Thoughts on First Aid

These thoughts have arisen out of 8 years experience of first aid with a wide variety of first aid and EMS organisations, including but not limited to the East Hanover First Aid Squad, St. John Ambulance UK and the Oxford University First Aid Unit. They are therefore not to be taken as representative of opinions held by these organisations as a whole, or by any particular member of these organisations.

All opinions expressed in here are mine, and mine alone. If this is insufficently clear, stop reading right now.

Intro

Introduction to first aid

First Aid in the UK

First aid related organisations

First aid training

The First Aider

The first aiding bystander

The workplace first aider

Incident exercises

Skills required of a first aider

What Is Wrong

Deficiencies in training

Voluntary societies

Conclusions

Proposals For Improvement

Summary

References

The Thoughts

Introduction to First Aid

This essay looks at the current provisions for first aid in the United Kingdom. It assesses the requirements for a first aider's skills, examines the links between first aiders and the professional emergency services, and sets out recommendations for improvements to the way that first aiders are trained and provided.

First Aid In The UK Today

First Aid Related Organisations

It is important to note that none of these organisations has any official status in terms of determining what is or is not standard first aid practice. They do however publish the First Aid Manual which is a generally very good publication on first aid practice for the general public. This is kept up to date with current medical practices by re-publishing every few years. Most of the recent changes have concerned resuscitation.

The organisation which provides what are regarded as definitive protocols for resuscitation is the Resuscitation Council (UK). This works with the European Resuscitation Council to determine and update guidelines and protocols according to the current state of medical knowledge. Their advice is adopted by the National Health Service (via the Royal College of Surgeons and related professional medical bodies) for use by hospital staff and the NHS ambulance personnel. It is also generally adopted by the voluntary organisations, although can take time to filter down to training of members and is not always correctly represented in the First Aid Manual. Indeed, the resuscitation section in the current (7th Edition) manual is its one major flaw, diverging significantly from the RC(UK)'s Resuscitation for the Citizen. A revised edition is apparently due out soon to correct this.

As far as first aid in the workplace is concerned the Health and Safety Commission lays down the rules and guidelines for first aid provision in their ACOP. The 1997 amendments to this document have given the employer much more flexibility in determining first aid needs for his workplace. The rule of thumb, however, is that one first aider is expected to be present for every 50 employees in an average workplace. This will generally entail having two or three people per 50 actually trained, so that cover is maintained when the designated first aider is absent.

For first aiders to be regarded as such by the HSC rules, they should have attended a first aid course approved by the HSC. Nowadays such approval is handled by TASC and the First Aid Approval Monitoring Service (FAAMS), independent organisations which report back to the HSC. These courses are normally 4 days long, with an examination at the end, and are valid for 3 years. A refresher course of 2 days duration must be taken to renew for a further 3 years. These courses generally go by the title "First Aid at Work."

The British Association of EMTs (BAEMT) is aimed at the non-professional first aider who wishes to develop their skills to an equivalent of the USA Emergency Medical Technician (EMT) course. This organisation currently does not have much impact in national first aid policies.

First Aid Training

The HSC recognises the concept of a 4-hour course building on the Basic Life Support skills, which also teaches control of bleeding, recognition of possible heart attack or angina in a casualty, and the laws regarding first aid in the workplace. Such a course may be termed "Emergency Aid" or similar. For companies under 50 employees in size, the HSC recommends that at least one person present has taken this course.

The four day First Aid at Work course is the nearest that the UK has come to a national standard for first aid courses. The course syllabus, organisers, trainers and examiners must have the approval of the FAAMS and TASC, who are notified of every course and may visit any course at any time. Courses not meeting the standards may cause approval to be withdrawn from the teaching organisation concerned until suitable changes are made.

The syllabus for this course must include a list of skills given in the HSC ACOP. They include all the Emergency Aid skills plus identification and treatment of fractures, head injuries, various medical problems and eye injuries.

The HSC also recognises the need for oxygen administration in the workplace, and allows for oxygen courses supplemental to the basic First Aid at Work course (hereafter referred to as FAW.)

There is nothing near a standard for further first aider training. The NHS ambulance technician and paramedic courses provide excellent training, but of course are aimed at the professional rescuer and may only be taken by NHS personnel. The SJA and Red Cross have their own advanced courses which may vary by region, but the core syllabuses are usually the same nationwide. These courses have their own deficiencies which we shall discuss later. The Pre-Hospital Trauma Life Support course (PHTLS) currently taught in the United States is intended to be spread world-wide. It is a 2-day course aimed at people who regularly encounter trauma casualties (those injured by impacts, such as long falls, car accidents or physical assault) and who have already trained to the EMT standard. As such, it is of very limited use to most first aiders.

