6 things to stop teaching in First Aid - now!
25th January 2021
A while back we launched a few polls on our Facebook page along the line of basic, core knowledge a First Aider should have.
The results were disappointing but not surprising.
More surprising was that given these polls were on a First Aid related page, the target audiences were those with at least an interest in First Aid, probably trained in First Aid and possibly First Aid trainers. This was not a poll targeted at the general population.
For far too long, so many things are still taught or taught badly, that really shouldn’t. This article does not go into the reasons for that but here are the things you need to stop teaching in First Aid, now!
1. Heart Attack & Angina are easily differentiated based on symptoms
The results here are not too bad, but still, a quarter of respondents believed that heart attack and angina are easily differentiated based on the casualty’s symptoms.
In books and websites, a heart attack is sometimes described as a ‘stabbing or vice-like central chest pain with a sense of impending doom’ whereas an episode of angina presents a pain that ‘radiates down the left arm or up into the left jaw’.
This is not only a gross simplification, it is wrong.
Both the signs and symptoms of heart attack and angina can present similarly as:
A vice-like, diffuse, crushing chest pain or sharp, localised, stabbing pain
A pain in the center of the chest, between the shoulder blades or radiating into either left or right jaw or arm.
Ranging from excruciating pain to mild discomfort, sometimes mistaken for indigestion.
The casualty may appear pale, sweaty, with difficulty breathing and a look of fear or panic in either case.
Given the similarities between the symptoms and also the triggers - exercise and stress for both - the signs and symptoms merely enable to us to recognise a potential heart problem, they do not allow us to differentiate between heart attack and angina.
2. You should never put your hands in the pockets of an unconscious casualty
Over a third of respondents believe this to be true. Why? The most common answer received is because of “sharps”. Yes, putting your hand inside somewhere you can’t see, there is a risk of sharps injury but…that risk is actually very low.
What sharps can one expect to find? Our nature always takes us to the dark place of ‘needles. Even crack-heads don’t routinely carry bare needles in their pockets. It really hurts.
For the same reason most people don’t walk around with broken glass, razor blades or barbed wire in their pockets.
A more pragmatic approach would be to encourage a dynamic risk assessment each time. If Gerald from the Accounts Department or Linda, one of the football mums, has collapsed, it is highly unlikely they are tweaking on meth.
If we are dealing with a homeless casualty who is found collapsed in a shop doorway, your suspicion of substance misuse should be raised.
Isn’t this politically incorrect typecasting? No. It is appropriate. Not all members of the lower socio-economic classes misuse substances and, of course well paid, highly educated professionals also abuse drugs.
A risk assessment is based on probability which is more appropriate than teaching rigid “Always” and “Never” rules.
There is real benefit in encouraging candidates to have the confidence to check casualties pockets, following that super-brief dynamic risk assessment:
Pockets contain a wealth of information about the casualty; their name, address, age, medical conditions and medications.
No one wants to be rolled onto their car keys and left there for half an hour, waiting for the ambulance.
The same goes for jacket pockets, handbags, man-bags, desk draws, lockers, bedside tables and bathroom cabinets which is where most people keep their medication. Get amongst it and gather information.
”But won’t I be sued?”
Stop it. You’re being silly now.
3. A casualty with a head injury should not be allowed to go to sleep
OK. this is serious. More than half of respondents believe that you should not let a casualty to go to sleep. Why? Because it is what we have been told since the dawn of time.
There is absolutely zero evidence that allowing a casualty to go to sleep increases their morbidity or mortality, in fact, sleep is beneficial. It’s why we do it.
“But they might not wake up!”
Correct, they might not. But that is because of their head injury, not because you allowed them to go to sleep.
“But you can’t monitor them?”
Incorrect. While the casualty is sleeping you can monitor their airway, breathing and signs of circulation very easily. You can also monitor their level of response:
Someone who is sleeping should wake up to the sound of voice. If they don’t and you need to apply a measured amount of pain to get a response, they are now no longer sleeping, they are unconscious but responding to pain. You didn’t cause it and you can’t stop it, but you noticed it and you can now act on it.
If you think about it, can you actually keep someone awake who really wants to go to sleep? It’s just not nice.
Do allow casualties to go to sleep but monitor them. Do not send them home to sleep it off and hope to see them tomorrow. That is the issue.
