Training for First Aid Teams or First Aid Responders Part I

What can we learn from OSHA's training guidelines? Their scope goes well beyond the generally understood meaning of "first aid."

HE sounded just like a hundred other managers: "We don't need a trained first aid team for our site. We're only five minutes from the hospital, fer cryin' out loud!" His pronouncement was right up there with "We can't afford to do first aid training in this economy" and "If someone gets hurt we'll just call 911, that's what they're for." These are common proclamations from people who do not necessarily see the value of first aid teams and the associated training.

All too often, first aid training receives only a cursory glance. Along with other aspects of safety, first aid is frequently among the last items approved for any given budget year and among the first items cut when finances are tight. That may well be a shortsighted approach to both safety and budget. It also may reflect a concern by some that OSHA has transformed basic first aid training into medical training. There are reports of employers that eliminated first aid teams after OSHA adopted its Bloodborne Pathogens Standard because they were not willing to incur the far greater costs of implementing the Exposure Control Plan required by that standard.

There are many reasons to conduct first aid training. Some might say OSHA compliance is at the top of the list. Others cite self-preservation: If I get hurt, I want someone around who can help me right now. Then there are those enlightened souls who understand that having trained people to respond quickly in case of an emergency actually can save them time, energy, and possibly money.

In the preface of its second edition, the National Guidelines for First Aid Training in Occupational Settings (NGFATOS) cites economics as an important reason to provide rapid first aid intervention. It says according to NIOSH, an average of 9,000 workers sustain disabling on-the-job injuries, 16 workers die from an on-the-job injury, and 137 workers die from work-related diseases each day. Also in the preface, NGFATOS references NIOSH data as saying the direct and indirect cost of occupational injuries and illnesses is $171 billion annually.

There are indeed legal reasons to provide first aid training for employees. OSHA's Medical Services and First Aid Standards are a good place to start. Although they have many common elements, there are distinct standards for general industry activities (Section 1910.151) and construction activities (1926.50). Both standards are interpreted to mandate: 1) "the availability of medical personnel for advice and consultation on matters of (occupational) health"; 2) the availability of a person adequately trained to render first aid in the absence of an infirmary, clinic, or hospital that is either "in near proximity to the workplace" or "readily accessible in terms of time and distance to the worksite"; 3) readily available first aid kits; and 4) suitable and immediately available facilities "for quick drenching or flushing of the eyes and body" in work areas where there is potential exposure to corrosive materials. In addition, OSHA's First Aid Standard for Construction requires the employer to arrange in advance for prompt medical treatment of serious injuries and to provide either prompt transportation to a medical facility in an appropriate vehicle or a suitable communication system for contacting a nearby ambulance service.

Defining 'First Aid'
While the language of OSHA's First Aid Standards is fairly brief, there is continuing uncertainty as to when an employer is required to provide first aid response and what services come within the definition of the term "first aid." The employer's obligation to have one or more trained first aiders whose job descriptions include providing first aid turns on what is meant by the phrases "in near proximity to the workplace" or "readily accessible in terms of time and distance to the worksite."

The confusion surrounding the phrase "near proximity" was recognized in litigation during the early 1970s. OSHA cited the operator of a freight handling terminal with 170 employees that operated 24 hours a day and did not have a trained first aider on site. The closest medical center was a hospital 3.25 miles away. Under optimal conditions, travel time to the hospital was seven minutes and an ambulance service driven by personnel with first aid training was four minutes away. The OSH Review Commission vacated the OSHA citation on the ground the phrase "near proximity" was impermissibly vague, making the rule unenforceable. A federal appeals court reversed the Review Commission, held the rule was not impermissibly vague and proclaimed: "In serious accidents causing severe breathing or breath stoppage first aid, to be effective, must be administered within 3 minutes."

Apparently basing it on that language, OSHA issued a Feb. 9, 1994 interpretation letter stating:

In areas where accidents resulting in suffocation, severe bleeding, or other life threatening or permanently disabling injury or illness can be expected, a 3 to 4 minute response time, from time of injury to time of administering first aid, is required. In other circumstances, i.e., where a life-threatening or permanently disabling injury is an unlikely outcome of an accident, a longer response time such as 15 minutes is acceptable.