The First Aider

The First Aiding Bystander

In the UK, the popularity of programs such as "Casualty" (a drama series set in an Accident and Emergency department, in some ways the British "E.R.") and "999" (re-enactments of actual life-threatening incidents) means that a relatively high percentage of the adult population know the very basics of first aid. I would define these basics as:

1. Moving injured people is a bad thing
2. You can check whether someone is breathing by listening over their mouth -- if they're not breathing then you need to call an ambulance
3. To get an ambulance, dial 999 and ask for the ambulance service

We can reasonably expect that in any crowd (5 or more people) around an injured person, at least one of the crowd will know the above rules.

Beyond this, any further help to the casualty will come from either a first aider or someone with medical training such as a nurse, doctor or (if the casualty's guardian agent is doing their job) an off-duty paramedic.

It is worth noting that the general experience of first aiders is that many doctors' first aid knowledge leaves a lot to be desired. This is much less true of doctors trained in the past 5 years, but even A & E consultants have been known to be temporarily stymied in a situation where no skilled help or equipment is available.

If a bystander is trained in first aid, then to make a difference he or she will be required to:

• Identify themselves as a first aider and step forward
• Take charge of the situation, possibly ordering other bystanders to step away from the casualty
• Safeguard the safety of themselves, bystanders and the casualty
• Accurately assess the condition of the casualty
• Perform life-saving interventions such as opening of airway, C-spine immobilisation and control of major bleeding where needed.
• Arrange for calling of the ambulance if appropriate
• Organise the remaining bystanders to provide help
• Reassure the casualty and any relatives or friends present
• Monitor the casualty's condition and give any further aid appropriate
• Upon arrival of the ambulance, hand over the casualty to the paramedic with a concise and accurate summary of the history, injuries found and treatment given.

This is a lot to ask of a first aider even at their best, and on average the FAW-trained bystander will have gone 1.5 years since their last training course.

Of the FAW courses I have experienced as a student (one SJA four-day course, one 4-day course at an independent training organisation in Staffordshire and one SJA 2-day refresher) none have provided anything close to the instruction which I regard as necessary to manage a situation such as the above. The focus is always on treatment skills which, while valuable, count for little unless the first aider has the overall situation under control.

The Workplace First Aider

On one site at which I worked there were three first aid skilled personnel, myself included. However, the only one of us who was actually in the office over 80% of the time was an office assistant who had recently taken her FAW with St. John. She was very nervous about the prospect of actually treating someone, feeling that while she had adequately learned what was taught, there was a big gap in how this translated into reality. As she was a bright lady, it was not a question of ignorance -- she simply had no idea what it would be like when someone really got injured.

This is the biggest problem with workplace first aiders. Their practical experience of injured people could easily be non-existent. How do you get them over the hurdle of their first casualty without their confidence or the casualty being harmed?

Incident Exercises

Each term, one of these meetings is devoted to an "Incident Exercise". This is typically organised by one of the trainers, with the help of other members of the group. Its purpose is to provide an opportunity for group's first aiders to deal with a situation involving multiple serious casualties and a complicated scenario. Normally 5-10 people act as first aiders, with a similar number playing casualties and bystanders.

While the scenario is typically somewhat outrageous and relatively unlikely to happen in real life, the purpose is not so much for the first aiders to practice for a specific incident as for them to make as many mistakes as possible. The exercise is typically very successful in this aim. The rationale is that after being in such a difficult, noisy and messy situation, the first aiders learn how they react and can start to relate what they've been taught in the classroom to an actual situation.

The actual benefits of participating in such exercises have been observed to be significant. The most noticable gains are in the ability of first aiders to work in a team, and in the application of a systematic approach to incidents (normally the DRS ABC form of the Primary Survey.) It has been found that a post-exercise debrief is helpful, as long as it is relatively short and focuses on the general performance of the team rather than that of individuals.

The obvious problem is that such an incident takes time and significant resources to organise. Even if realistic make-up is thrown out of the window, a good three hours from start to finish is realistic, with the incident starting about an hour and a half after the casualty and bystander actors arrive. Several people have to be around to manage the situation, instruct casualties on changes of circumstance if appropriate, and ensure that the safety of everyone participating is maintained.

Skills Required Of A First Aider

Self-Confidence

The first aider should be able to put themselves forward at the scene of an accident and take charge of the situation. They may have to face down someone else giving wrong or dangerous treatment, and ignore suggestions from the bystanders (the old classic, which I have personally heard, when someone has an epileptic attack is for someone to tell me to "stick a spoon in his mouth.") This takes considerable trust in one's abilities and knowledge.