4. Elevating limbs is proven to stop bleeding and reduce swelling
This won’t take long. It isn’t proven.
Elevation was removed from the European Resuscitation Guidelines in 2015 as a treatment for bleeding because there is such little evidence to support it. (page 283)
Elevation is often incorporated into ‘RICE’ (or another variant) to manage musculoskeletal injuries. The National Institute for Health and Care Excellence include Elevation in their PRICE recommendations but references in their “Basis for Guidance”:
No randomized trials were available on the effectiveness of elevation measures.
found no evidence for the individual effects of rest and elevation after lateral ankle sprain injury
Expert opinion in various review articles has noted the poor evidence base for the use of standard practice 'RICE' protocols
For a conscious casualty, the best position for an injured limb is the most comfortable position. If they are holding it down there, they want it down there, don’t elevate it.
For an unconscious casualty, as long as the airway is not compromised, the best position for an injured limb is where you found it.
Again, have the confidence to allow responsible adults to make reasonable decisions rather than teaching “Always” and “Never” rules.
5. The Shock Position
There is so much archaic wisdom deeply engrained here.
There is limited evidence that elevating the legs may provide a transient (<7 min) improvement in heart rate, mean arterial pressure, cardiac index, or stroke volume for those with no evidence of trauma.
There is no evidence that applies to a hypovolaemic casualty who is already compensating. If you think about it, you know there is no available blood in the legs because the casualty is cold and pale - they are already shunting any available blood to the core by vasoconstriction.
ERC 2020 draft guidelines (p.14) state:
”• Place individuals with shock into the supine (lying-on-back) position
• Where there is no evidence of trauma first aid providers might consider the use of passive leg raising as a temporizing measure while awaiting more advanced emergency medical care.
Because improvement with Passive Leg Raising is brief and its clinical significance uncertain, it is not recommended as a routine procedure, although it may be appropriate in some first aid settings.”
6. A crushed injury should not be released after 15 minutes.
So we are all happy that the potential consequence of a crushed limb is a loss of circulation causing toxins to build up? Good. This happens, it is called rhabdomyolysis. There is no evidence on the face of the Earth that this happens in 15 minutes.
Now that tourniquets are fashionable again, we are happy to advise candidates that tourniquets can be applied for many hours without risk of further injury, but we still teach that if a limb is crushed by any other means, they will drop dead because of ‘toxins’ if we remove it after 15 minutes.
Just. Let. That. Sink. In.
If we leave our crushed casualty because their limb has been entrapped for more than 15 minutes, what do the Paramedics do when they arrive? They release them. And there is guidance for this.
”The patient should be released as quickly as possible, irrespective of the length of time trapped.”
This “15 Minute Rule” has been in circulation for a long time based on our understanding of things 40 years ago when the Health and Safety (First Aid) Regulations1981 were written along with the inception of the First Aid at Work course.
Things change, knowledge changes, our understanding changes. But we still teach people what we were told once.
First Aid is a unique industry where anyone can teach it with very little training or experience. After completing a 3-day First Aid at Work course followed by a 5-Day course in Education or Training, one is now able to teach that same accredited qualification to paying customers. Someone is literally taking people’s money off them for telling them what they were told a week ago.
Is there any other industry that works this way?
Does this mean only Paramedics, doctors and nurses should teach First Aid? Absolutely not, I know some pan-dimensionally intelligent, exceptional medical professionals who can’t teach to save their life. And that’s OK, that is not their expertise.
Some of the finest Trainers we know - our colleagues and competitors - are not Special Forces medics or Consultant grade practitioners, but they know how to educate and how to get the most out of their candidates.
This is not an issue of snobbery or elitism, it is about diligence and professionalism.
At the very least we have an obligation to those we are training to provide them with reliable, robust, evidence-based information that follows Nationally accepted best-practice guidelines. At the very least. Not, teaching people something you were told once or read a book somewhere 20 years ago.
More importantly, one day, someone will have to deal with a casualty. There are real, genuine consequences to that person dealing with a casualty with no understanding of what they are doing but with the best of intentions. Because someone told them to do it.
We have a duty to learners and casualties to stay current and informed. Even if that means having to stop doing what we have been doing for so long.
Definitive guidance can be found here: