FIRST AID

Antonio J. Dajer

First aid is the immediate care given to victims of accidents before trained medical workers arrive. Its goal is to stop and, if possible, reverse harm. It involves rapid and simple measures such as clearing the air passageway, applying pressure to bleeding wounds or dousing chemical burns to eyes or skin. The critical factors which shape first aid facilities in a workplace are work-specific risk and availability of definitive medical care. The care of a high-powered saw injury is obviously radically different from that of a chemical inhalation. From a first aid perspective, a severe thigh wound occurring near a surgical hospital requires little more than proper transport for the same injury in a rural area eight hours from the nearest medical facility, first aid would include-among other things-debridement, tying off bleeding vessels and administration of tetanus immunoglobulin and antibiotics. First aid is a fluid concept not only in what !how long, how comple"# must be done, but in who can do it. Though a very careful attitude is required, every worker can be trained in the top five or ten dos and donts of first aid. In some situations, immediate action can save life, limb or eyesight. $o-workers of victims should not remain paraly%ed while waiting for trained personnel to arrive. &oreover, the 'top-ten( list will vary with each workplace and must be taught accordingly. Importance of First Aid In cases of cardiac arrest, defibrillation administered within four minutes yields survival rates of )* to +*,, versus less than +, if given later. Five hundred thousand people die of cardiac arrest every year in the -nited .tates alone. For chemical eye injuries, immediate flushing with water can save eyesight. For spinal cord injuries, correct immobili%ation can make the difference between full recovery and paralysis. For haemorrhages, the simple application of a fingertip to a bleeding vessel can stop life-threatening blood loss. /ven the most sophisticated medical care in the world often cannot undo the effects of poor first aid. First Aid in the Context of the General Organization of Health and Safety The provision of first aid should always have a direct relationship to general health and safety organi%ation, because first aid itself will not handle more than a small part of workers0 total care. First aid is a part of the total health care for workers. In practice, its application will depend to a large e"tent on persons present at the time of an accident, whether co-workers or formally trained medical personnel. This immediate intervention must be followed by speciali%ed medical care whenever needed. First aid and emergency treatment in cases of accident and indisposition of workers at the workplace are listed as an important part of the functions of the occupational health services in the I12 2ccupational 3ealth .ervices $onvention !4o. 565#, 7rticle +, and the 8ecommendation of the same name. 9oth adopted in 5:;+, they provide for the progressive development of occupational health services for all workers. 7ny comprehensive occupational safety and health programme should include first aid, which contributes to minimi%ing the consequences of accidents and is therefore one of the components of tertiary prevention. There is a continuum leading from the knowledge of the occupational ha%ards, their prevention, first aid, emergency treatment, further medical care and speciali%ed treatment for reintegration into and readaptation to work. There are important roles that occupational health professionals can play along this continuum.

It is not infrequent that several small incidents or minor accidents take place before a severe accident occurs. 7ccidents requiring only first aid represent a signal which should be heard and used by the occupational health and safety professionals to guide and promote preventive action. Relation to Other Health Related Ser!ices The institutions which may be involved in the organi%ation of first aid and provide assistance following an accident or illness at work include the following< = the occupational health service of the enterprise itself or other occupational health entities = other institutions which may provide services, such as< ambulance services public emergency and rescue services hospitals, clinics and health centres, both public and private private physicians poison centres civil defence fire departments and police. /ach of these institutions has a variety of functions and capabilities, but it must be understood that what applies to one type of institution-say a poison centre-in one country, may not necessarily apply to a poison centre in another country. The employer, in consultation with, for e"ample, the factory physician or outside medical advisers, must ensure that the capabilities and facilities of neighbouring medical institutions are adequate to deal with the injuries e"pected in the event of serious accidents. This assessment is the basis for deciding which institutions will be entered into the referral plan. The cooperation of these related services is very important in providing proper first aid, particularly for small enterprises. &any of them may provide advice on the organi%ation of first aid and on planning for emergencies. There are good practices which are very simple and effective for e"ample, even a shop or a small enterprise may invite the fire brigade to visit its premises. The employer or owner will receive advice on fire prevention, fire control, emergency planning, e"tinguishers, the first aid bo" and so on. $onversely, the fire brigade will know the enterprise and will be ready to intervene more rapidly and efficiently. There are many other institutions which may play a role, such as industrial and trade associations, safety associations, insurance companies, standards organi%ations, trade unions and other non-governmental organi%ations. .ome of these organi%ations may be knowledgeable about occupational health and safety and can be a valuable resource in the planning and organi%ation of first aid. An Organized Approach to First Aid Organization and planning First aid cannot be planned in isolation. First aid requires an organi%ed approach involving people, equipment and supplies, facilities, support and arrangements for the removal of victims and non-victims from the site of an accident. 2rgani%ing first aid should be a cooperative effort, involving employers, occupational health and public health services, the labour inspectorate, plant managers and relevant non-governmental organi%ations. Involving workers themselves is essential< they are often the best source on the likelihood of accidents in specific situations. >hatever the degree of sophistication or the absence of facilities, the sequence of actions to be taken in the case of an unforeseen event must be determined in advance. This must be done taking due account of e"isting and potential occupational and non-occupational ha%ards or occurrences, as well as ways of obtaining immediate and appropriate assistance. .ituations vary not only with the si%e of the enterprise but also with its location !in a town or a rural area# and with the development of the health system and of labour legislation at the national level. 7s regards the organi%ation of first aid, there are several key variables to be considered< = type of work and associated level of risk = potential ha%ards = si%e and layout of the enterprise = other enterprise characteristics !e.g., configuration# = availability of other health services.