A Strong Stomach

It may be labouring the obvious, but a tendency to faint at the sight of blood is not helpful for a first aider. This is not to say that they should take everything in their stride -- many first aiders feel nauseous when someone has been sick, and others may be very uncomfortable when needles are being stuck into people. But a basic ability to see a spurting arterial bleed and not faint is important. We have observed that people do become less averse to bodily substances over time.

Manual Dexterity

While first aiders need not have the fine motor control of a concert pianist, there are a number of first aiding skills which are awkward for someone who is all fingers and thumbs.

Reasonable Fitness

It is not unrealistic to suggest that if a workmate collapses with a heart attack and goes into cardiac arrest, the ambulance crew will not be on scene for at least 15 minutes even if called immediately -- the time taken by them to get from their vehicle to the scene may be substantial. The first aider may well be the only person skilled in CPR. Doing this for 15 minutes is hard work. The first aider should also have reasonable physical strength, not so much for lifting people as for manual immobilisation of limbs and head.

Knowledge

"A little learning is a dangerous thing -- drink deep, or taste not the Pierian spring" suggested Alexander Pope. He was half-right as far as first aid knowledge goes. It's always possible to delve deeper, so the pragmatic first aider has to choose when to stop. Of course, their instructor may make this decision for them; I have had a trainer on one course tell me that tying a tight bandage around the chest of a casualty with fractured ribs is an excellent idea. But I digress. I would say that the knowledge that a first aider requires consists of the current protocol for adult CPR, understanding of the very basic physiology of the human circulatory and respiratory system, knowing that a clear airway is the most important need of a casualty, and an understanding that moving a conscious casualty suspected of having broken something is generally a bad idea.

Knowing One's Limits

A first aider who attempts a tracheostomy with a steak knife and ball-point pen has watched one too many episodes of E.R. They should appreciate their limitations and act accordingly. A tendency to call for an ambulance early in a situation is far from a bad thing.

Trustability

Inherent in what they do, the work of a first aider implies substantial trust in them by their casualties. They are to be trusted to keep their skills and knowledge up to date, to give a casualty the best care possible, not to take personal advantage of information they gain by being a first aider, and not to act unprofessionally when examining an injured casualty. Hence, it is a good idea for them to be trustworthy.

The Sympathetic Ear

These first aiders generally learn their first aiding skills because of a caring personality that wants to be able to help others. They will, if other options fail, sit up most of the night with a tearful (and very drunk) casualty lending an ear while the casualty pours out their heart (and occasionally bits of their last meal) over the mean boy/girlfriend who's just dumped them.

The Well

These first aiders possess an unusual ability to absorb knowledge and skills. They tend to approach first aid classes as just another set of lectures, and read around the subject. They will tend to push hard for the opportunity to attend more and more advanced classes. Their weakness is usually that their knowledge outruns what they are permitted to do legally (and they are aware of this), causing some frustration.

The Medic

University first aid groups are in the unusual situation of having a high number of medical students as members; normal first aiding groups such as SJA divisions will either have fully fledged doctors / nurses, or pre-university students. Their medical knowledge is extensive, but other than that all the basic first aiding types are found. Many of them end up specialising in A & E medicine, and are generally very good at it.

The Repressed Paramedic

These first aiders are best seen at an incident where someone is seriously ill or injured. Their hallmarks are a calm and controlled appearance, rapid and effective treatment, ability to control the scene, and general good organisation. If the casualty stops breathing, these people are likely to have anticipated it and got a bag and mask to hand already. Note that you see this whatever the level of training -- such skills are generally naturally present in these people.

The Teacher

These first aiders have a natural or acquired skill in teaching, and are keen to communicate first aid skills to others. Often they are or become teachers or lecturers in their chosen career. Their weakness is generally that it is hard to keep personal first aid skills and knowledge current while teaching a busy course schedule.

What Is Wrong

Training

Poor BLS training

This really is not excusable. The training for basic life support skills should use a reasonably realistic mannikin (the Laerdal Resusci-Annie, for instance), with no more than one between 6 students. Each student should have at least four cycles of CPR practice, together with around 30 seconds of artificial ventilation, all supervised closely by the instructor. Experience has shown that one instructor can monitor students on two Annies, just about, but nothing more.

Inaccurate teaching

There are times when this is understandable, and times when it is not. If the instructor is asked a question slightly outside his or her expertise, there is an understandable temptation to bluff or guess an answer; this is a temptation that should be resisted, but it generally does not do much harm. The real damage is done when incorrect, out-of-date or harmful techniques are used. A particular danger comes when the instructors for an organisation (or certain area of a large organisation) requalify their skills at that same place. This creates a feedback cycle of bad techniques, and is to be avoided at all cost.

