The primary task of the Salt Working Group was solve this nation's interoperability crisis. The data necessary to form an understanding of the nation’s degree of fragmentation or the number of triage systems in use does not exits. The only data that does exist is inaccurate and unverified. Tangible data suggest there is no interoperability or lack of standardization issue that needs to be addressed.
U.S. S.T.A.R.T. triage Adoption by State.
The warning next to the map that the data was prone to error and not validated.
The infamous map used by the Working Group validate a fragmentation crisis exists.
Chicken Little this…:
All parties involved in the creation of SALT knew of, but ignored, these issues and presented the bad data as gospel and built a citadel of crisis upon it. Maybe they thought it would slip under the radar and go unquestioned. Consider it questioned. These are our academic best and industry leaders that we intrust and empower to make accurate directional decisions based off facts, not survey-
NASEMSO 2010 Survey
The 2010 NASEMSO survey also warns they asked the wrong people the right question with regard to triage systems. The Working Group included a senior member of NASEMO. It would be implausible to suggest they were not aware of their own SALT-
“The Model Uniform Core Criteria for Mass Casualty Triage were designed to increase interoperability among various mass casualty triage protocols.” -
“The intent of the Core Criteria is to ensure that providers at a mass casualty incident use triage methodologies that incorporate core principles in an effort to promote interoperability and standardization.” -
All existing surveys of our triage structure are unscientific, have no data validation component and were not constructed in a manner that their resulting data could be used for any reliable measure of the condition.
The creators of the 2011 National EMS Assessment Survey appropriately included a repetitive disclosure making it abundantly clear to the reader the data was prone to error and objective. And for good cause, the data was radically incorrect and in no way represented anything remotely close to the actual condition.
It used to be that science was fairly easy to define. A hypothesis is made and an outcome predicted. Tests are performed to validate the hypothesis and after the results are validated by repetitive blind tests, science is born. That’s now how it works anymore.
Here is how the Working Group defined “science” as it pertains to SALT.
“Science” was defined as the existence of at least 1 peer-
In layman terms: Somebody wrote an opinion paper on the MCI triage, threw in some untested data, someone else read it, and science was born. It did not matter if the supporting data was accurate or embellished because it was never tested. As long as it was from a ‘peer’ and it supported the Working Group’s position, it was science.
The only ‘science-
Arguably the antidote science conclusion is flawed. One of two article cited makes no reference to antidote usage during triage and the second uses the word ‘triage’ in a different context than that of obtaining an acuity class based on an algorithm. If you can’t get a pulse you can’t perform triage in the context of SALT. We can conduct LSI, as the author was implying. To what beneficial extent immediate application of that LSI has on a patient who has been unattended for 40-
The chest decompression citations are compelling and it would be hard to question this treatment's value in pre-
What we are left with is exactly what START began with: Tourniquet, pulse and airway management. Take out the items of clear conjecture above and START is as ‘science-
The Second Science:
There is even a new kind of science, something called “indirect science”. The Working Group classifies it as such:
“Indirect science” was defined as the existence of at least 1 peer-
In laymen terms: Read one peer-
The subject here is SALT being based on science. Indirect science is not that so we won’t delve into the issues related to it. However, one reference we are not clear on is the indirect science for not counting vitals. We may be wrong on this, but search as we may we cannot find a clear answer. We believe this is in reference to respirations since it is already agreed science that pulse-
On this subject, START does not include shallow breathing for a reason. It’s covered by checking Mental. There is no need for the <10 we’ve seen in some department guidelines for adults.
Searching for the Science:
Every proponent of SALT we have spoken to knows very little about it. They seem content with trusting that since its ‘science based’ it must be better. After all it is comprised of the ‘best available evidence’ derived from subject matter experts. What could possibly be wrong with that? Glad you asked.
“Qualitative and quantitative data sources reviewed by the Preparedness Committee indicate variability across the nation in the MCI triage systems used by state and local EMS systems.”
Stop the Madness:
In what could be the worst exaggeration of data is the citation inside the FICEMS report in reference to a 2013 publication from the Institute of Medicine’s Crisis Standards of Care: A systems Framework for Catastrophic Disaster Response. Upon analysis by the Working Group they claim the Preparedness Committee found qualitative and quantitative data showing variability across the nation with respect to MCI triage systems being used.
This is blatantly false. In reviewing the 520 page document there is only mention of two systems being used. START and SALT and no specificity is given to the quantitative coverage area of each. (Close to 98% to 2%).
Further, a member of the working group is quoted in the publication states:
“EMS personnel utilizing disaster triage systems (sort, assess, life-
However in the publication the Preparedness Committee does make this recommendation with regard to how new crisis management concepts should be considered and adopted:
“The state EMS office, in cooperation with the state health department, should ensure that EMS agencies have an opportunity to review and discuss the CSC plan at the state, regional, and local levels. EMS agencies should be engaged in the planning process from the beginning, and this can easily be accomplished through regional advisory councils or committees.”
We don’t recall that process occurring.
Best Available Evidence?…Not So Much:
This is the last information type the working Group used to draw its conclusions.
“Consensus” was defined as criteria that were unanimously agreed to by the workgroup; there also may be existing nonresearch publications that support the concept. A criterion was considered to be part of an existing triage system if it was included in 1 or more of the triage systems that are in use today, excluding SALT Triage.”
In laymen terms: A show of hands.
No need to discuss this process save to say these are highly skilled medical professionals that did their best due diligence to arrive at what they felt were qualified sound decisions based on medical knowledge and extensive research on a complex subject where little data exists. Our only issue is that they apparently limited their evidence gathering to the realm of academia and selected subject-
“…Alternatively, it is possible that minimally injured or noninjured victims may carry injured children or smaller adults to the designated area when the “walk” command is given. Although there is no scientific evidence to support these possibilities, it was the consensus of the panel, with support of the published data described above, that every victim must be assessed individually.”
No scientific evidence? Tell that to the Triage Unit Leader of Century Division in Aurora. An interview with him certainly would have removed the necessity of a consensus opinion and quite possibly would have given the Working Group the insight to see just how important it is to assess the walking early on instead of requiring it to be dead last.
Expert from an article co-
Question: What changed?
“…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.”
“At this time, no specific recommendation based on strong evidence can be made to support any one triage system over another.”
Review this document in our research section.
Not long ago a well-
Is There a Doctor in the House?:
It’s not just us. Several predominate members in the medical community concur with our findings that the process used by the Working Group is flawed, or at a minimum premature. As one example is this interview with the professor of emergency medicine at the University of California at Irvine and codirector of the school's EMS and disaster medicine sciences fellowship.