Type of work and associated level of risk The risks of injury vary greatly from one enterprise and from one occupation to another. /ven within a single enterprise, such as a metalworking firm, different risks e"ist depending on whether the worker is engaged in the handling and cutting of metal sheets !where cuts are frequent#, welding !with the risk of burns and electrocution#, the assembly of parts, or metal plating !which has the potential of poisoning and skin injury#. The risks associated with one type of work vary according to many other factors, such as the design and age of the machinery used, the maintenance of the equipment, the safety measures applied and their regular control. The ways in which the type of work or the associated risks influence the organi%ation of first aid have been fully recogni%ed in most legislation concerning first aid. The equipment and supplies required for first aid, or the number of first aid personnel and their training, may vary in accordance with the type of work and the associated risks. $ountries use different models for classifying them for the purpose of planning first aid and deciding whether higher or lower requirements are to be set. 7 distinction is sometimes made between the type of work and the specific potential risks< = low risk-for e"ample, in offices or shops = higher risk-for e"ample, in warehouses, farms and in some factories and yards = specific or unusual risks-for e"ample, in steelmaking !especially when working on furnaces#, coking, nonferrous smelting and processing, forging, foundries shipbuilding quarrying, mining or other underground work work in compressed air and diving operations construction, lumbering and woodworking abattoirs and rendering plants transportation and shipping most industries involving harmful or dangerous substances. Potential hazards /ven in enterprises which seem clean and safe, many types of injury can occur. .erious injuries may result from falling, striking against objects or contact with sharp edges or moving vehicles. The specific requirements for first aid will vary depending on whether the following occur< = falls = serious cuts, severed limbs = crushing injuries and entanglements = high risks of spreading fire and e"plosions = into"ication by chemicals at work = other chemical e"posure = electrocution = e"posure to e"cessive heat or cold = lack of o"ygen = e"posure to infectious agents, animal bites and stings. The above is only a general guide. The detailed assessment of the potential risks in the working environment helps greatly to identify the need for first aid. Size and layout of the enterprise First aid must be available in every enterprise, regardless of si%e, taking into account that the frequency rate of accidents is often inversely related to the si%e of the enterprise. In larger enterprises, the planning and organi%ation of first aid can be more systematic. This is because individual workshops have distinct functions and the workforce is more specifically deployed than in smaller enterprises. Therefore the equipment, supplies and facilities for first aid, and first aid personnel and their training, can normally be organi%ed more precisely in response to the potential ha%ards in a large enterprise than in a smaller one. 4evertheless, first aid can also be effectively organi%ed in smaller enterprises. $ountries use different criteria for the planning of first aid in accordance with the si%e and other characteristics of the enterprise. 4o general rule can be set. In the -nited ?ingdom, enterprises with fewer than 5+* workers and involving low risks, or enterprises with fewer than +* workers with higher risks, are considered small, and different criteria for the planning of first aid are applied in comparison with enterprises where the number of workers present at work e"ceeds these limits. In @ermany, the approach is different< whenever there are fewer than A* workers e"pected at work one set of criteria would apply if the number of