Over-easy examination criteria

The generally accepted standard for first aiders in the workplace is "safe, prompt, effective." There seems to be too much latitude in what is accepted in FAW exams, generally more so in the injury scenario than in the resuscitation section. I have taken courses where I estimate that 30-40% of the students did not fulfill these criteria, yet nearly all of them passed. Some definitive and standardised guidelines on which errors would require re-testing, and which immediate failure, would be helpful.

Teaching obsolete skills

There is, in my opinion, too much of an emphasis on teaching skills such as scalp bandaging which has very limited utility at any level of first aid. Slings are certainly useful, but hand and scalp bandages less so. Immobilisation of fractured limbs with multiple narrowfold triangular bandages should have no place in most workplaces; far better to focus on effective manual stabilisation. A figure-of-eight around the feet to hold legs together for an injury such as a fractured pelvis is as far as it should go.

No handover skills taught

Any workplace first aider is likely to have to hand over a casualty to an ambulance crew at some stage. Since an effective handover is not often done, it would make sense for the course to spend at least quarter of an hour on this topic.

Voluntary Societies

Slow reaction to training changes (particularly in resusc)

This is an inevitable problem with the larger organisations, but is present in smaller ones too and in both cases there are steps which can be taken to alleviate it. St. John has recently taken the positive step of requiring all its members to requalify adult, child and baby BLS each year; this is an excellent idea and all such organisations are encouraged to adopt it.

Restricted access to defibrillator training

Modern automatic defibrillators are extremely simple to operate, and there is absolutely no reason why every first aider of the FAW skill level should not be trained to use them if they are available. There is a reasonable case for extending this training to BLS-qualified first aiders, but this may be going too far for now. While manual defibrillators are clearly the preserve of paramedics and other ALS providers, the wider that AED training is distributed the better.

Over-emphasis on rank

In any ranked organisation it is inevitable that there will be problems; however, the wise man does not actively invite them with the structure and conduct of his organisation. Too often the treatment of casualties is directed by the highest-ranking first aider rather than the most capable -- there is little correlation between the two.

Attempt to dominate UK first aiding

The rivalry between SJA and the Red Cross goes back many years, and is usually friendly. However there have been numerous incidents where an established Red Cross or SJA division has reacted with rancor to the appearance of a different organisation on what it regards as its "territory". There is also some concern that the Red Cross and SJA have persuaded the HSC in its "Purple Book" on first aiding at mass crowd events that their first aiders, and only their first aiders, should be recognised for such purposes. This is unjustified and is likely to do substantial harm in the future.

Conclusions

Proposals For Improvement

1. Make it compulsory for workplace first aiders (holding First Aid at Work) to renew their Basic Life Support skills every year on a 2-hour course covering CPR and the recovery position.
2. Create and fund a national organisation to define and publicise current first aid practice. This should be independent of any first aid teaching organisation, although it should liaise with them as well as with the HSC, Resuscitation Council (UK) and appropriate international EMS and first aid organisations.
3. Include First Aid on the National Curriculum as one day every school year between ages 8 and 14. Estimated cost: based on 700 000 children per school year, 6 school years, one trainer per class of 30 at ukp 60 per day is ukp 8.4 million.
4. Specify a four-day Advanced First Aid course as part of the HSC regulations, to be taken by first aiders in dangerous workplaces (e.g. oil and gas platforms, the fire and police services and large industrial plants). This should cover the essentials of trauma, spinal immobilisation with collars and backboards, splinting, use of oxygen and Entonox, and a systematic approach to the critically-injured casualty.

Summary

The major deficiency is that there is very little standardising of first aid practices; the major first aid training organisations provide training that has significant flaws, and diverges in points from the advice of those organisations that should be listened to. There is, in effect and in law, no regulatory organisation for first aid practice and teaching.

First Aid is very hard to do well, and the consequences of it being done badly can threaten life and limb. People being certified as first aiders today are not equipped to deal with situations that they may reasonably be expected to face. It only takes a minimal investment of legislation and financing to improve this situation substantially. If only 20-40 lives per year are saved, this investment will more than pay for itself.

References

• [1] The Hillsborough Report
• [2] The Purple Book, Guide to first aid provision at large crowd events, The Health and Safety Commission
• [3] First Aid In the Workplace, Approved Code of Practice, Health and Safety Commission, April 1997
• [4] The First Aid Manual, Joint Voluntary Services, April 1997
• [5] The Health And Safety At Work Act, 1974
• [6] Resuscitation for the Citizen, The Resuscitation Council (UK), 1997