In a refreshing non-bias effort, one of the Working Group members did pit SALT against START, although in a virtual environment.

Another study to compare SALT to START by a Working Group member but once again the methodology had flaws.

Keep an open mind when reading this information. Our intent was not to taint your ability to think objectively while looking at arguments from both sides. At a minimum you can review this material knowing there are opposing views.  


Do look for the repetitive justification of SALT as the solve to our interoperability issue and the acknowledgments that SALT’s current state is based on limited science at best.

Research Portal

Use the below collection of links to PDF’s and SALT-related sites to streamline your own research.

FICEMS - Federal Interagency Committee on EMSInteresting ReadsSALT Overview

The Working Group’s white paper that describes the process used to develop SALT.

What to look for:

If the document wasn't based on an interoperability myth it would be a fascinating read. It is interesting how a small group of people can get in a room, pour through published documents, take votes and come to conclusions of how something should be. What stands out most? How they define Science: “Science” was defined as the existence of at least 1 peer-reviewed publication that explicitly tested the criterion in regard to mass casualty triage. Really? Someone writes something, someone else agrees with it and it’s science?

The lead Working Group member’s mid-stream presentation on how to overcome the rejection of SALT by EMS agencies.

What to look for:

Good overview of how SALT is presented and explained. The ‘What went wrong’ slide (Page 10) left out one bullet: • No one needs it.
Of particular interest is the author’s recognition that our EMS agencies had expressed concern that a SALT adoption would create less interoperability. (Page 14).
Impressive list of SALT progress points including being in an episode of Doomsday Preppers. The city listed as the adoptee is the where the author works and the training organization mentioned its executives were part of the Working Group.   

The final 2014 FICEMS report recommending triage processes use the MUCC to solve the interoperability issue.

What to look for:

The basis for the FICEMS position was the belief that fragmentation existed and with good intentions endorsed MUCC as a method to solve the problem. They do not directly endorse SALT. In fact they allow for the modifications of ‘existing systems’ to become compliant. Had the FICEMS known the severity of interoperability was based off bad data their opinion may have changed. The only source they relied on to substantiate the data was the Working Group’s presentation.

In 2011 the Working Group went to the FICEMS to get them to consider endorsing the MUCC / SALT.

What to look for:

A couple of things stand out. In the conclusion(Page 5) the Working Group advises this is an ‘urgent’ matter and to consider adopting a process of adoption similar to the FICEMS’s Pandemic Influenza Preparedness.

In describing ‘Best Available Science’ (Page 3) we learn that the Working Group found gaps in its own science and ‘would revise the MUCC as new evidence becomes available.’
(Maybe they'll consider some of the evidence on this site).

In the 2011 meeting the FICEMS directed their own working group to get input from the NEMSAC for an implementation strategy.

What to look for:

The FICEMS TWG (Technical Working Group) recommends adoption of the MUCC to the NEMSAC (National EMS Advisory Council) to solve the interoperability crisis. (Page 5)
They cite some research they conducted but only in determining if START could be replaced by the NHTSA’s National Standard Curricula.
Had they just looked into the interoperability crisis data source instead the outcome might have been different.

The Chair of the FICEMS Preparedness Committee presented this to the NEMSAC.  

What to look for:

This is a very interesting look into the way that the ‘interoperability crisis’ narrative drives the process. The presentation acknowledges we are a nation of START and that SALT has never been tested against other systems. It further acknowledges there are ‘gaps in the science’ but still endorse it. One would think a recommendation of running a few tests before recommending such a radical change would be more sound. Ironically the the document recognizes that SALT is creating fragmentation where it did not exist before and that most states use START.

What to look for:

This is your typical triage training portal but with a SALT twist. A few things to note is it’s lack of mention of the importance of obtaining a count quickly and the ‘Minimal’ non-ambulatory injury depicted.

As a side note, this company used to be strong proponents of MASS and had two members on the SALT Working Group.
Of particular note is their claim that S.A.L.T. Triage™ is a trademark. SALT’s core criteria states no system can be proprietary. You can only trademark goods you own and intend to sell. If you own something it is proprietary.

Training

A training site to see the SALT instructional materials and video. Grab the CE’s if you need’em.  

What to look for:

They also seem to be in the SALT triage tag business. That might explain the trademark. Strange they use blue instead of gray for Expectant.

Their western training center seems to still emphasize MASS triage training. Seems a little contrary to the concept of interoperability.
Is it just us or does it seems strange that the one training organization that had the most to lose if SALT was adopted - the death of MASS, a system they created - would be part of the Working Group and now the official SALT training portal?

