As the deep red liquid pooled on the ground from a small bullet hole in the victim's leg, Bryan Wilson measured three fingers of space above the wound and tightened a tourniquet until the bleeding stopped.
It was swift, easy and designed to be lifesaving. Hemorrhage is the leading cause of death among trauma sufferers.
"It's like the Heimlich and CPR; you hope you never need it," said Wilson, a production technician at Operative Experience in North East, which makes high-tech, life-like simulation dummies that breathe and bleed and teach people the basics of keeping victims alive.
These mannequins are mostly used by the military and other government agencies, but the small Maryland company near the Delaware border is getting more attention lately from police forces, hospitals and others that are increasingly training their own staffs and the public how to apply pressure, pack wounds and use a tourniquet.
The "Stop the Bleed" movement arose after the 2012 mass shooting at Sandy Hook Elementary School in Connecticut but gained steam with more recent mass casualty events in Las Vegas and Parkland, Fla. Organizers say bystanders need to know how to stop bleeding from gunshot wounds and other injuries because they are on the scene already. Emergency services could be minutes away, enough time for the most grievously wounded victims to bleed to death.
The campaign was established by a group of trauma surgeons, law enforcement, military and others who recognized that more victims might survive if more people were trained as "initial responders."
Dr. Lenworth Jacobs, director of trauma and emergency medicine at Hartford Hospital in Connecticut, was among them.
"We were put on alert during Sandy Hook and then we came off alert, and we assumed it was because it was a false alarm," Jacobs said. "It turned out that it was because everyone was dead, and they were 6 years olds. That was a profound experience."
Jacobs helped spearhead the effort called the Hartford Consensus, part of the American College of Surgeons, that decided to train bystanders and encourage placement of kits including gauze and tourniquets in schools, offices, shopping malls and people's homes and cars.
The movement gained attention from then-President Barrack Obama, who championed the Stop the Bleed campaign. Jacobs said at least 150,000 people and hundreds of thousands of law enforcement officers have been trained so far, which he called "a good start." Maryland Gov. Larry Hogan got a demonstration in Annapolis in March during a Stop the Bleed event.
Each of Baltimore's four trauma hospitals either offers public training in bleeding control basics or plans to, with opportunities listed as they're available on the Maryland Committee on Trauma website.
Sinai Hospital in North Baltimore plans to begin training soon for employees and the public using lower-tech simulators than those supplied by Operative Experience.
Lauren Smith, the hospital's trauma program coordinator, said much of the effort is awareness. Bystanders may not feel like they should touch someone who is injured or they fear they will hurt them or damage them further. A tourniquet will hurt, she said, but it could keep trauma victims alive, like CPR or a shock from a portable defibrillator would do for a heart attack victims or the Heimlich maneuver could for someone choking.
"This would save lives," Smith said. "The No. 1 reason people have bad outcomes, they die, from traumatic injuries is bleeding, especially in the first hour."
She said training takes about 45 minutes to an hour depending on how much practice is offered. Most people understand pressure stops bleeding, but training makes people more comfortable.
Tourniquets are necessary when bleeding won't stop with pressure or packing, and they require the most instruction. They must be tight enough around a limb to compress the major artery. She said even doctors and nurses she trains don't always twist the tourniquet tight enough.
They also should be marked with the time they were applied for emergency responders. Limbs generally can survive about two hours with a tourniquet.
"We can take it from there," Smith said about the professionals who transport patients to a hospital and emergency staff that can transfuse blood and quickly patch severed vessels in the operating room.
At the University of Maryland Shock Trauma, which offers community classes twice a month, trainers have instructed 1,500 people so far. They include high school students, health care workers, Boy Scouts, police officers, members of the military and others. Many became interested since the shooting in Florida, though people are much more likely to need the training after household and workplace accidents, said Dr. Jason Pasley, director of the Stop the Bleed efforts at Shock Trauma.
Trainers at Shock Trauma use Operative Experience's high-tech models when they train members of the military in combat casualty care instruction. They generally use lower-tech models to give the public the basics of bleeding control because of the extra time and cost associated with high-tech simulators, but plan to incorporate them more, Pasley said.
"The training isn't hard," Pasley said. "I like to say 'if you cut yourself on your face or leg shaving, what do you do? You put pressure on it.' This is the same thing with larger wounds and holding pressure. We do also teach wound packing and tourniquet placement, but the basics of holding pressure is something anyone can learn and apply at any time without any special equipment."
The biggest hurdle for most people is "the freak out factor" at seeing a lot of blood spewing from a family member, friend or stranger, said Mick Navin, CEO of Operative Experience. Sometimes a blast can amputate part of a limb or gunshots can produce a gory scene.
That's why the company makes its 6-foot-1-inch, 180-pound dummies so life-like, with silicone-based skin and several liters of red water-based blood, which can be turned on with a remote control. An electrical system stored in the chest makes the dummies appear to breathe. And a speaker system allows a trainer to make the victim scream or call for help.
In addition to its traumatic injury models, used mostly by the military for training, the company also makes models used to train medical professionals in different kinds of surgery and for labor and delivery. The models, which cost tens of thousands of dollars each, are meticulously prepared and painted to look realistic on the outside and feel realistic on the inside.
"It's not difficult to stop hemorrhage," Navin said. "The key is developing a level of confidence. And you get that confidence by dealing with circumstances that are realistic."
Founded by a trauma surgeon, Operative Experience began as a research and development firm to come up with surgical training models. It later began making the trauma dummies, selling its first model to the U.S. State Department in 2014. Some parts are manufactured in-house by its 28 employees, but many others are contracted. Basic models to teach hemorrhage control cost about $30,000.
Better models could help training of both the public and professionals, those in the field say.
Maryland has taken an active role in training and providing kits alongside those portable defibrillators in schools and office and government buildings, said Dr. Richard Alcorta, the state EMS medical director.
The state's emergency service providers have been serving as trainers for other professionals and the public. That includes training law enforcement officers who often get to the scene first.
State protocols also have been changed recently to allow EMS providers to get closer to active shooter situations to apply aid themselves.
Alcorta said training the public is the last frontier. Being able to save a stranger is important, but plenty of people accidentally harm themselves in their own kitchen or in their yards, he said.
"Everyone should know how to apply pressure, pack a wound or apply a tourniquet," he said. "EMS can get there in minutes, but that may not be fast enough."