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Breathing new life
into first aid

Research 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 local situations.

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 literature.

“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 approach.

“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 to Africa.”

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, evidence-based practices.”

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.















Images from 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.

A 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.




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