[COLUMNIST] Improving first aid in Malaysia - difference between a life saved and lost

FIRST aid refers to on-site interventions performed in order to save a life and decrease severity of injury until medical help arrives using little to no medical equipment ("Knowledge, awareness and attitude of first aid among health sciences university students”, Jamaludin et al., International Journal of Care Scholars, Vol. 1, Issue 1, 2018).

Importance of First Aid

First aid is “the difference between a life saved and a life lost.”

Thousands of lives in Malaysia – 2,500 lives by asphyxiation from choking or 29,000 lives from heart attacks – could be saved annually if the general public is trained to recognise signs of an emergency and provide first aid (“A comparative evaluation of first aid knowledge and attitude among medical, dental and pharmacy students in AIMST University, Malaysia”, Gupta et al., International Journal of Applied Dental Sciences, Vol. 5, Issue 3, 2019).

Around 59% of deaths from injuries during emergencies could be saved had first aid been administered ("Mapping the public first-aid training landscape: a scoping review”, Heard et al., Disasters, Vol. 44, Issue 1, 2020).

A cardiac arrest (where the heart suddenly stops pumping) is the most frequent out-of-hospital medical emergency (“First Aid Training in Malaysia and Reality We Face”, Alphat Training, September 10, 2017).

Cardiopulmonary resuscitation (CPR) which includes chest compressions and sometimes manual ventilation to increase blood flow is the typical first-aid response.

The initial stage is crucial – the probability of survival decreases by 7%-9% every minute a CPR is not administered (“How frequent is bystander cardiopulmonary resuscitation performed in the community of Kota Bharu, Malaysia?”, Chew et al., Singapore Med J, Vol. 49, Issue 8, 2008).

Nine of 10 out-of-hospital cardiac arrests cases result in deaths – because of lack of external intervention and the ambulance response time in Malaysia can be well over 15 minutes.

This points to the necessity of increasing awareness and exposure to first-aid training and capability, including not least in CPR.

The estimated survival rate for an out-of-hospital cardiac arrest in Kuala Lumpur was 22.5% in 2011 (“Knowledge of and willingness to perform hands-only cardiopulmonary resuscitation among college students in Malaysia”, Karuthan et al., Medicine, Vol. 98, Issue 51, 2019).

Providing CPR within the first few minutes can double or triple survival chances (“Three Things You May Not Know About CPR”, CDC, October 22, 2021).

Like cardiac arrests, first aid is critical in the case of burn injuries – first aid decreases injury severity, chances of death and length of hospitalisation and improves healing process (“Awareness of first aids in burn injuries: A survey in the population of east coast and central of Malaysia”, Seow Sul Na).

The instances of requiring first aid are only increasing over time.

As it is, heart attacks are one of the most common causes of death in Malaysia.

In 2007, 8,700 people (24 per day) died of a coronary heart disease (CHD) which increased to 13,500 people (37 per day) in 2017. Malaysia has the lowest average age of onset for CHD in the region at 58 years compared to 65 in Thailand as well as higher obesity rates (“Young age no barrier for heart disease”, New Straits Times, November 29, 2019).

Frequency of First Aid

Despite its life-saving importance, knowledge and occurrence of first aid is worryingly low.

A study of IIUM Kuantan students that was done in 2017 found that although 90.8% had awareness and a positive attitude towards first aid, only 42.8% have moderate knowledge and 55.4% had little knowledge regarding first aid.

In 2018, 222 final-year medical, dental and pharmacy students at the Asian Institute of Medicine, Science and Technology (AIMST, Malaysia) were surveyed as to their knowledge about first aid. Not one of the participants was able to correctly answer all the questions. For instance, only 21.1% of students answered correctly on a question related to choking. Likewise, only 26% responded correctly when asked what to do when a chemical (foreign element) enters the eye.

A Melaka study found that in 2019 only 2 of the 1780 (0.11%) out-of-hospital heart attacks were given CPR by the general public and that households performed CPR successfully only in 1% of the cases (“The Prevalence of Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest in Melaka State, Malaysia”, Yasin et al., Advances in Health Sciences Research, 39, 2021).

A study on the Burn Unit of Hospital Universiti Sains Malaysia involving 485 burn patients showed that 222 patients (45.8%) received no first aid, and of the 261 patients (53.8%) that did practice, only 24 patients (5%) performed it correctly (running under cool water for more than 20 minutes).

First Aid Training

First aid training is essential to equip the general public with the necessary skillset needed to assess and react in a medical emergency. Research confirms that training improves one’s probability and willingness to perform first aid.

First aid training has been linked to increased confidence and decreased fear of hurting the recipient. In some cases, trained individuals are almost three times more likely to feel confident in performing CPR than non-trained individuals.