workers e"ceeds A*, other criteria will be used. In 9elgium, one set of criteria applies to industrial enterprises with A* or fewer workers at work, a second to those with between A* and +** workers, and a third to those with 5,*** workers and more. Other enterprise characteristics The configuration of the enterprise !i.e., the site or sites where the workers are at work# is important to the planning and organi%ation of first aid. 7n enterprise might be located at one site or spread over several sites either within a town or region, or even a country. >orkers may be assigned to areas away from the enterprise0s central establishment, such as in agriculture, lumbering, construction or other trades. This will influence the provision of equipment and supplies, the number and distribution of first aid personnel, and the means for the rescue of injured workers and their transportation to more speciali%ed medical care. .ome enterprises are temporary or seasonal in nature. This implies that some workplaces e"ist only temporarily or that in one and the same place of work some functions will be performed only at certain periods of time and may therefore involve different risks. First aid must be available whenever needed, irrespective of the changing situation, and planned accordingly. In some situations employees of more than one employer work together in joint ventures or in an ad hoc manner such as in building and construction. In such cases the employers may make arrangements to pool their provision of first aid. 7 clear allocation of responsibilities is necessary, as well as a clear understanding by the workers of each employer as to how first aid is provided. The employers must ensure that the first aid organi%ed for this particular situation is as simple as possible. Availability of other health services The level of training and the e"tent of organi%ation for first aid is, in essence, dictated by the pro"imity of the enterprise to, and its integration with, readily available health services. >ith close, good backup, avoiding delay in transport or calling for help can be more crucial to a good outcome than is skilful application of medical manoeuvres. /ach workplace0s first aid programme must mold itself to-and become an e"tension of-the medical facility which provides the definitive care for its injured workers. "asic Re#$irements of a First Aid %rogramme First aid must be considered part of sound management and making work safe. /"perience in countries where first aid is strongly established suggests that the best way to ensure effective first aid provision is to make it mandatory by legislation. In countries which have chosen this approach, the main requirements are set out in specific legislation or, more commonly, in national labour codes or similar regulations. In these cases, subsidiary regulations contain more detailed provisions. In most cases, the overall responsibility of the employer for providing and organi%ing first aid is laid down in the basic enabling legislation. The basic elements of a first aid programme include the following< Equipment, supplies and facilities = equipment to rescue the victim at the site of the accident so as to prevent further harm !e.g., in the case of fire, gassing, electrocution# = first aid bo"es, first aid kits or similar containers, with a sufficient quantity of the materials and appliances required for the delivery of basic first aid = speciali%ed equipment and supplies which may be required in enterprises involving specific or unusual risks at work = an adequately identified first aid room or a similar facility where first aid can be administered = provision of means of evacuation and emergency transportation of the injured persons to the first aid facility or the sites where further medical care is available = means of giving the alarm and communicating the alert Human resources = selection, training and retraining of suitable persons for administering first aid, their appointment and location at critical sites throughout the enterprise, and the assurance that they are permanently available and accessible = retraining, including practical e"ercises simulating emergency situations, with due account given to specific occupational ha%ards in the enterprise Other

= establishment of a plan, including links between the relevant health or public health services, with a view to the delivery of medical care following first aid = education and information of all workers concerning the prevention of accidents and injuries, and the actions workers must themselves take following an injury !e.g., a shower immediately after a chemical burn# = information on the arrangements for first aid, and the periodic updating of this information = posting of information, visual guides !e.g., posters# and instruction about first aid, and plans with a view to the delivery of medical care after first aid = record keeping !the first aid treatment record is an internal report which will provide information concerning the health of the victim, as well as contributing to safety at work it should include information on< the accident !time, location, occurrence#, the type and severity of the injury, the first aid delivered, the additional medical care requested, the name of the casualty and the names of witnesses and other workers involved, especially those transporting the casualty# 7lthough basic responsibility for implementing a first aid programme lies with the employer, without full participation of the workers, first aid cannot be effective. For e"ample, workers may need to cooperate in rescue and first aid operations they should thus be informed of first aid arrangements and should make suggestions, based on their knowledge of the workplace. >ritten instructions about first aid, preferably in the form of posters, should be displayed by the employer at strategic places within the enterprise. In addition, the employer should organi%e briefings for all workers. The following are essential parts of the briefing< = the organi%ation of first aid in the enterprise, including the procedure for access to additional care = colleagues who have been appointed as first aid personnel = ways in which information about an accident should be communicated, and to whom = location of the first aid bo" = location of the first aid room = location of the rescue equipment = what the workers must do in case of an accident = location of the escape routes = workers0 actions following an accident = ways of supporting first aid personnel in their task. First Aid %ersonnel First aid personnel are persons on the spot, generally workers who are familiar with the specific conditions of work, and who might not be medically qualified but must be trained and prepared to perform very specific tasks. 4ot every worker is suitable to be trained for providing first aid. First aid personnel should be selected carefully, taking into account attributes such as reliability, motivation and the ability to cope with people in a crisis situation. Type and num er 4ational regulations for first aid vary with respect to both the type and number of first aid personnel required. In some countries the emphasis is on the number of persons employed in the workplace. In other countries, the overriding criteria are the potential risks at work. In yet others, both of these factors are taken into account. In countries with a long tradition of occupational safety and health practices and where the frequency of accidents is lower, more attention is usually given to the type of first aid personnel. In countries where first aid is not regulated, emphasis is normally placed on numbers of first aid personnel. 7 distinction may be made in practice between two types of first aid personnel< = the basic-level first-aider, who receives basic training as outlined below and who qualifies for appointment where the potential risk at work is low = the advanced-level first-aider, who will receive the basic and advanced training and will qualify for appointment where the potential risk is higher, special or unusual. The following four e"amples are indicative of the differences in approach used in determining the type and number of first aid personnel in different countries< United Kingdo

= If the work involves relatively low ha%ards only, no first aid personnel are required unless there are 5+* or more workers present at work in this case a ratio of one first-aider per 5+* workers is considered adequate. /ven if fewer than 5+* workers are at work, the employer should nevertheless designate an 'appointed person( at all times when workers are present. = .hould the work involve higher risk, one first-aider will normally be required when the number of workers at work is between +* and 5+*. If more than 5+* workers are at work, one additional first-aider for every 5+* will be required and, if the number of workers at work is less than +*, an 'appointed person( should be designated. = If the potential risk is unusual or special, there will be a need, in addition to the number of first aid personnel already required under the criteria set out above, for an additional person who will be trained specifically in first aid in case of accidents arising from these unusual or special ha%ards !the occupational first-aider#. !elgiu = 2ne first-aider is usually required for every A* workers present at work. 3owever, a full-time occupational health staff member is required if there are special ha%ards and if the number of workers e"ceeds +**, or in the case of any enterprise where the number of workers on site is 5,*** or more. = .ome degree of fle"ibility is possible in accordance with particular situations. "er any = 2ne first-aider is required if there are A* or fewer workers present at work. = If more than A* workers are present, the number of first-aiders should be +, of those at work in offices or general trade, or 5*, in all other enterprises. Bepending on other measures which may have been taken by the enterprise to deal with emergencies and accidents, these numbers may be revised. = If work involves unusual or specific risks !for instance, if ha%ardous substances are involved#, a special type of first aid personnel needs to be provided and trained no specific number is stipulated for such personnel !i.e., the above-mentioned numbers apply#. = If more than +** workers are present and if unusual or special ha%ards e"ist !burns, poisonings, electrocutions, impairment of vital functions such as respiratory or cardiac arrest#, specially trained full-time personnel must be made available to deal with cases where a delay in arrival of no more than 5* minutes may be allowable. This provision will apply in most larger construction sites where a number of enterprises often employ a workforce of several hundred workers. #ew $ealand = If more than five workers are present, an employee is appointed and put in charge of the equipment, supplies and facilities for first aid. = If more than +* persons are present, the person appointed must be either a registered nurse or hold a certificate !issued by the .t. Cohn0s 7mbulance 7ssociation or the 4ew Dealand 8ed $ross .ociety#. Training The training of first aid personnel is the single most important factor determining the effectiveness of organi%ed first aid. Training programmes will depend on the circumstances within the enterprise, especially the type of work and the risks involved. "asic Training 9asic training programmes are usually on the order of 5* hours. This is a minimum. Erogrammes can be divided into two parts, dealing with the general tasks to be performed and the actual delivery of first aid. They will cover the areas listed below. !eneral tas"s = how first aid is organi%ed = how to assess the situation, the magnitude and severity of the injuries and the need for additional medical help