Where first aid treatment cannot be administered to injured employees by outside professionals within the required response time for the expected types of injuries, a person or persons within the facility shall be adequately trained to render first aid.

In asserting the required response time starts to run from the time of the injury rather than discovery of the injury, OSHA appears to interject an idealistic but totally impractical standard into the mix--and there is no evidence it is one OSHA has enforced. To do so would require that each employee be continuously monitored by the employer.

In a letter dated Dec. 11, 1996, OSHA reiterated the Feb. 9 interpretation and further explained that "(t)he rationale for requiring a 4 minute response time is brain death when the heart or breathing has stopped for that period of time." OSHA then appeared to reverse course in an interpretation letter dated April 18, 2002. The question posed to OSHA was whether an employer could use the interpretation for "near proximity" (the 3-4 minute and 15 minute standards) in determining the quantity and location for required first aid supplies.

OSHA's surprising answer was as follows:No. The 3-4 minute (life-threatening) and 15-minute (non-life-threatening) time frames to which you refer apply to response and start times to administer first aid, dependent upon the severity of the injury. As an employer would not know in advance whether a life-threatening injury would occur, an employer should not use the 15-minute (non-life-threatening) time frame for determining the quantity and location of first aid supplies; however, the 3-4 minute (life-threatening) time frame would be acceptable.

All of these letters are posted on OSHA's Web site. On June 12, 2002, apparently recognizing that the rationale used in the April 18 letter had substantially if not completely undermined and superseded the previously discussed Feb. 9, 1994, and Dec. 11, 1996, letters, OSHA "edited" the Dec. 11 letter posted on its site by lining out the paragraph that provided the rationale for the separate 3-4 minute and 15 minute response times. The Feb. 9 letter remains unedited on OSHA's site, and the rationale for the separate 3-4 minute and 15 minute response times is also reflected in the discussion of the "Initial Evaluation" in Appendix F to OSHA's Permit-Required Confined Spaces Standard (which, fortunately, cannot be amended by unilateral lineouts). Where does that leave employers?

Carried to its logical conclusion, OSHA's position could be interpreted to mean that every employer must ensure first aid response can be administered to every one of its employees who are anywhere on its site within four minutes. Furthermore, as an OSHA interpretive letter of July 24, 1995, makes clear, "There are no exceptions from (OSHA's First Aid Standards) due to a company's size." Beyond the scope of this article are questions concerning back-up requirements (e.g., in case the designated first aid responder is injured) or first aid for contractor employees.

For those employers who have decided to provide trained and dedicated first aid response or are still considering the idea, the next question is: What services fall within the definition of the term "first aid"? The OSHA letter of July 24, 1995, also says: " . . . the employer's first aid program must correspond to the hazards which can be reasonably expected to occur in the workplace." This makes sense. Why should office employees spend a great deal of time learning how to provide first aid to people with chemical exposures if they never work in an environment with those types of exposures? They should spend more time concentrating on those emergencies (e.g., heart attacks, slips, trips) they are most likely to experience. However, as is clear from the following discussion, OSHA's July 24 letter should have said, "(T)he employer's first aid program must correspond to the hazards that can be reasonably expected to occur in the workplace, and must be limited to those activities that fall within the scope of the term 'first aid' as that term is generally understood or defined by the governing state medical authority or defined by the curriculum for the seven hour basic first aid course offered by the American Red Cross."

OSHA has its own unique ideas about what falls within the scope of first aid and first aid training. The problem is that they are conflicting, go beyond the commonly understood meaning of the term, and appear to call on employers to provide medical services that could only be provided by an EMT, nurse, or physician. OSHA's Guidelines for First Aid Training Programs (CPL 2-2.53, Jan. 7, 1991) list quite a variety of topics.

