Safe patient, safe rescuer?

Doctor of Medical Sciences, Master of Law Jacek Siewiera

At the end of 2015, the Polish Resuscitation Council issued the long-awaited update of recommendations regarding the principles of conducting basic life-saving procedures. It is already a tradition that, following the European Resuscitation Council, a Polish body of specialists, under the leadership of Professor Janusz Andres, every 5 years publishes a set of rules that reflect the most current knowledge in the field of first aid in the world. Resuscitation guidelines are today a document that has a significant impact on the way medical staff, emergency services, as well as those responsible for organizing the first aid system in workplaces, practice. Today, following the recommendations of the Polish Resuscitation Council is considered to be the requirements of medical knowledge, and non-compliance with them, which may expose persons in a state of danger to life to additional danger, is perceived as an error or lack of due diligence. This way of understanding the recommendations is reflected in both the opinions of court experts and the court ruling, which refers to the principles of providing first aid, also in workplaces.

Employer's Obligation

From this point of view, the 2015 Resuscitation Guidelines are also of great importance for those responsible for organizing and providing first aid in workplaces. Whereas in art. 2091 § 1 point 2 of the Labor Code of June 26, 1974 (i.e. Journal of Laws of 1998, No. 21, item 94, as amended). The legislator specified that the employer is obliged to provide means of communication, first aid points and staff training, it should be stated that these provisions indirectly indicate the scope of responsibility of the OHS service in the organization of and supervision over the functioning of the first aid system. The same regulation was included in the content of the Regulation of the Minister of Labor and Social Policy of 26 September 1997 on general health and safety regulations (i.e. DzU of 2003, No. 169, item 1650, as amended). Also in § 44 paragraph 1 describes the employer's obligation to provide employees with an efficiently operating first aid system in the event of an accident, and first aid measures.

Legal scope of first aid

The above-mentioned provisions do not leave the slightest doubt as to the person responsible for preparing staff for first aid. Resuscitation guidelines are instructions specifying detailed rules of conduct and training of personnel designated for first aid. In 2015, these rules take on special significance because the recommendations published by the Polish Resuscitation Council included both information on resuscitation and broadly understood first aid. The understanding of this term was indicated by the Legislator in art. 3 point 7 of the Act on State Emergency Medical Services, defining that first aid is: "a set of actions taken to rescue a person in a state of emergency health performed by a person at the scene of an accident, including the use of medical devices [...] and products medicinal products without a prescription ... '.

Limits of legality in providing first aid

The interpretation of the definition of legal "first aid" indicates that this concept refers to the conduct of each person, regardless of his education and authority, in situations of danger to life or health. Meanwhile, the guidelines contained in the guidelines of the Polish Resuscitation Council regarding recommended methods of treatment sometimes raise doubts as to the scope of rights and responsibilities of persons providing first aid incurred for the consequences of their own actions. First of all, it draws attention to the fact that the authors of the guidelines precisely distinguished situations requiring assistance provided by a person designated for first aid, from active actions carried out by them on the victims.

Acute shortness of breath and bronchodilators

In the section on the use of bronchodilators, the authors of the guidelines state that "people with asthma who have breathing problems should be helped to take their bronchodilator." By this, we mean that it is the duty of the first aid personnel not to recognize the bronchospastic condition (narrowing of the bronchial lumen by contraction), and even more so to 'administer' the dilating drug - which is the doctor's responsibility - but only to assist a person with dyspnoea symptoms her permanent medication, which had previously been ordered by a doctor to treat a specific disease entity (in this case, dyspnoea in the course of asthma). In such cases, the authors of the guidelines do not impose on persons providing first aid an obligation to perform activities for which they do not have the appropriate powers, but recommend action limited only to the scope of their qualifications. Similarly, recommendations have been made regarding the use of oxygen therapy. The authors of the guidelines rightly stated that "there are no direct indications for oxygen supply by first aiders." This observation indicates that the resuscitation guidelines do not require oxygen delivery to first aiders in the basic range and often do not have adequate knowledge and skills. The situation is different in the case of "rescuers" entitled to qualified first aid, for whom the supply of oxygen is a compulsory element of training.

Adrenaline supply in 1st and 2nd dose

The resuscitation guidelines of the European Resuscitation Council state that "in pre-hospital conditions, a second intramuscular dose of adrenaline should be given to people whose symptoms of anaphylaxis do not subside after 5-15 minutes [...]". In this case, it should be noted that the authors of the document do not mention "assisting" by the person providing first aid when injecting the drug, but clearly indicate the need for intramuscular "administration" of the drug. The content of the discussed recommendation may result from the fact that the guidelines of the European Resuscitation Council are prepared by medical circles as a common set of recommendations not including the legal systems in force in individual European countries. On the basis of the Polish legal order, it should be noted that a person with only a few hours of training in first aid does not have the knowledge and skills sufficient to independently choose the therapeutic treatment using adrenaline administered by injection, not to mention the competences provided in this respect only for the doctor and paramedic. Incorrect administration of adrenaline, or incorrectly recognized indications for its use may not only be perceived as an activity without appropriate qualifications by first aiders, but also a basis for claims for damages.

This recommendation under Polish law should be understood as a suggestion that the first aid provider undertakes the supply of adrenaline in the case of people who are particularly vulnerable to life-threatening mechanisms of anaphylactic shock, having an adrenaline syringe pre-ordered by a doctor. It should be noted that pre-filled syringes with a specific adrenaline content are sometimes dispensed with a doctor's prescription to persons who have been diagnosed with an allergy that may pose a direct threat to their life and health (e.g. insect venom). In these cases, these people often carry with them pre-prepared adrenaline kits. Resuscitation guidelines in this area should be treated as a recommendation for the use of the medicine next to the patient, if it was previously prescribed by the doctor. Such proceedings on the basis of substantive criminal law may then be seen as acting in a state of higher necessity aimed at saving a person's life. In no way should the recommendations of the European Resuscitation Council be understood as indications for the standard equipment of company kits and emergency kits with pre-filled syringes containing adrenaline or any other pharmacological agent (e.g. glucagon).

Aspirin for chest pain

The guidelines published by the Polish Resuscitation Council include a point regarding the use of acetylsalicylic acid (aspirin) in cases of suspected acute coronary syndrome. The recommendation states that in pre-hospital conditions, victims with chest pain due to suspected myocardial infarction (ACS) should be given 160-325 mg of aspirin to chew early. The risk of complications such as anaphylaxis or major bleeding is relatively small. "The fact that the authors further indicate that" aspirin should not be given to adults with chest pain of unclear origin "is noteworthy." It should be explained here that anti-aggregation mechanism of action of acetylsalicylic acid, its early administration allows people with acute coronary syndrome to reduce blood clotting and reduce the likelihood of myocardial necrosis. Unfortunately, aspirin, due to these properties and the fact of irreversible inhibition of platelet cyclooxygenase, also increases the risk of bleeding (e.g., in dissecting aortic aneurysm) in diseases characterized by symptoms similar to acute coronary syndrome. The guidelines therefore contain a recommendation on its supply with the proviso that it should not be given in cases where chest pain (nonspecific symptom of myocardial infarction) is not of clear origin. The content of the recommendations formulated in this way shifts the burden of responsibility for the proper diagnosis of the cause of chest pain to the person obliged to provide first aid in the workplace. Given that these people do not have the qualifications or tools sufficient to identify the cause of the observed symptoms, it should be assumed under Polish law that while aspirin should be in the equipment of the first-aid kit, it can only be used by a person, who have symptoms suggestive of acute coronary syndrome. A prerequisite for taking and chewing the acetylsalicylic acid tablet is in this case the patient's full consciousness (in an unconscious person choking may occur, therefore oral administration is impossible), and thus there are no reasonable grounds for which the patient could not take legal responsibility for the effects of the medicine taken, as recommended by the European Resuscitation Council, the tablet found in the company's first aid kit.

Clinical observations of doctors and paramedics, as well as many years of experience in training the company emergency services show that in providing first aid special prudence requires contact with pharmacological agents and drugs used by persons without medical education. Observance of the precautionary conditions described above will allow both first aid workers and persons responsible for the organization of the first aid system in the workplace, to carry this help in the sense of their own legal security and a duty well fulfilled.

1 - OJ 2006 No. 191 item 1410 Act of 8 September 2006 on the State Emergency Medical Services 2 - Andres J, Krawczyk P, Drab E, Dembkowska M, Summary of key changes in 2015 ERC Guidelines | www.prc.krakow.pl p. 13 3 - Andres J, Krawczyk P, Drab E, Dembkowska M, Summary of key changes in ERC 2015 Guidelines | www.prc.krakow.pl p. 13 4 - OJ 2007 No. 60 item 408 Regulation of the Minister of Health of 19 March 2007 on a course in qualified first aid

Źródło: Atest 4/2016

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