communities. The ACT program can be taught via community workshops, during lunch breaks or within a classroom period.

The ACT program has reinvented the concept of citizen first-aid training. It’s brief, effective and evidence-based. It’s a simple solution for complex times.


1. Berk A, Paringer LC, Woolsey TD. Estimating deaths for the United States in 1900 by cause, age, and sex. Public Health Reports. 1978;93(5):479–482.

2. Anderson ML, Cox M, Al-Khatib SM. Cardiopulmonary resuscitation training rates in the United States. JAMA Internal Medicine. 2014;174(2):194–201.

3. Collyer S: Managing amidst rapid change. Project Management Institute: Newtown Square, Pa., 2015.

4. Alpert M, McCaig L, Uddin S. (April 09, 2015.) Emergency department visits for drug poisoning: United States, 2008–2011. National Center for Health Statistics. Retrieved May 24, 2018, from www.cdc.gov/nchs/data/databriefs/db196.htm.

5. DeValve MJ: Terrorism. In: Salem Press Encyclopedia. Salem Press: Hackensack, N.J., 2017.

6. Hunter Martaindale M, Sandel WL, Pete Blair J. Active-shooter events in the workplace: Findings and policy implications. Journal Of Business Continuity & Emergency Planning, 11(1), 6-20.

7. Jentzer JC, Clements CM, Murphy JG, et al. Recent developments in the management of patients resuscitated from cardiac arrest. J Bus Contin Emer Plan. 2017;11(1):6–20.

8. Bryan P, Pane P. Evaluating fire service delivery. Fire Engineering. 2008;161(4):207–210.

9. Maxwell SG: Designing for better health in the future. Grand Canyon University: Arizona, 2018.

10. Priolcar X. First-aid at workplace-past, current and future. Indian J Occup Environ Med. 2012;16(1):1–2.

11. National Center for Health Statistics. (May 3, 2017.) Deaths and mortality. Centers for Disease Control and Prevention. Retrieved Aug. 23, 2018, from www.cdc.gov/nchs/fastats/deaths.htm.

12. Seth P, Rudd RA, Noonan RK, at al. Quantifying the epidemic of prescription opioid overdose deaths. Am J Public Health. 2018;108(4):500–502.

13. Capellan JA. Lone wolf terrorist or deranged shooter? A study of ideological active shooter events in the United States, 1970–2014. Studies in Conflict & Terrorism. 2015;38(6):395–413.

14. Skura E. Pros and cons of first aid training? CMAJ. 2010;182(12):E549–E550.

15. Einspruch EL, Lynch B, Aufderheide TP, et al. Retention of CPR skills learned in a traditional AHA Heartsaver course versus 30-min video self-training: A controlled randomized study. Resuscitation. 2007;74(3):476–486.

16. Kitamura T, Iwami T, Kawamura T, et al. Time-dependent effectiveness of chest compression-only and conventional cardiopulmonary resuscitation for out-of-hospital cardiac arrest of cardiac origin. Resuscitation. 2011;82(1):3–9.

17. HeartCode BLS. (n.d.) American Heart Association. Retrieved Aug. 24, 2018, from https://cpr.heart.org/AHAECC/CPRAndECC/Training/HealthcareProfessional/BasicLifeSupportBLS/UCM_476242_HeartCode-BLS.jsp.

18. Doe-Simkins M, Walley AY, Epstein A, et al. Saved by the nose: Bystander-administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health. 2009;99(5):788–791.

19. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: An evaluation of six overdose training and naloxone distribution programs in the United States. Addiction. 2008;103(6):979–989.

20. Stop the Bleed. (Oct. 1, 2015.). Department of Homeland Security. Retrieved May 24, 2018, from https://www.dhs.gov/stopthebleed

21. Goolsby C, Branting A, Chen E, et al. Just-in-time to save lives: A pilot study of layperson tourniquet application. Acad Emerg Med. 2015;22(9):1113–1117.

22. MyLife.com. (January 2008). National survey reveals consumers are overwhelmed by social media. Business Wire. Retrieved May 17, 2019, from www.businesswire.com/news/home/20120801005524/en/National-Survey-Reveals-Consumers-Overwhelmed-Social-Media.

23 McGovern SK, Blewer AL, Murray A, et al. Characterizing barriers to CPR training attainment using Twitter. Resuscitation. 2018;127:164–167.

24. Brinkrolf P, Bohn A, Lukas RP, et al. Senior citizens as rescuers: Is reduced knowledge the reason for omitted lay-resuscitation-attempts? Results from a representative survey with 2004 interviews. PLoS One. 2017;12(6):e0178938.

25. Syed ST, Gerber BS, Sharp LK. Traveling towards disease: Transportation barriers to health care access. J Community Health. 2013;38(5):976–993.

26. Rikard RV, Thompson MS, McKinney J, et al. Examining health literacy disparities in the United States: A third look at the National Assessment of Adult Literacy (NAA7L). BMC Public Health. 2016;16:975.

27. Ratner KG, Katona LB. The peacebuilding potential of healthcare training programs. Confl Health. 2016;10(1):29.

28. Johnson W. Never the same river. ETC: A Review of General Semantics. 2004;61(3):381–390.

29. Galeener CA. Factfulness: Ten reasons we’re wrong about the world—and why things are better than you think. Texas Public Health Journal. 2018;70(3):6–7.

30. Chaffee MW, McNeill MM. A model of nursing as a complex adaptive system. Nurs Outlook. 2007;55(5):232–241.

31. Maxwell SG. (May 21, 2018.). A.C.T. First Aid & Antidote – CPR/AED – Tourniquet ~ Accelerated Citizen Training [conference presentation]. Washington Fire Chiefs Annual Conference: Kennewick, Washington, 2018.