Community-based first aid: a program report on the intersection of community-based participatory research and first aid education in a remote Canadian Aboriginal community

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Context

This article considers the intersection of conventional first aid education and the remote fly-in Aboriginal community of Sachigo Lake First Nation in sub-Arctic Canada. This intersection highlighted incompatibilities between standard first aid and local community needs. These were addressed through a community-based collaboration and the development of a unique, community-specific first aid program.

Over the past 4 years, through a process of community consultation and collaboration, the Sachigo Lake Wilderness Emergency Response Education Initiative (SLWEREI) was developed, delivered, and evaluated. This unique community-based first aid program involved two intensive 5-day first aid training courses for lay community members, held in 2010 and 2012. Through two courses, the program has trained 26 adults, approximately 5% of the community population.

Training centered on providing essential life-support in emergency situations, with a focus on patient transport and the provision of adaptive care in low-resource and wilderness settings. Course curriculum and pedagogy were based on community priorities, needs, and feedback received through community consultation.

Community consultation was both formal and informal involving an initial 3-day site visit and needs assessment, formal interviews with key stakeholders focused on curriculum and pedagogy, survey feedback from course participants, and conversations with community members over the telephone and during the weeks spent in Sachigo Lake First Nation over the past 4 years.

Curriculum covered topics ranging from basic trauma care and cardiopulmonary resuscitation to mental health first aid, diabetic emergencies, and safe patient transport. The courses involved little time in a classroom setting with the majority of learning focused on practical skills training and simulation with debrief. The SLWEREI was based on a simple premise, buttressed by World Health Organization and American Heart Association guidelines: in underserviced settings, first response education may enhance community resilience and capacity to manage emergencies and save lives^1,2.

This article reports on curricular and pedagogical lessons learned as the authors developed a unique first aid training program. Its purpose is not to present the research details or outcomes of this initiative; these have been described elsewhere^3,4. The specific adaptations to first aid educational content and methodology required to deliver effective community-based training in remote Aboriginal communities have not been described elsewhere.

Sachigo Lake First Nation is a remote Aboriginal community of 450 people in northern Ontario, Canada with no local paramedical services. The community is accessible by plane throughout the year, and by seasonal ice road for several weeks during the winter. Full-time nursing staff provides services at a local nursing station. A family physician visits the community for 2-3 days per month. Hospital care is provided hundreds of kilometres away in Sioux Lookout, with transport times rarely less than 4 hours.

Issue: Standard first aid and community-based first aid

First aid is 'the assessment and interventions that can be performed by a bystander (or by the victim) with minimal or no medical equipment'². First aid emerged from a paramilitary tradition, rooted in the International Red Cross⁵. In North America, organizations such as the American Heart Association, National Life Saving Society, and the Red Cross outline the scope and principles of conventional first aid education.

As a field of clinical practice, first aid arises from a tradition of algorithmic guidelines, universal practice standards, strictly delineated levels of certification and scopes of practice, and a normative and a fundamentally positivistic approach to health and physiology. The notion that health emergencies are adequately similar across cultures and geographies forms a central premise of 'standard first aid', permitting a universal and algorithmic bystander response and educational model. Clinical protocols and first aid practice have been rooted in the simplification of diagnostic, therapeutic, and transport decisions for sick patients, coupled with a drive to provide simple and universal approaches to emergencies through basic training for non-clinicians. This model for immediate and on-scene clinical care and transportation has proven tremendously successful across a variety of settings from the battlefield to shopping centers, and first aid training programs have been recognized internationally as an essential form of health protection and promotion⁶. Non-conventional first aid programs have been successful at improving outcomes in low-resource contexts with minimal paramedical services in places such Ghana, Northern Iraq, Cambodia, and Uganda^7-10.

Over a period of years, this team has worked with Sachigo Lake First Nation to analyze the pedagogy and curricula of conventional courses. Through this partnership, the team has customized a first aid training curriculum to Sachigo Lake First Nation. This collaborative approach revealed incompatibilities between standard first aid and the lived experience and needs of the Sachigo Lake community. The customized first aid program and experience captures several lessons learned that the authors now identify as central to first response capacity-building and first aid programs in remote settings. Together, these core concepts describe what the authors call 'community-based first aid', a community-oriented approach to first aid education.

