into best practices is shaping the way first aid is taught
and delivered. The challenge: how to bring everyone up to
speed with practices based on evidence while adapting to
IN APRIL, PAUL OKOT was riding through Kampala,
Uganda when he came across a motorcycle crash. The driver,
a young man, was bleeding profusely. An emergency health
programme officer for the Uganda Red Cross Society, Okot
knew what to do first.
While others were looking for water to clean the wound,
Okot knew that stopping blood loss was the most crucial first
response in this case. “For every cut, you apply pressure,” says
Okot , recounting how he took off his tie and pushed it steadily
against the victim’s arm.
If the situation had occurred a few years earlier, before
the Africa First Aid Materials were developed, Okot might
not have been so sure. “Before the evidence-based methods,
there were mixed messages,” he says, noting that until
recently, there were no clear, uniform recommendations about
which first-aid treatments were most effective.
In Europe, for example, before regional certification standards
were adopted five years ago, many National Societies taught
different techniques for things as basic as ‘recovery
positions’ — the best postures for keeping an
unconscious person’s airway open — says Pascal
Cassan, a medical adviser with the French Red Cross.
“The French had their way, and they thought it was
best. The British had theirs. The Germans had theirs,” says
Cassan, whose National Society hosts the European Reference
Centre for First-Aid Education. “There were eight to
ten different recovery positions being taught.”
But which one was best? Which technique saved the most lives?
In 2005, Red Cross experts in Europe and the United States
created separate research groups to find answers to questions
and discrepancies relating to a wide range of procedures.
They reviewed thousands of scientific research papers to
determine which medical interventions and first-aid methods
had the best outcomes.
One of the first results was the European
First Aid Manual,
first published by the Belgian Red Cross in 2006 and most
recently updated as the 2011 European
First Aid Manual. In
the United States, the American Red Cross and the American
Heart Association teamed up to produce similar guidelines.
Since then, the effort to harmonize best practices, based
on evidence, has gone global. The IFRC, along with leading
National Societies in Europe, the Americas, Africa and Asia,
combined experience to produce the International First Aid
and Resuscitation Guidelines 2010. This document, the authors
say, represents the first global, evidence-based recommendations
for first aid.
What does ‘evidence-based’ really mean? The
phrase has become a buzzword in the humanitarian and development
worlds. In short, it defines approaches or actions that are
based on scientific proof that a given practice is effective.
In the medical field, the term came into use in the 1990s
as researchers sought to give doctors sound advice on a wide
range of practices based on a thorough review of scientific
“Normally, doctors or physicians who want to keep
up with the best practices need to read dozens of academic
articles,” says Philippe Vandekerckhove, CEO of the
Belgian Red Cross–Flemish community, which published
the 2011 European First Aid Manual. “It’s not
possible for one person to make a critical review of all
the research that’s out there and determine the best
“In this case, for first-aid responders, we’ve
consolidated the research, we’ve cut through the clutter,” says
Vandekerckhove, whose National Society also hosts the Centre
of Expertise, a reference centre that promotes evidence-based
practices. “We’ve judged which of the research
papers out there are of a high enough quality, assessed the
findings and then made recommendations.”
It was no light task. In developing the IFRC guidelines,
for example, a global team of reviewers poured over more
than 30,000 articles that examined treatment for emergencies
such as heart attacks, blood loss, small wounds, broken bones
and much more.
First, a small team of trained researchers discounted
low-quality research papers that did not follow sound scientific
research methodology. Then an advisory body of medical experts
reviewed the papers and synthesized the data to determine
the approaches that have had the best results.
From that, recommendations were developed to suit particular
contexts, says David Markenson, who chairs the American Red
Cross’s Scientific Advisory Council.
“The evidence shows what the best technique is universally,” he
says. “But what can be applied to different environments
is not universal. The process allows all National Societies
in different countries to say, ‘There are five things
that are proven to work for this disease, but in my country,
with this type of emergency and limited resources, number
three works the best’.”
No ‘one size fits all’
That’s essentially what happened after Europe began
implementing its first region-wide first-aid certification
in 2006. People like Okot — and others in Red Cross
Red Crescent National Societies in Africa — saw a gap
in how the guidelines would apply in their countries.
“It became clear that a simple translation of the
European guidelines was not enough, it was not going to work,” says
Vandekerckhove. “There had to be materials adapted
The recommendations in the European manual, for example,
were based on the assumption that people could reach a doctor,
or be met by an ambulance, within 10 to 15 minutes. In some
parts of rural Africa, it can take days to get medical attention.
The way people are treated at the scene is therefore different
and situations first aiders might face are often different.
For example, the African materials, which were developed
by African medical experts, has a chapter on child birth
while the European manual does not.
The way victims are transported in rural Africa can also
be different. “You find things like bicycle ambulances,” says
Okot. “The first-aid manual used in these areas,
therefore, had to address how to transport someone on a cart
pulled by a bicycle without making certain injuries worse.”
Spreading the message
But getting the word out about the best techniques around
the world can prove tricky, says Vandekerckhove. “There
were interesting examples in which certain illustrations
in the European guidelines would be misinterpreted in some
African communities.” In the European guidelines, for
example, a ‘thumbs-up’ indicated an approved
technique, but in many parts of the world, a thumbs-up means
something is bad or it can be taken as an insult.
The way people learn also varies. In Europe, the guidelines
are always put into manuals, which can serve as textbooks
for a course. In Africa, guidelines are compiled into ‘materials’ that
National Societies can transform into theatrical performances,
posters, talks, DVDs and even songs.
Perhaps the biggest challenge for global implementation
is resources. “It’s not easy to get all volunteers
in all countries, even the trainers, up to speed on the latest
approaches,” notes the French Red Cross’s Cassan. “It
is going to take time and resources and a lot of commitment.”
But it’s worth the investment, he argues. “When
it comes to first aid, the Red Cross Red Crescent sets the
standard in many countries — so it’s important
that we position ourselves as a leader in terms of the best,
That appears to be exactly what bystanders understood when
the Uganda Red Cross’s Okot jumped in to help the injured
man in the streets of Kampala. “They were attempting
to do something, but it was different from what I was planning
to do. When they saw I was Red Cross, they left me to administer
first aid. They knew I knew how to do it.”
By Ricci Shryock
Ricci Shryock is a freelance journalist based in Washington DC and Dakar, Senegal.
the African First Aid Materials (a
set of guidance documents developed by the Belgian
Red Cross with a consortium of African National Societies)
show evidence-based first-aid techniques have been
adapted to suit the local context.
review of medical research proves that traditional, local
remedies can be more effective than modern medicines.
Research carried out for the African First Aid Materials,
for example, validated some traditional techniques for
disinfecting wounds and treating people dehydrated due
to diarrhoea. A traditional technique of putting honey
on wounds is particularly effective in reducing the risk
of infection if done properly. By contrast, the European
First Aid Manual suggests the application of over-the-counter
disinfectants that are not necessarily available in many
parts of Africa. Likewise, the advice to Europeans to
buy an over-the-counter oral rehydration fluid for people
suffering from dehydration is replaced in the African
context with variations of traditional recipes for mixtures
using corn flour or locally available plants and salt.