The NDLSF S.A.L.T. Triage tag.

What to look for:

The authors make some interesting outside observation of reasons to question SALT, the MUCC and even START.

Of particular interest is their simple request to actually test SALT head-to-head against other triage systems.

Some studies are cited to validate their other opinions but like all studies we have encountered on this subject, they should be taken with a grain of salt. (No pun intended)


The creators of the proprietary SACCO Triage Method (STM) were not happy with the Working Group when they ruled the MUCC cannot use proprietary systems.

What to look for:

This is the sliver of unscientific data the Working Group used to validate the existence of an interoperability crisis. The pertinent section is on page 333 and the infamous map on page 334. The data was derived from a 200+ question unscientific survey of one EMS representative for each state. Even the survey warns: “The aggregate results are based on a combination of fact and opinion dependent on each state’s available data sources and awareness relative to each specific question.” Somehow that disclaimer never made it into any of the Working Group’s literature.

2011 National EMS Assessment contained the information on MCI protocol standards nationwide.

The Data

2010 National Association of State EMS Officials survey to 50 state trauma systems mangers.

What to look for:

The single question relative to ‘triage guidelines' seems suspicious in that it lists two systems SALT and START. In 2009 when the question was asked the NASEMSO knew no state-wide adoption of SALT had occurred. (One response indicated one did but this is not accurate.)

Further they tout that SALT is in ‘wide usage’. Sounds biased.
It would be nice to see the data collected for ‘Other’. No doubt it would likely end up being START. At lease they acknowledge that trauma system managers are not the right folks to answer this type of question.

What to look for:

(SMART is a triage tool that uses START as a system)
Although START performed better than the SALT system in accuracy, overtriage, undertriage, and speed, this study was more to observe how virtual environments work so there is no ‘winner’. As with any ‘study’ is should only lead the way to further testing and validation.

The biggest issue with the methodology is it did not account for responder travel time. A great example of why testing of something for the field should be done in the field.

What to look for:

If the objective of this study was to compare how SALT stacked up against START for speed and accuracy in applying the algorithms it was successful. Both are about the same, as one would expect.

Unfortunately the ‘victims' started their ‘timers’ when the responder approached them -so only the triage time was recorded. Had the entire test had an incident clock running the speed data would have been significantly different. Can the creator of something have zero bias when testing it? Maybe they should leave the testing to others.

In Koenig & Schultz’s Disaster Medicine: Comprehensive Principals and Practices, two of the Working Group members discuss triage systems.

What to look for:

Brooke Lerner and David Cone, both top Working Group members, diligently contribute to an overview of all known triage systems including SALT. What is of particular interest is their quote regarding a ‘best’ system:

“…Accordingly, this chapter will describe the existing triage systems but will be unable to recommend one system be used over the other due to lack of scientific data.”


Interesting.

The Crisis Standards of Care publication referenced in the FICEMS report..

What to look for:

The FICEMS report claims this publication recognized ‘quantifiably and qualitatively’ that multiple triage systems are in use to further justify the fragmentation myth. However only two triage systems are mentioned. START and SALT.

Even within the report one of the Working Group members is quoted as saying:EMS personnel utilizing disaster triage systems (SALT, START and JumpSTART) triage methods so they can assess patients within 60 seconds and categorize them for immediate or delayed care.” -(HHS,2011; Lerner et al., 2011; Romig, 2011)

What to look for:

This reference document is included only because we make mention of it in our Science section. It is one of two documents reviewed by the Working Group with regard to MCI and HazMat triage. In reading the report there is no inference that triage teams felt antidotes would have been of benefit. It is airway, PPE and transport that are their concerns. They do refer to mobile decon capability and infer that at the point of decon that antidotes could be used.

Part 2 of this report is the hospital perspective and is not included because it is unrelated.

A report on the Tokyo Subway Sarin Attack from the Tokyo Fire Debarment's perspective.

What to look for:

This article was written over 15 years ago and was one of the first written on this subject. A plethora of recent research exist on the subject that, one would think, should have been reviewed.

Regardless, the author does not make any conclusion that antidote intervention should be applied immediately to patient vs. waiting to do so in the decon corridor.
We can’t link our copy for legal reasons but you can get a good preview on the right side of this page next to the abstract.

Civilian Exposure to Toxic Agents: Emergency Medical Response. A 2004 article cited by the Working Group as  ‘science’ for use of antidotes.