Lessons learned

The authors distilled several concepts into three lessons:

1. Standard algorithmic approaches may not be relevant or appropriate.
2. Relationships between course participants and the people they help are relevant and important.
3. Curriculum must be attentive to existing informal and formal emergency response systems.

First aid education pedagogy in a unique context

In a remote community, standard first aid approaches may be neither relevant nor appropriate. Standard first aid curricula face limitations in a remote Aboriginal community such as Sachigo Lake. To build a first response curriculum for this program, the authors drew on basic life support and first aid resources from the Heart & Stroke Foundation, American Heart Association and the European Resuscitation Council; wilderness medicine programs from Wilderness Medical Associates International; and emerging mental health first aid materials from the Mental Health Commission of Canada. These conventional first aid resources face two serious limitations for effective capacity building in a remote setting like Sachigo Lake.

First, these sources often assume an advanced literacy and the cultural and cognitive dominance of the written word among learners. Participants had a wide range of literacy levels, but few participants learned primarily from text. It was identified that these first aid curricula place heavy emphasis on flow charts and acronyms, both of which led to significant challenges for participants. For example, some conventional first aid curricula use the acronym AVPU when assessing a patient's level of consciousness to represent Awake, responds to Voice, responds to Pain, or Unresponsive. Early course simulations showed that prompting learners to use this acronym as a memory tool was leading to confusion and flustering students. This issue was not specific to one or two students, but a challenge expressed by all students. Assessment of the patient's level of consciousness was altered to an intuitive approach, requiring participants to identify if the patient was behaving normally, abnormally, or unresponsive, and to identify if the level of consciousness was improving or worsening. Through consultation, the authors focused on similar assessment principles but phased acronyms out of the curriculum as they were found to be a stumbling block, rather than a helpful cognitive aid.

Second, conventional curricula emphasize pathophysiology, requiring trainees to develop health and physiology literacy in order to understand and provide emergency care. For example, Heart & Stroke Foundation resources on stroke and myocardial infarction are laden with graphics about atherosclerosis and thrombosis. While these pathophysiological teachings serve some learners well, it was observed that this approach could distract participants from the essential steps involved in responding to a family member with signs of stroke or chest pain. The program described in the present article did not treat pathophysiological knowledge as a prerequisite for problem solving and decision-making. Pathophysiology was addressed in the curriculum when questions arose from participants. Participants were not taught to identify symptoms of a myocardial infarction in order to make first response decisions because this would require an unnecessary cognitive link between symptoms, pathophysiology, and first response decision-making. Instead, participants were taught a generalized approach to patients complaining of chest pain, requiring only a link between observed symptoms and behaviors, and first response actions. This approach focused on symptom recognition, critical decision-making, safety, and treatment.

Third, both conventional and wilderness first response algorithms were found to be contextually and geographically inappropriate. Seemingly universal instructions like 'call 911', 'wait for the ambulance' or 'go to your nearest emergency department' appear throughout commonly available first aid programs. This provides incomplete or inappropriate training to first responders who provide care over extended periods in settings without ambulances or formalized dispatch services.

In Sachigo Lake, where there are no paramedical or 911 services, using conventional urban first aid materials re-emphasized service inequities without providing meaningful training alternatives. The current program focused not on when to call for help, nor on protocols, but on relying on oneself and each other to identify a problem, think critically about the situation, and to initiate an appropriate treatment based on the situation. A significant amount of time was spent discussing which patients needed to be transported to the nursing station, how, how quickly, and by whom. While similar principles are taught in conventional first aid courses, the emphasis is on the fact that there is a professional coming to help in an emergency. This is not the case in remote communities such as Sachigo Lake.

