Triage is a fast, challenging and unforgiving dance with life and death. Those who have the task will carry the memory of the decisions they were forced to make forever. SALT, which stands for Sort, Assess, Lifesaving interventions, Treatment and/or transport is the four step process for responders to manage mass casualty incidents proposed by the National Association of EMS Physicians as part of a Centers for Disease Control and Prevention sponsored project to use the best available science and expert opinion to develop a standard guideline for mass casualty management.
- Patients must be stabilized to the best of the facility’s ability prior to transfer. Any life-threatening process that requires immediate management must be treated prior to transfer.
- If speciality consultation is required, it is important that as the receiving physician accepting a transfer, you ensure the specialist has agreed to accept and see the patient.
- As a receiving physician, you have an obligation to report inappropriate transfers within 72 hours – not doing may result in unnecessary delays in the future.
- A common pitfall for ED physicians is to perform an extensive evaluation on a trauma patient that requires a transfer. Recognize the resource limitations of your facility early. Avoid workups that won’t change patient management.
- Frequently, patients are transferred long distances, which may make discharge difficult if there is limited social support. Engage case workers and discharge planners to address these unique situations.
The Ministry of Health in Kenya reported that in 2016, about 13,159 people were seriously injured on the road. It is not just road traffic accidents, but also tens of
The major indication for Lights & Sirens (L&S) is a presumed significant decrease in response and transport time. However, multiple studies reveal a minimal decrease in transit time with L&S use, with an average of 1.7 to 3.6 minutes saved.
For most conditions, EMS providers can provide timely care on-site or en route to diminish the importance of time saved by L&S transport, thus reducing the risk to providers, patients, and the public. In greater than 90 percent of patients, there is no improved outcome from L&S use. For some conditions, such as ST-elevation myocardial infarctions, trauma with life-threatening haemorrhage, obstetrical emergencies, or ischemic strokes, the use of L&S use may improve patient outcome by decreasing transit time. However accurate prehospital notifications to the receiving hospitals may be more beneficial than L&S as this should reduce in-hospital delays waiting for therapeutic interventions. In some cases, prehospital notification has shown an evidence-based improvement in patient outcome by mobilizing the necessary resources.
This assessment, conducted by external EMS experts with expertise in African and international EMS systems and EMS education, reports several key findings and offers important recommendations to help standardise and enhance the quality of training in Kenyan prehospital care.
In brief, the key recommendations are as follows:
- A standard Kenyan EMS scope of practice (document and policy) is needed that defines levels (i.e. tiers or cadres) of EMS providers and delineates all knowledge and skills required to practice as a prehospital provider at the given level.
- A standard for EMS training should be developed and implemented to help ensure high quality and uniformity in EMS training across institutions, and alignment with the Kenyan EMS scope of practice.
- There should be a transition from over-reliance on non-Kenyan curricula and training content, to more Kenya-specific materials and content targeted to the local burden of disease, healthcare system, and available resources. External reference texts/material can function as a guide for initial training initiatives and provide coarse structure, but training content should be edited as much as possible to reflect local needs.
- The EMS training culture should shift away from diagnosis-based training to syndrome or
- EMS trainees could greatly benefit from stronger foundational didactic classroom-based education (classroom education) at the Basic (EMT) level with a specific focus on clinically relevant basic anatomy and physiology. This should be limited to the knowledge and basics directly relevant to their scope of practice.
- To improve foundational clinical training in emergency care, all trainees should first achieve competencies and attain adequate field experience at a basic (EMT) provider level, before receiving additional training to higher qualifications (e.g. Intermediate Life Support (ILS) or Advanced Life Support (ALS).
- Higher-order and critical thinking skills need to be developed, by integrating basic knowledge and skills into real-world clinical scenarios, which should be heavily woven into all aspects of EMS training programs.
Access to emergency medical care should not be for the privileged few who can afford private evacuation by road, sea or air. It should be available to all. A robust medical emergency response service should be a priority for our Ministry of Health. All our medical facilities must have the necessary infrastructure to support emergency care and we must train and continuously impart skills to our emergency medicine specialists of every cadre, to run these emergency rooms.