OSHA CPL 2-2.53
Guidelines for Basic First Aid Training Programs
Appendix A

I. GENERAL PROGRAM ELEMENTS

A. Teaching Methods

1. Trainees should develop "hands on" skills through the use of manikins and trainee partners during their training.

2. Trainees should be exposed to acute injury and illness settings as well as the appropriate response to those settings through the use of visual aids, such as videotape and slides.

3. Training should include a course workbook which discusses first aid principles and responses to settings that require interventions.

4. Training duration should allow enough time for particular emphasis on situations likely encountered in particular workplaces.

5. An emphasis on quick response to first aid situations should be incorporated throughout the program.

B. Principles of responding to a health emergency

The training program should include instruction in:

1. Injury and acute illness as a health problem.

2. Interactions with the local emergency medical services system. Trainees have the responsibility for maintaining a current list of emergency telephone numbers (police, fire, ambulance, poison control) easily accessible to all employees.

3. The principles of triage.

4. The legal aspects of providing first aid services.

C. Methods of surveying the scene and the victim(s)

The training program should include instruction in:

1. The assessment of scenes that require first aid services including:

a. general scene safety.

b. likely event sequence.

c. rapid estimate of the number of persons injured.

d. identification of others able to help at the scene.

2. Performing a primary survey of each victim including airway, breathing, and circulation assessments as well as the presence of any bleeding.

3. The techniques and principles of taking a victim's history at the scene of an emergency.

4. Performing a secondary survey of the victim including assessments of vital signs, skin appearance, head and neck, eye, chest, abdomen, back, extremities, and medical alert symbols.

D. Basic Adult Cardiopulmonary Resuscitation (CPR)

1. Basic Adult CPR training should be included in the program. Retesting should occur every year. The training program should include instruction in:

a. establishing and maintaining adult airway patency.

b. performing adult breathing resuscitation.

c. performing adult circulatory resuscitation.

d. performing choking assessments and appropriate first aid interventions.

e. resuscitating the drowning victim.

E. Basic First Aid Intervention

Trainees should receive instruction in the principles and performance of:

1. Bandaging of the head, chest, shoulder, arm, leg, wrist, elbow, foot, ankle, fingers, toes, and knee.

2. Splinting of the arm, elbow, clavicle, fingers, hand, forearm, ribs, hip, femur, lower leg, ankle, knee, foot, and toes.

3. Moving and rescuing victims including one and two person lifts, ankle and shoulder pulls, and the blanket pull.

F. Universal Precautions

1. Trainees should be provided with adequate instruction on the need for and use of universal precautions. This should include:

a. the meaning of universal precautions, which body fluids are considered potentially infectious, and which are regarded as hazardous.

b. the value of universal precautions for infectious diseases such as AIDS and hepatitis B.

c. a copy of the OSHA proposed Standard for occupational exposure to bloodborne pathogens or information on how to obtain a copy.

d. the necessity for keeping gloves and other protective equipment readily available and the appropriate use of them.

e. the appropriate tagging and disposal of any sharp item or instrument requiring special disposal measures such as blood soaked material.

f. the appropriate management of blood spills.

G. First Aid Supplies

The first aid provider should be responsible for the type, amount, and maintenance of first aid supplies needed for their particular plant. These supplies need to be stored in a convenient area available for emergency access.

H. Trainee Assessments

Assessment of successful completion of the first aid training program should include instructor observation of acquired skills and written performance assessments. First aid skills and knowledge should be reviewed every three years.

I. Program Update

The training program should be periodically reviewed with current first aid techniques and knowledge. Outdated material should be replaced or removed.

II. SPECIFIC PROGRAM ELEMENTS

A. Type of Injury Training

1. Shock

Instruction in the principles and first aid intervention in:

a. shock due to injury

b. shock due to allergic reactions.

c. the appropriate assessment and first aid treatment of a victim who has fainted.

2. Bleeding

a. the types of bleeding including arterial, venous, capillary, external, and internal.

b. the principles and performance of bleeding control interventions including direct pressure, pressure points, elevation, and pressure bandaging.

c. the assessment and approach to wounds including abrasions, incisions, lacerations, punctures, avulsions, amputations, and crush injuries.

d. the principles of wound care including infection precautions, wounds requiring medical attention, and the need for tetanus prophylaxis.