Conversely, wilderness medicine curricula offer an emphasis on remote settings and delays in accessing professional care, but this approach implies a specific notion of 'wilderness' that may alienate an indigenous community from their traditional environment and way of life. Further, wilderness medicine curricula often are designed for the person who occasionally travels in a remote context. This program's participants articulated a sense of home, safety, and comfort in remote parts of the boreal forest, which was incongruous with discourses and imagery of intrepid adventurers and rescue helicopters that dominate wilderness medicine approaches. Helicopters do not have the range to reach Sachigo Lake First Nation. As such, to reach the nursing station or an aircraft, patients are transported by a combination of snow machine, all-terrain vehicle, boat or truck, depending on location and season.

In Sachigo Lake, presenting wilderness medicine materials might inappropriately convey that the program participants' traditional way of life is inherently or unacceptably dangerous. For example, it is common for members of Sachigo Lake to travel alone or in small groups to hunt and fish in the region surrounding the community. While this might represent a health or safety risk to outsiders, locals in Sachigo Lake understand traveling in their local region and wilderness surroundings as a safe and normal activity. As part of the program curriculum, simulations were based on this context. During simulations, participants had only the materials and resources that they would have with them while traveling by snow machine or boat, such as a tarpaulin, a gun, an axe, a sleeping bag, rope, tape, food, water, and an extra set of clothes. To manage mock patients, they were instructed to use the materials and equipment they would carry routinely to stabilize, treat, and transport patients to the nursing station in their community. Significant periods of time were spent debriefing simulations, discussing ways to improvise splints, bandages, or transportation packages. This program's curriculum offered approaches to emergency management suited for extended patient care in remote settings.

Developing a community-based first aid program with a remote First Nations community highlights subtle conflicts between the culture of first aid and the context in which it was being taught. Neither conventional urban programs nor alternative wilderness first response curricula offer training that is particularly well suited to an isolated, Aboriginal community like Sachigo Lake First Nation. Delivering community-based first response curricula may reveal similar geographical or cultural themes in other unique settings.

First aid delivery in a small close-knit community

Community-based first aid programs must consider the relationships between course participants and the people they may help. Conventional structured approaches to teaching first response, whether designed for the general public or for professional rescuers, are developed under the assumption that the majority of responses involve patients who are strangers. 'You are walking along the street and you suddenly come across an elderly man who has collapsed ...', and so the scenario plays out. This 'stranger assumption' in standard first aid education, where the victim is identified as an anonymous individual identifiable only by their pathology or clinical problem, is incongruous in a tightly-knit community such as Sachigo Lake, where everyone is a friend or a family member.

The stranger assumption in standard first aid creates barriers in a remote community by disregarding existing well-developed relationships. Course participants in Sachigo Lake approached first aid role-play scenarios not as an individual within a community of strangers, but within a network of existing interwoven relationships. This community-based first aid education program adapted to meet the needs in such a community. Patients had names, rescuers were related, first response necessarily involved close friends. These relationships were important community resources. For example, during training exercises, relationships and personal connections to the patient were mentioned frequently and were treated as an asset in the provision of personalized, appropriate, and holistic care. Conventional medical and professional models might identify these relationships as a liability, conflict, or problematic barrier to dispassionate decision-making. In Sachigo Lake, these relationships were used as an asset, to involve close family members from within the community as a health resource, and to build community resilience by strengthening the health capacity of families rather than addressing community needs exclusively through access to health professionals.

As part of the 2012 course, the authors added a module on mental health curriculum that focused on three key areas: thoughts of suicide or self-harm, substance misuse and intoxication, and disorganized behavior. These themes were identified by the community as priority topics based on their shared experience and previous incidents.

Mental health and substance abuse issues disproportionately impact Aboriginal population compared to the rest of Canadian population. Suicide is one of the largest contributors to premature death on reserve in Canada, with Aboriginal populations suffering three times the potential life years lost due to intentional injury compared to the general population¹¹. There were several suicide attempts in 2011 in Sachigo Lake, all among young people. All were non-fatal. Similarly, substance abuse is a major issue in the region, with some remote communities reporting a narcotic addiction rate of 70% among their adult population¹². In a survey investigating the severity of substance misuse problems as reported by Aboriginal Canadians, 83% of locally elected leaders reported alcohol and illegal drugs as problems in their community¹³.

