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.
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.
Busting Trauma Myths…
- Nasopharyngeal airway placement can safely be performed in patients with a head injury when airway management is needed. The benefit of establishing an airway outweighs the incredibly small risk of the NPA entering the brain.
- Backboards (Spine boards) have no proven benefit for the trauma patient and can be harmful by compromising a patient’s ventilations, placing them at risk for pressure ulcers and delaying transport to definitive care. That being said, spinal motion restriction in trauma patients is good practice.
- The evidence demonstrates that not only does the Trendelenburg position not help patients experiencing hemorrhagic shock, but it can actually be harmful because of effects on both ventilatory and circulatory systems.
- The KED increases spinal column motion during the extrication process; alternative methods of extrication need to be considered and explored.
- If initial direct pressure fails to control haemorrhage, remove the dressing and apply well-aimed direct pressure onto the haemorrhage location. When this fails, a tourniquet or hemostatic agent should be used.
- Using the 80/70/60 rule for peripheral pulses overestimates a haemorrhaging patient’s blood pressure and may put them at risk for delayed intervention. Obtain accurate blood pressures. There is a key component of common sense here, though—if you cannot feel your patient’s radial pulse they are likely to be very hypotensive and ill.
- Delivery of patients suffering from a traumatic injury to a trauma centre within 60 minutes of their incident does not improve their outcomes unless they present in hemorrhagic shock. Safe transport to a trauma centre is more important than rapid transport.
Spinal motion restriction should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules. Spinal motion restriction should be considered for patients with plausible blunt mechanism of injury and any of the following:
- Altered level of consciousness or clinical intoxication
- Mid-line spinal pain and/or tenderness
- Focal neurologic signs and /or symptoms (e.g., numbness and/or motor weakness)
- Anatomic deformity of the spine
- Distracting injury