3. Poisoning

Instruction in the principles and first aid intervention of:

a. alkali, acid and systemic poisons. In addition, all trainees should know how and when to contact the local Poison Control Center.

b. inhaled poisons including carbon monoxide, carbon dioxide, smoke, and chemical fumes, vapors and gases, as well as the importance of assessing the toxic potential of the environment to the rescuer and the need for respirators. Trainees should be instructed in the acute effect of chemicals utilized in their plants, the location of chemical inventories, material safety data sheets (MSDSs), chemical emergency information, and antidote supplies.

c. topical poisons including poison ivy, poison sumac, poison oak, and insecticides.

d. drugs of abuse including alcohol, narcotics such as heroin and cocaine, tranquilizers, and amphetamines.

4. Burns

Instruction in the principles and first aid intervention of:

a. assessing the severity of the burn including first degree, second degree, and third degree burns.

b. differentiate between the types of third degree burns (thermal, electrical, and chemical) and their specific interventions. Particular attention should be focused upon chemical burns, and the use of specific chemicals in the workplace which may cause them.

5. Temperature Extremes

Instruction in the principles and first aid intervention of:

a. exposure to cold including frostbite and hypothermia.

b. exposure to heat including heat cramps, heat exhaustion, and heat stroke.

6. Musculoskeletal Injuries

The training program should include instruction in the principles and first aid intervention in:

a. open fractures, closed fractures, and splinting.

b. dislocations, especially the methods of joint dislocations of the upper extremity. The importance of differentiating dislocations from fractures.

c. joint sprains.

d. muscle strains, contusions, and cramps.

e. head, neck, back, and spinal injuries.

7. Bites and Stings

Instruction in the principles and first aid intervention in:

a. human and animal (especially dog and snake) bites.

b. bites and stings from insects (spiders, ticks, scorpions, hornets and wasps) Interventions should include responses to anaphylactic shock; other allergic manifestations; rabies and tetanus prophylaxis.

8. Medical Emergencies

Instruction in the principles and first aid intervention of:

a. heart attacks

b. strokes

c. asthma attacks

d. diabetic emergencies including diabetic coma, insulin shock, hyperglycemia, and hypoglycemia.

e. seizures including tonic-clonic and absence seizures. Importance of not putting gags in mouth.

f. pregnancy including the appropriate care of any abdominal injury or vaginal bleeding.

9. Confined spaces

a. the danger of entering a confined space to administer first aid without having the appropriate respiratory protection. If first aid personnel will be required to assist evacuations from confined spaces additional training will be needed.

B. Site of Injury Training

Instruction in the principles and first aid intervention of injuries to the following sites:

1. Head and Neck

a. including skull fractures, concussions, and mental status assessments with particular attention to temporary loss of consciousness and the need for referral to a physician.

b. including the appropriate approach to the management of the individual who has suffered a potential neck injury or fracture.

2. Eye

a. foreign bodies, corneal abrasions and lacerations.

b. chemical burns and the importance of flushing out the eye.

c. the importance of not applying antibiotics without physician supervision.

3. Nose

a. nose injuries and nosebleeds.

4. Mouth and Teeth

a. oral injuries, lip and tongue injuries, and broken and removed teeth. The importance of preventing inhalation of blood and teeth.

5. Chest

a. rib fractures, flail chest, and penetrating wounds.

6. Abdomen

a. blunt injuries, penetrating injuries, and protruding organs.

7. Hand, Finger, and Foot Injuries

a. finger/toe nail hematoma, lacerations, splinters, finger avulsion, ring removal, and foreign bodies.

b. the importance of identifying amputation care hospitals in the area. When an amputation occurs, appropriate handling of amputated fingers, hands, and feet during the immediate transportation of the victim and body part to the hospital.

Revision Date: Feb. 9, 2000

Please See "Training for First Aid Teams or First Aid Responders Part II" for conclusion of article.

This article originally appeared in the July 2003 issue of Occupational Health & Safety.

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