When a layperson provides first aid to a stranger, one would rarely encounter someone who would disclose their suicidal thoughts. This program's needs assessment and evaluation identified that although mental health first aid is rarely considered part of a conventional life-saving first response program, mental health emergency skills were as important to local responders as trauma management or cardiopulmonary resuscitation. In this small, remote Aboriginal community, where everyone is a family member or close friend, the mental health curriculum was central to meeting community needs and building local capacity to manage emergencies in a holistic and realistic fashion.

Language and curricula need to embrace established relationships for a community-based course to connect with community priorities and to reflect the community in which they live. The authors believe that community-based first aid programs can enhance community capacity by adapting curriculum to recognize these existing and important relationships.

Formal and informal systems

In a remote community, first aid education must be attentive to existing informal and formal emergency response systems. Conventional first aid training is intrinsically reliant on the existence of an identifiable transition point between bystander first aid providers and a formal healthcare system. Red Cross or American Heart Association Guidelines, for example, assume that first aid providers will intersect with a formal system of professional providers outside the hospital. In many Canadian communities, informal emergency response involves a bystander performing a varying level of first aid, and using a telephone to dial 911 dispatch services. Once dispatch services are contacted, a formal system is activated, and a patient's care will flow from paramedical to hospital care. In settings where emergencies are not addressed in this manner, developing local capacity requires that planners understand how a community responds to an emergency to be able to enhance systems without supplanting, bypassing, or ignoring them.

Because Sachigo Lake has no formal dispatch or paramedical services, the activation of formal emergency services begins when the patient arrives at the nursing station. All pre-nursing station care is provided through an informal system. Trying to understand this informal system has been part of the collaboration. In Sachigo Lake, this informal system is complex, situational, seasonal, adaptive, and well understood by community leaders. The authors' observation is that, in many cases, it is also extremely effective. Patients requiring urgent care often receive treatment and transport to the nursing station within minutes. In many cases, nearly the entire community responds to an emergency. Hence, nearly all available resources are present.

During course development and delivery in Sachigo Lake, curriculum and simulations allowed participants to activate and enhance both formal and informal response systems. Just as course delivery was unique because everyone on course was a friend or family member, so too was it distinct because of a shared experience of an informal emergency response system.

In a final large simulation on course, community members responded to a mock plane crash where four patients had been critically injured. This simulation was based on a previous aircraft crash in the community, and other similar incidents in the region. Participants responded to the incident, stabilized, packaged, and transported the four patients to the nursing station where two nurses on duty received the patients. This simulation integrated an informal pre-nursing station response system with professional nursing care, and it was seen as a success by course participants, local government, nursing staff, and course instructors. This simulation represented a unique intersection of community-based methods and first aid education where the conventional interface between layperson and professional emergency systems was modified to meet the needs in this remote community. Understanding how individuals in a community respond informally to an emergency is a latent strength in the community that can be reinforced through adaptive curricula. Other communities may have similar informal response systems that can be enhanced through a similar approach to community-based first aid. Community-based first response training initiatives must be mindful of these informal systems, and find ways to enhance, rather than supplant or undermine, them.

Conclusions

Conventional first aid education relies on the notion that protocols and approaches to managing emergencies are applicable across all settings. In a remote Aboriginal community in northern Canada, with no paramedical services, such algorithmic approaches to first response are inappropriate. This program's collaborative approach to community-based first aid revealed three lessons central to building capacity in a remote community through the development of an education program. They stand in contrast to principles of 'standard' and 'universal' first aid that have previously dominated this field. The reported observations may be instructive for the development of other programs in similar settings.

Acknowledgements

The authors acknowledge the SLWEREI course participants, and community leaders and Elders in Sachigo Lake for their support and insight that helped the team learn the lessons shared in this paper. They also acknowledge Karen Born, Jeffrey Curran, Baijayanta Mukhopadhyay, Calen Sacevich, and Mike Webster for their role in this research collaboration.

This project was funded by grants from the Canadian Institutes of Health Research and the Northern Ontario Academic Medical Association (NOAMA; http://www.noama.ca). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

DV, RJ, AO have worked with Wilderness Medical Associates International, a wilderness medicine education organization. This organization was not involved in any part of the research submitted as part of this manuscript.

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