Bystander CPR administration in Arizona increased from 19.6% in 2005 to 75.9% in 2009 after a large-scale public hands-only CPR campaign. Similarly, it was found that exposure to an ultra-brief 60 second video on hands-only CPR increased the likelihood of an individual attempting CPR and displayed superior skills than an individual who did not watch the video.

Studies demonstrate that children as young as 9–10-years old have the capability to learn theoretical knowledge, practical skills, and improve self-belief in providing first aid (“The (second) year of first aid: A 15-month follow-up after a 3-day first aid programme”, Banfai et al., Emerg Med J, Vol. 36, Issue 11, 2019).

This shows that primary school children should also be given first aid training.

Past training predicts future training.

Hence, “early exposure to training may increase the likelihood of continued, lifelong training”. Since knowledge has shown to be significantly less in those who attended training more than 5 years ago compared to those who attended less within the same time frame, it is crucial to provide refresher and follow-up trainings. Poor knowledge on the procedure is a primary reason for an unwillingness to perform CPR.

However, first aid training simulations may not necessarily reflect real life situations.

Trainers often test a single skill and provide feedback in contrast to real-life situations wherein individuals can suffer from multiple emergencies (such as bleeding and lack of breathing).

Hence, it is critical to improve first aid training to resemble life-like situations more closely.

Bystander Effect

The bystander effect is a psychological phenomenon wherein the presence of other individuals discourages people from intervening in an emergency situation.

The more bystanders are present during an emergency, the less personally responsible one feels to act – this is known as the diffusion of responsibility.

As such, no one takes the initiative to intervene. Furthermore, as humans are socially influenced by other individuals’ behaviour to guide their own actions, lack of intervention from others reinforces their own inaction (“Bystander Effect”, Psychology Today).

As a result, individuals in an emergency situation are unknowingly influenced by the bystander effect.

Good Samaritan Laws (GSLs)

A primary concern for the public is the fear of facing legal consequences for performing first aid wrongly and harming the person more by mistake. GSLs are designed to protect first aiders from litigation of any form and thus, encourage individuals to perform first aid without fear of repercussions and any inhibition. Unfortunately, the public are usually unaware of the existence of GSLs.

A study in Hong Kong found that only 12.1% were aware of what GSLs were. When informed about GSLs, 95.2% of respondents supported enacting GSLs of which 57% said that implementing GSLs will change their willingness to perform bystander CPR (“Good Samaritan Law and bystander cardiopulmonary resuscitation: Cross-sectional study of 1223 first-aid learners in Hong Kong”, Hung et al., Hong Kong Journal of Emergency Medicine, Vol. 28, Issue 1, 2019).

Numerous countries such as USA, Canada, Australia, Finland, and China have implemented GSLs.

There are currently no GSL in Malaysia.

Hence, EMIR Research recommends that Parliament enacts a Good Samaritan Bill – to provide a “conducive” and first-aid friendly environment and eco-system for first responders.

In addition, EMIR Research also recommend the following policy proposals:

• Workplaces to hold mandatory first aid workshops once a year – which should be claimable via the Human Resource Development Fund (HRDF).

In addition, every workplace should have a specially designated first responder who would attend and participate in refresher courses (and related programmes on, e.g., emergency response planning, crisis and disaster management, etc.) on a regular basis;

• Make first aid training a mandatory part of the curriculum wherein schools and tertiary institutions provide thorough first aid training to all staff (teaching and administrative) and students with refresher courses – rather than a complete training conducted annually – aimed at improving retention;

• The Ministry of Health (MOH) to create an online interactive first aid learning platform as a website and an app – with numerous real-world and simulated scenarios;

• The MOH to launch an awareness campaign blitz in collaboration with the relevant authorities such as the Ministry of Women, Family and Community Development (MWFCD), Ministry of Local Government Development (KPKT), Red Crescent Society, St John Ambulance, Fire and Rescue Department, Civil Defence Force (MCDF), etc. to create publicity materials such as posters and short videos on first aid.

The contents are to be circulated through social media, broadcasting (TV & radio), newspapers, public transport advertisements, signages, etc.;

In addition, the stakeholders should also organise numerous first aid roadshows and workshops nationwide, especially among lower income and deprived areas. These areas are more likely to be vulnerable to medical emergencies and have longer ambulance response times.

• Improve first aid training so that it resembles real-life situations more closely by:

1. Training for handling multiple emergencies simultaneously such as bleeding and asphyxiation rather than just focussing on a single situation like cardiac arrest only;

2. Promoting awareness of the “bystander effect”; and

3. Addressing the fear of litigation by explaining about the principles and provisions of the GSL (post-implementation);

• According to the Ministry of Transport (MOT), 18 people on average die every day due to road accidents in Malaysia. As road accidents are only increasing, basic first aid training should be part of the process to obtain a driver’s license.

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Jason Loh and Juhi Todi are part of the research team at EMIR Research, an independent think tank focused on strategic policy recommendations based on rigorous research.

** The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the position of Astro AWANI.