Snakebite first aid training in Papua New Guinea:

1. Snakebite first aid training in Papua New Guinea: Determining efficacy of training by quantitative assessment of skill retention. Vincent Atua1*, David Williams2, Chris Curry3, and Kenneth D Winkel2 1 Modilon Hospital, Madang, Madang Province, Papua New Guinea. 2 Australian Venom Research Unit, University of Melbourne, Melbourne, Vic, 3010. Australia. 3 School of Medicine & Health Sciences, University of Papua New Guinea, Boroko, Papua New Guinea.

2. Introduction Many different methods of snakebite first aid are in use in PNG Many have no efficacy, and some are dangerous Some have traditional origins while others were introduced to PNG by colonialists Overall, use is sporadic; many patients present with no first aid at all Studies abroad suggest that prompt application of effective first aid can delay venom absorption and assist pre-hospital survival

6. Introduction In 1979 Australian scientist Dr Struan Sutherland proposed pressure-immobilisation bandaging (PIB) for Australo-Papuan snakebite first aid PIB is endorsed and recommended by the Australian Resuscitation Council It is included in formal first aid training by both the St. John Ambulance, and by Australian State and Territory Ambulance Services Until recently it was rarely used in Papua New Guinea, but is now being taught to rural people and health workers

8. Teaching PIB in Papua New Guinea Conducting a trial of PIB training to determine if the technique can be taught effectively in rural communities Started with a pool of 200 volunteers from Karkar Island, including 50 health workers 89 (44.5%) of volunteers lost during study period. Aim is to evaluate the efficacy of training by measuring skill retention over time Trial involves 2 hours of initial training and evaluation, followed by skills testing and repeat training at three month intervals over 1 year

9. Primary Training Technique Volunteers have the rationale for PIB explained to them, and are given a demonstration of the technique. The four key principles of successful PIB are stressed: Commencement just above fingertips or toes Full length application of bandage to whole limb Effective immobilisation using splints Application of adequate pressure (leg: 50-75 mmHg) to occlude lymphatic flow without exceeding venous return pressure Volunteers practice PIB and receive feedback

10. Primary Training Technique Bandage pressures are monitored using a Druck DPI705 force transducer coupled to a paediatric BP cuff bladder Measures pressure exerted by bandage on cuff Volunteers learn the technique in groups of 8-10 people per instructor over 2 hours Final examination involves evaluation against the four principles Trainees receive bandages and PIB instructions translated into pidgin

11. Pressure transducer: Druck DPI705

12. Tarak village youths learning PIB

13. Correctly applied PIB

14. Volunteer demographics Study involves volunteers from communities at, and near Kaviak, Tarak, Keng and Gaubin, on Karkar Island 71 males from 10-60 years (median: 23 yrs) 40 females from 15-52 years (median: 24 yrs) 30 (27%) health workers (including 1st & 2nd yr CHW trainees) 30 (27%) school students from Miak High School and Primary Schools 42 (37.8%) unskilled labour & unemployed

15. Volunteers by occupation

16. Results of primary training Results of initial assessment conducted after just 30 minutes of instruction showed that only 45.0% of volunteers who applied PIB met all four criteria for successful use. After a further 90 minutes of training, combining feedback with repetitive practice, 81.1% of all volunteers were able to meet the four criteria. Health workers performed better than non-health workers at initial assessment, with 60% meeting all criteria compared to 39.5% of non-health workers.

17. Results of primary training

18. Assessment of skill retention Skill retention follow-ups were conducted at 3-4 month intervals over the next 12 months. From an initial pool of 200 volunteers, 111 were able to be traced to completion. 89 were lost due to relocation or absence from the study locations. Volunteers were asked to �demonstrate the first aid we have taught you� and were again scored against the four criteria for successful PIB use Results were recorded, and then each volunteer was given feedback, shown errors (if any), and allowed to practice the technique before leaving

19. Use of PIB by children Several children who volunteered were very capable, and learned to apply PIB successfully At followup these children succeeded in passing the skill retention assessment Howarth et al (1994) do not provide effective pressure ranges for children The ranges taught 50-75 mmHg may be too high for children, and a study to determine optimal, effective paediatric pressures will be needed

20. Use of PIB by children

21. Skill retention results 29/30 (96.7%) health workers and 67/81 (82.7%) of other volunteers were able to meet all four criteria for correct PIB use Mean pressures: 62.4 mmHg (Health workers) and 60.8 mmHg (other volunteers) Ranges: 45.5-74.8 mmHg (Health workers) and 37.6-72.1 mmHg (other volunteers)

22. Uptake of skills Many volunteers stated that they regularly practiced PIB with their family members since the first training visit >90% still had original bandages and instruction sheets provided at initial training 1 volunteer reported using PIB as first aid for a woman bitten by a death adder Gaubin Hospital records confirm the case; the patient received antivenom and was discharged Reports of patients presenting with attempted PIB in place have increased.

23. Practicality as a training method The training program uses paediatric BP cuff liners and an electronic pressure transducer to obtain accurate readings In practice however, the BP cuff can be used with a standard analogue gauge to monitor and measure pressures; most health centres have one This means the technique can be taught in PNG in a cost-effective manner with readily available low-cost training equipment Local health workers could be taught to act as instructors for their communities

24. Low cost training technology

25. Conclusions PIB is easy to teach in rural communities using readily available materials Trainees had 80-81.5% compliance with four strict application criteria after just two hours training, with no reduction in these proportions after 12 months. Health worker compliance increased from 80% to 96.7% Volunteers actively took up the technique, and it has contributed to saving the life of a snakebite patient At completion evidence from this study should provide a strong funding argument for a national PIB training scheme to reduce snakebite deaths

26. Howarth DM, Southee AE, Whyte IM (1994) Lymphatic flow rates and first-aid in simulated peripheral snake or spider envenomation. MJA 161:695-699 Sutherland SK, Coulter AR, Harris RD (1979) Rationalisation of first aid measures for elapid snakebite. Lancet 1: 183-186 References