Science to the Rescue: Learning What Works in First Aid

The science behind first aid guidelines has been reevaluated, and, as a result, changes are coming in training practices and real-world applications.

Injury and illness on the job kill more than 2 million people around the world each year. That's 6,000 people a day. If a co-worker experienced chest pains or breathing difficulties, or severed an artery in an industrial accident, would you know what to do?

Every layperson who receives training in basic first aid hopes that he or she will never have to use it. When injury or sudden illness strikes, however, effective first aid can make a significant difference between life and death, rapid versus prolonged recovery and temporary versus permanent disability. By first aid, we mean "assessments or interventions that a bystander or the victim can perform with minimal or no medical equipment."

But what is effective first aid? Which common first aid procedures are truly helpful? Are familiar first aid procedures actually safe to perform? Conversely, are any of the currently recommended procedures harmful? Most importantly, what is the scientific evidence behind first aid?

Evaluating the Evidence

You may have heard the phrase "evidence-based medicine." It refers to a movement to apply scientific method to the practice of medicine especially to long-established practices that never have been subjected to adequate scientific study. The advantage of basing medical treatment, including first aid protocols, on scientific evidence is that it is less subject to personal or professional bias.

In an attempt to answer some of the many questions concerning current first aid treatment recommendations, the American Safety & Health Institute (ASHI) joined 25 other nationally recognized organizations on the 2005 National First Aid Science Advisory Board (NFASAB). Co-founded by the American Heart Association Inc. (AHA) and the American Red Cross (ARC), NFASAB was charged with reviewing and evaluating the scientific literature on first aid.

NFASAB members agreed that first aid recommendations should be medically sound and based on scientific evidence. To this end, we reviewed data from the U.S. Centers for Disease Control and Prevention, Cochrane Reviews (evidence-based evaluations of the effects of various health care treatments), the U.S. National Library of Medicine, medical journals, textbooks and other sources.

Our research topics spanned a wide range: positioning a victim; oxygen delivery; asthma; allergic reactions; seizures; severe bleeding; wounds and abrasions; thermal, chemical and electrical burns; spinal injury; sprains; strains; contusions; fractures; snakebite; dental injuries; drowning; emergencies involving exposure to hot and cold environments; and poisoning.

Fact or Fiction?

What we found or, more accurately, what we did not find didn't surprise us. Scientific evidence for first aid treatment is scarce or lacking in many critical areas. As a result, much of what is recommended today is based on practical experience and the consensus of experts. While experience and expert opinion are valuable, treatment recommendations unaccompanied by reliable scientific facts can simply be wrong.

For example, the medical community has long recommended keeping syrup of ipecac on hand for the emergency treatment of poisoning. In fact, syrup of ipecac never has been proven effective and even can be harmful.

During the NFASAB evidence evaluation process, controversy emerged in critical areas such as the use of tourniquets, pressure points and extremity elevation to control life-threatening bleeding. Similarly, issues arose in less-critical areas, such as a preference for triple-agent antibiotic ointment over double- or single-agent antibiotic ointment for superficial wounds.

Although debate ensued on some topics, in many cases there simply was not enough evidence to argue for or against the currently recommended first aid protocol. This was frustrating because it often prevented us from defining which first aid treatments work and which ones fail to stand up to the rigors of scientific scrutiny.

Even so, the process was tremendously useful. It allowed us to make several authoritative recommendations that will provide reliable information, which a formally trained first aid provider can use to give an ill or injured person reasonable care and comfort while waiting for professional medical assistance.

New Consensus Recommendations

Beyond the science, we need to know much more about the first aid interventions that are recommended for the home and workplace. For example, we need to know more about the benefits of occupational first aid training: What is the effect on injury rates, severity and cost? Do different educational approaches produce different behavioral outcomes in first aid-trained workers? Do these outcomes translate to effective care? How much does effective first aid care reduce the physical and fiscal impact of occupational injury and illness? NFASAB hopes that its work will stimulate more research to help answer some of these important questions.

Even though the science is lacking, the humanitarian and common sense benefits of providing first aid seem obvious. NFASAB strongly believes that education in first aid should be universal; everyone can and should learn first aid.

The Latest Advice for First Aid Providers

As a result of NFASAB's review and evaluation of the scientific literature on first aid, the guidelines for several common procedures have been revised. Updated guidelines appear in bold type.

Bleeding: Apply pressure firmly and for a long time, until bleeding stops or paramedics arrive. Earlier guidelines also recommended elevating a bleeding limb above heart level and, if direct pressure is ineffective, pressing on specific arterial points. Evidence is insufficient to recommend for or against these practices or the use of tourniquets.

Thermal burns: Thermal burns should be treated with cold water as soon as possible, but direct application of ice to a burn can cause harm. Specifically, avoid cooling of burns with ice or ice water for longer than 10 minutes, especially if the burn covers more than 20 percent of a person's body.

Musculoskeletal trauma: Soft-tissue injuries include sprains, strains, contusions and fractures. Applying cold to these injuries decreases hemorrhage, edema, pain and disability. Cooling is best accomplished with a plastic bag or damp cloth filled with a material that undergoes a phase change (i.e., solid ice to melted ice), which is more effective than re-freezable gel packs. To prevent cold injury, limit each application of cold to periods of no more than 20 minutes and place a barrier, such as a thin towel, between the cold container and skin.

Minor wounds: To prevent infection, cleanse the wound with clean tap water until all foreign matter has been flushed. Apply triple-antibiotic ointment or cream only to a scratch or superficial wound a new recommendation.

Poisoning: Do not give water, milk or syrup of ipecac to someone who has ingested poison. Previous guidelines allowed use of these substances in certain cases after consultation with a poison control center, but they may be harmful and now are not recommended.

Next Steps

As of this writing, every major national and international training organization is in the process of developing evidence-based training materials to reflect the new treatment recommendations. Training material revision, publication and rollout are expected to continue throughout 2006.

In our organizations, ASHI and St. John Ambulance Canada, we have just signed an alliance to jointly develop and deliver updated and enhanced programs for CPR/AED, first aid, bloodborne pathogens, emergency oxygen, first responder, advanced cardiac life support and pediatric advanced life support. These next-generation programs will move toward harmonizing best practices used around the world while ensuring that individual countries' minimum requirements and guidelines continue to be met. For one of our joint clients, a large retailer, we are able to offer comprehensive training to all locations in the United States and Canada.

What Is the Public's Role?

If it's been a while since you or your employees participated in a recognized first aid training program, it's a great time to consider a refresher. While much remains for us to learn about what works and doesn't work in first aid, treatment recommendations have improved.

It is a frightening feeling to be faced with a person struggling for life and to be unsure what to do. Learning first aid is a great way to overcome this fear and prepare yourself to confidently provide effective care to someone who may urgently need it. Just in case you have to use that training.

Ralph M. Shenefelt is a paramedic, a member of the 2005 National First Aid Science Advisory Board (NFASAB), and executive program director of the American Safety & Health Institute, the third-largest training accreditation organization in the United States. Les Johnson is director of client services for the national headquarters of St. John Ambulance Canada, which is the Canadian affiliate of St. John, a worldwide, nonprofit, nondenominational training organization with a 90-year history of saving lives.

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