True story: I went out to eat in Toronto at a Chinese restaurant several years ago. A young boy one table over started to choke on a piece of food. Before anyone at his table, which included his hysterical mother, or my table, which included several EHS managers trained in first aid and emergency response, could get to him, a swarm of servers from the restaurant surrounded him and the only words I could make out in a torrent of Chinese was “Heimlich.”
As it turns out, choking is a workplace risk in a restaurant and that forward-thinking employer had provided training in cardiopulmonary resuscitation (CPR) and the Heimlich maneuver to his employees. The boy was fine; probably better off than his mother, who looked like she was in need of some first aid herself after that experience.
One thing is certain about first aid in the workplace: it’s not just about splints and aspirin anymore. But what should employers and safety managers be prepared to provide in terms of training, tools and supplies for employees?
Mary Fran Hazinski, a registered nurse at Vanderbilt University Medical Center in Nashville and compensated senior scientist for the American Heart Association, notes, “Remarkable advances in the workplace have influenced workplace safety and the prevention of injuries.” These advances, she says, greatly have reduced what were once thought to be the “traditional” workplace injuries of cuts, sprains and strains and broken bones. While the contents of first aid kits are used on a regular basis and should be replenished and refreshed, the direction of first aid efforts in the workplace is changing.
Now, says Hazinski, first aid efforts are refocused on detecting signs and symptoms related to breathing problems, allergic reactions, heat stroke and cardiac arrest. In other words, critical situations when immediate action, whether by coworkers or trained first responders, can save lives.
“The emphasis is on training and technology – such as automated external defibrillators (AED) – and planning and practice. The more practice, the better the response when an emergency occurs,” says Hazinski. “Training is focusing on the critical things that make a difference, like performing effective CPR, using an EpiPen [a prescribed treatment for people with a history of anaphylaxis, a life-threatening allergic reaction to foods or insect stings], recognizing when someone with diabetes is suffering from abnormal blood sugar and using an AED. We’ve realized that recollection of minor things limits the recollection of major things, so training is focusing on the major things.”
Richard Kowalski, RN, COHN-S, president of the American Association of Occupational Health Nurses and president of Northern Michigan Occupational Health Consultants, spent 32 years as a supervisor of regional medical services for GM and Delphi. He says that by the time he retired, “Much of the on-site first aid that once was provided by a nurse was being handled by other employees. Occupational health nurses moved into OSHA recordkeeping, employee health education, wellness, supervising OSHA-mandated testing and workers’ comp case management. With EMS 10 minutes or less away, nurses almost have been outsourced out of [traditional] occupational health.”
What OSHA Says
OSHA, for the purpose of recordkeeping, defines first aid as “medical attention that is usually administered immediately after the injury occurs and at the location where it occurred. It often consists of a one-time, short-term treatment and requires little technology or training to administer. First aid can include cleaning minor cuts, scrapes, or scratches; treating a minor burn; applying bandages and dressings; the use of non-prescription medicine; draining blisters; removing debris from the eyes; massage; and drinking fluids to relieve heat stress.”
“There is no federal government regulation that specifically defines the content of a first aid program,” says Ralph Shenefelt, executive program director for the Health and Safety Institute (HSI), which produces the American Safety and Health Institute (ASHI) and MEDIC FIRST AID brands of emergency care training materials, MEDIC FIRST AID International, and a former firefighter/paramedic and member of the International First Aid Science Advisory Board. “Each employer needs to look at the workplace, review the risks and provide training to meet those risks. Employers often don’t have that skill set, so there’s a default to a national training organization [such as the American Red Cross, the American Heart Association, ASHI or Medic First Aid], where first aid programs generally focus on high frequency or high criticality-type issues.”
When considering first aid program content, Shenefelt suggests employers refer to OSHA’s “Best Practices Guide: Fundamentals of a Workplace First-Aid Program,” which was released in May 2006.
The guide identifies four essential elements for first-aid programs to be effective and successful: management leadership and employee involvement, worksite analysis, hazard prevention and control and safety and health training. The guide details the primary components of a first-aid program at the workplace:
- Identifying and assessing workplace risks;
- Designing a program that is specific to the worksite and complies with OSHA first-aid requirements;
- Instructing all workers about the program – which should be in writing – including what to do if a coworker is injured or ill; and
- Evaluating and modifying the program to keep it current, including regular assessment of the first-aid training course.
The guide also recommends that first-aid training courses include instruction in general and workplace hazard-specific knowledge and skills, incorporate AED training with CPR training if an AED is available at the work site and periodically repeat first-aid training to help maintain and update knowledge and skills.
The Evolution of First Aid
Prior to the 1960s, basic emergency response service (EMS) primarily was provided by ambulances owned by mortuary services, which, unfortunately, is indicative of the anticipated survival rate at the time for most cardiac arrest and severely injured accident victims. Bill Rowe, an EMT-paramedic who is the director of Product Development for the Health and Safety Institute, remembers a slogan that described many of these services: “You call. We haul. That’s all.”
At that time, says Rowe, first aid training focused on “providing as much detail as possible, for whatever emergency situation that could occur. Since there wasn’t a reliable EMS service, you did as much as you could before the person was transported to a doctor’s office or hospital.”
As EMS services became faster and more reliable and responders were trained in more advanced medical care, providing detailed first aid training such as splinting became unnecessary. “One of the biggest reasons for splinting is to prepare a person who might have a fracture to be moved or transported. If EMS was coming to pick the person up, it was much easier and less risky for the first aid trained provider to simply keep the injured person still, and let EMS do the splinting before the patient was moved,” says Rowe.
“Today, the premise in an urban environment is that EMS is responding, so what do you need to know in the first 10 minutes before EMS providers arrive?” he adds. The answer is to focus first aid providers on problems that are or may become life-threatening prior to the arrival of EMS. In many cases, that is how to conduct CPR and use an AED.
The American Red Cross estimates sudden cardiac arrest claims the lives of more than 166,000 people in this country every year. An astonishing 94 percent of people who suffer sudden cardiac arrest die before reaching a hospital. For every minute without defibrillation, a sudden cardiac arrest victim’s chance of surviving drops.
It is critical for as many people as possible to be trained to perform CPR and know how to use an AED, and the Red Cross recommends at least one person in every household and workplace receive CPR and AED training. If coworkers or bystanders immediately take action with CPR and use an AED, instead of waiting for help to arrive, many thousands of lives can be saved every year.
“American Red Cross training helps save lives at home, school and the workplace,” says Scott Conner, senior vice president for American Red Cross Preparedness and Health and Safety Services. “We are committed to saving lives, one by one, and improving the quality of life in communities nationwide.”
“Train as many people as possible,” Shenefelt advises employers. “Just training one or two people doesn’t mean you’ve addressed the risk. If something happens and one of those people is on vacation and the other one is out sick and there’s no one else trained in first aid, you obviously have a problem. In the workplace, providing first aid training to all employees, rather than limiting it to a small number of designated first aid providers, may also help reduce both the frequency and severity of occupational injury and illness as first aid training has been shown to improve a participant’s motivation to avoid occupational injuries and illnesses. First aid training can also have a positive effect on personal safety. It has been shown to cause people to take fewer risks in traffic and to provide more immediate and adequate first aid at traffic crashes and other emergencies.”
Rowe points out that much as been learned about training and retention in the past 20 years, “about how much info to give people in a very short time and have them retain it.” As a result, he suggests employers “make training simpler, shorter and more to the point. Retention and simplicity.”
Most organizations offering first aid training – like the American Red Cross, the American Heart Association and ASHI – have retooled their training procedures to reflect this “less is more” approach.
Last year, approximately 11 million people took Red Cross health and safety training. But there still is a long way to go: Even adding those receiving training from other sources means that most people have not received first aid training.
Training Keeps Up With Science
With some of the new AEDs on the market, training, while advised, is not necessary. Rowe notes that advanced technology is taking the guesswork out of CPR and AEDs, with many products now offering step-by-step voice and written prompts that “talk” rescuers through the process.
Rowe mentions the AutoPulse, a non-invasive cardiac support pump from Zoll, which provides consistent heart compressions with no interruptions.
Hank Constantine, Zoll’s director of marketing for AEDs, says the device creates a 90 percent blood flow, whereas regular CPR might provide a 30 percent blood flow. The greater the blood flow, the better the chance of survival, he adds.
“When someone collapses suddenly, you have to be prepared to give good CPR and apply defibrillation to shock the heart back into a regular rhythm,” says Constantine, noting that once a shock is applied, 40 percent of victims don’t have a regular rhythm and heart compressions must be continued until help arrives. That’s why instruments such as AutoPulse or Zoll’s PocketCPR, which provides chest compression coaching and is small enough to fit in the palm of the hand, can be so helpful for untrained bystanders or workers.
He suggests that employers place AEDs in locations that can be reached within a minute or two of an employee collapsing, because the survival rate for victims of cardiac arrest drops so dramatically every minute the heart is not shocked back into a regular rhythm and blood flow through the body is hindered.
Hazinski also offers advice to perform effective CPR by hand. “Call 911 and start chest compressions” if someone appears to be in cardiac distress, Hazinski advises. “Place your hands in the center of the chest at the nipple line and push as hard as you can at a rate of 100 times a minute, which is the beat to the Bee Gees song ‘Stayin’ Alive.’ After you press down, release completely. If you do nothing, that person will almost certainly die.”
Determining What Works
Shenefelt says there is an “international effort to determine what really works in first aid.” There is, he says, “a search for scientific evidence that first aid treatment recommendations are safe, effective and helpful.”
One thing is certain, says Rowe: “There has been a paradigm shift to bystanders as the focus of training for an immediate life-threatening event. The general public, home or workplace can become the ultimate emergency room for sudden cardiac arrest, and for other life-threatening events.”