Training for First Aid Teams or First Aid Responders Part II
What can we learn from OSHA's training guidelines? Their scope goes well beyond the generally understood meaning of "first aid."
Beyond the Scope of EMT Practice
While OSHA says the training should match the hazards and be tailored to the workplace, its Guidelines for First Aid Training Programs include enough subjects that by the time you complete this program, you will have more training than an Emergency Medical Technician.
Says Ralph Shenefelt of American Safety & Health Institute and a co-investigator of the National Guidelines for First Aid Training in Occupational Settings, "Actually, in many areas, OSHA's Guidelines for First Aid Training Programs exceed the current scope of practice for an Emergency Medical Technician (EMT-Basic), especially the diagnostic differentiation and management of a major illness or significant trauma. For example, these guidelines recommend that a training program should include instruction in 'pregnancy including the appropriate care of any abdominal injury or vaginal bleeding.' Since assessment is fundamental to care, does OSHA believe that it is appropriate for a layperson to assess the abdomen or vagina of the pregnant woman in the workplace? If so, what should the assessment include and how should it be conducted?"
William Mehbod, EMT-P, a First Aid, CPR, and EMS instructor with 20 years of experience, says, "I feel that if someone is injured badly enough that they need to have a possible fracture splinted, then EMS needs to be called. EMS can achieve this easier and the patient can be transported with less discomfort. Certain cases exist when someone may require aid in the wilderness and needs to be moved to a less remote area before EMS can be reached. In this case, responders who may encounter these situations should be educated in splinting. I usually explain what we are trying to achieve by splinting a fracture, immobilization of the broken bone ends and the joints above and below the fracture, but this is the extent of what I recommend teaching the lay rescuer."
Consider how appropriate the subject matter is to individual work sites. Should an all-male organization concern itself with pregnancy emergencies? Should a downtown office be concerned with dog and snake bites, rabies prophylaxis, and flail chest? In fact, how would someone at virtually any work site diagnose flail chest, and what would they do about it? Flail chest is "a blunt chest injury in which three or more ribs are fractured in two or more places or in association with a sternal (breastbone) fracture so that a segment of chest wall is effectively detached from the rest of the thoracic cage." (James D. Hickman, MD, editor. American Academy of Orthopedics. Emergency Care and Transportation of the Sick and Injured. Fifth Edition 1992: 372.) How many of those have you seen lately?
As noted above, not only does the scope of the OSHA Guidelines for Basic First Aid Training Programs go well beyond the generally understood meaning of "first aid," but it also conflicts with OSHA's First Aid Rules for both general industry and construction. The Construction Standard requires the designated first aider to be trained to the level of the American Red Cross Basic First Aid training or equivalent. Similarly, OSHA Instruction CPL 2.2, dated Oct. 30, 1978, states:
Persons who have a current training certificate in the American Red Cross Basic, Standard or Advanced First Aid Course shall be considered as adequately trained to render first aid in fulfilling the requirements of . . . 29 CFR 1910.151(b). The American Red Cross Standard Course is the recommended MINIMUM level of first-aid training.
It appears the expansive scope of the OSHA Guidelines for Basic First Aid Training Programs reflects an effort by OSHA to amend its First Aid Rules for both construction and general industry without rulemaking by persuading the providers of that training they needed to expand the scope of their training programs.
NGFATOS and ASTM
In 1994, the State of Washington Department of Labor and Industries, in an effort to relieve itself of the burden of reviewing and approving occupational first aid programs, established the Washington State First Aid Training Task Force, Guidelines Development Group.
The guidelines the task force developed were based on the idea that the person who delivers first aid is an integral part of the Emergency Medical Services System. The task force members felt teaching first aid providers the same priorities of care and process of patient evaluation and treatment used by professional responders was important to good continuity of patient care. To accomplish that, they developed the guidelines by looking to the National Highway Traffic Safety Administration's revised First Responder: National Standard Curriculum.
According to the preface of the National Guidelines for First Aid Training in Occupational Settings, NGFATOS were born "as a result of the reality that no contemporary document existed to standardize first aid training program content for those with an occupational requirement to be first aid trained on a national basis." NGFATOS says OSHA's CPL 2-2.53, the guidelines of 1991, are "inconsistent with and often exceed the national standard curricula for professional emergency medical personnel." They believed the first aid provided by the person "in the occupational setting should be consistent with, but not made equivalent to, the expert level of proficiency attained by professional emergency medical personnel."
In a section of the NGFATOS preface, the authors discuss ASTM Standard F 2171-02. NGFATOS co-investigators worked with ASTM to develop the new standard on first aid training, so the two are similar. The one difference noted is that NGFATOS supports automated external defibrillators in the workplace and while their use is not part of the regular curriculum, it is included in an enrichment program. ASTM F 2171-02 (220.127.116.11) requires AED training when an AED is "available in the workplace."
The Consideration of Time
The time required to complete the topics on OSHA's list would be much longer than most companies allot for first aid training. Currently, it takes 120 hours plus 10 hours of clinical experience to complete the EMT-Basic curriculum, the equivalent of what OSHA is suggesting. How many companies are willing to commit to just eight hours of training for their employees?
In general, employers say their biggest expense when providing training is the cost of the employees' time. So an eight-hour class for 20 people who are paid $20 per hour is $3,200 in employee costs alone. Add in the cost of lost production time or the cost of overtime for people to cover production, and annual training can be pricey, especially for the small company.
But what is the cost to the company if care for an injured employee is delayed because there are no first aid-trained people on site? Perhaps the injury becomes more severe--resulting in more time away from work, more time in the hospital, or the need to receive additional medical services such as therapies. Perhaps the employee dies. Now, there are serious worker's comp costs and other insurance costs, death benefits, and the potential for lawsuits. If the employee must be replaced, there would be the time and cost of finding, hiring, and training a new employee. Training might be cheaper.
Other Considerations for Choosing A Program
Once a company decides to provide training, there are questions to be answered. Who will be trained? What topics should be covered? How do you want the training to be conducted?
Company philosophies on which employees should be trained vary. Some companies, usually smaller ones, allow all employees to participate in training. Others want representation from all physical areas; for example, a couple of people from the office, some from each area of manufacturing, and some from the warehouse. Then, there are the companies that want only supervisory people to take training. Some ask for volunteers, thinking not everyone is suited to providing first aid. Jaime Elledge, benefits and safety administrator at Hopkins Printing in Columbus, Ohio, says the company asked for volunteers in representative numbers per shift.
The first aid training's subject matter may not be negotiable, depending on the organization providing the training. Some trainers know only one way to conduct the class, and everyone gets the same class regardless of the nature of the company. You may not want to settle for that kind of training program. Keep in mind that OSHA says the first aid program must correspond to the hazards that can reasonably be expected to occur in the workplace. Conduct your own training needs survey and go from there.
What are your company's hazards? What kinds of injuries and illnesses do you experience most frequently? Given the age distribution of your employees, what medical problems might they have? What is a reasonable response time for Emergency Medical Services? What kinds of first aid emergencies do you want employees to respond to, and how much do you want them to do prior to the arrival of EMS? How close are area hospitals, including those capable of dealing with serious trauma?
To get the some of the answers to these questions, ask questions of others. Talk to a doctor or nurse if one is part of your company or if your company is affiliated with a hospital system's occupational health service. Make friends with your local fire department and Emergency Medical Service and ask department personnel for their opinions. Talk to people within your company: office and plant personnel, salaried and hourly. What is their vision of a good first aid program?
It should be an interactive program that allows participants to have some hands-on time and time for questions. A program that only gives employees time to watch a video or use a computer program will not be adequate. (See OSHA's Nov. 22, 1994, letter on the use of computer-based training to satisfy OSHA training requirements.)
If you choose an outside training organization, ask questions of its personnel, too. What qualifies them to teach first aid? How many years of experience do the instructors have? If you tell them you have the horrible chemical dimethylethylcrud at your facility, will they include information on dimethylethylcrud? If you ask them to emphasize your company's emergency procedures, will they take notes and include that information at your class? Do they offer different levels of training for people with different levels of experience and different needs?
If you are required to have a first aid team at your site and the training organization determines that the first aid responders at your site need eight hours of training, do not ask them to compress that into two hours because your company cannot spare the time. If you are not required to provide first aid and ask them to compress eight hours of training into two hours because your company cannot spare the time, will they agree? If you suggest this, shame on you. If they agree, shame on them. Your employees will not have had first aid training as that term is generally understood, and any representation to the contrary exposes the employer to significant liability should things go wrong.
First aid training should be relaxed. It should not instill fear in the students. Good first aid training should make students feel they can handle the basics of most emergencies until additional help arrives. Training also should be honest; it would be unfair to withhold the ugliness of emergencies, leaving students to discover them in the middle of an emergency. Good instructors must include information about patients vomiting and losing control of bowel and bladder during some medical and traumatic emergencies. Students need to be cautioned that not every patient will be sweet and kind and grateful for the attention. Some patients, often as a result of their illness or injury, become mean, nasty, and occasionally combative. If first aid providers are not warned about this tendency, they could easily become the next victims.
What is a confused safety professional--or whoever else is responsible for first aid training--supposed to do? Do the right thing. Provide a training program that will train to your company, its employees, and your potential emergencies. Pick a trustworthy trainer or training agency. Commit to the time and money needed for the training. You might just end up saving a life.
This article originally appeared in the July 2003 issue of Occupational Health & Safety.