= how to protect the casualty against further injury without creating a risk for oneself the location and use of the rescue equipment = how to observe and interpret the victim0s general condition !e.g., unconsciousness, respiratory and cardiovascular distress, bleeding# = the location, use and maintenance of first aid equipment and facilities = the plan for access to additional care. Deli#ery of first aid The objective is to provide basic knowledge and delivery of first aid. 7t the basic level, this includes, for e"ample< = wounds = bleeding = fractured bones or joints = crushing injuries !e.g., to the thora" or abdomen# = unconsciousness, especially if accompanied by respiratory difficulties or arrest = eye injuries = burns = low blood pressure, or shock = personal hygiene in dealing with wounds = care of amputated digits. Ad!anced Training The aim of advanced training is speciali%ation rather than comprehensiveness. It is of particular importance in relation to the following types of situation !though specific programmes normally deal only with some of these, in accordance with needs, and their duration varies considerably#< = cardiopulmonary resuscitation = poisoning !into"ication# = injuries caused by electric current = severe burns = severe eye injuries = skin injuries = contamination by radioactive material !internal, and skin or wound contamination# = other ha%ard-specific procedures !e.g., heat and cold stress, diving emergencies#. Training &aterials and Instit$tions 7 wealth of literature is available on training programmes for first aid. The national 8ed $ross and 8ed $rescent .ocieties and various organi%ations in many countries have issued material which covers much of the basic training programme. This material should be consulted in the design of actual training programmes, though it may need adaptation to the specific requirements of first aid at work !in contrast with first aid after traffic accidents, for instance#. Training programmes should be approved by the competent authority or a technical body authori%ed to do so. In many cases, this may be the national 8ed $ross or 8ed $rescent .ociety or related institutions. .ometimes safety associations, industrial or trade associations, health institutions, certain non-governmental organi%ations and the labour inspectorate !or their subsidiary bodies# may contribute to the design and provision of the training programme to suit specific situations. This authority should also be responsible for testing first aid personnel upon completion of their training. /"aminers independent of the training programmes should be designated. -pon successfully completing the e"amination, the candidates should be awarded a certificate upon which the employer or enterprise will base their appointment. $ertification should be made obligatory and should also follow refresher training, other instruction or participation in field work or demonstrations. First Aid '#$ipment( S$pplies and Facilities The employer is responsible for providing first aid personnel with adequate equipment, supplies and facilities.

$irst aid o%es, first aid "its and similar containers In some countries, only the principal requirements are set out in regulations !e.g., that adequate amounts of suitable materials and appliances are included, and that the employer must determine what precisely may be required, depending on the type of work, the associated risks and the configuration of the enterprise#. In most countries, however, more specific requirements have been set out, with some distinction made as to the si%e of the enterprise and the type of work and potential risks involved. !asic content The contents of these containers must obviously match the skills of the first aid personnel, the availability of a factory physician or other health personnel and the pro"imity of an ambulance or emergency service. The more elaborate the tasks of the first aid personnel, the more complete must be the contents of the containers. 7 relatively simple first aid bo" will usually include the following items< = individually wrapped sterile adhesive dressing = bandages !and pressure dressings, where appropriate# = a variety of dressings = sterile sheets for burns = sterile eye pads = triangular bandages = safety pins = a pair of scissors = antiseptic solution = cotton wool balls = a card with first aid instructions = sterile plastic bags = access to ice. %ocation First aid bo"es should always be easily accessible, near areas where accidents could occur. They should be able to be reached within one to two minutes. They should be made of suitable materials, and should protect the contents from heat, humidity, dust and abuse. They need to be identified clearly as first aid material in most countries, they are marked with a white cross or a white crescent, as applicable, on a green background with white borders. If the enterprise is subdivided into departments or shops, at least one first aid bo" should be available in each unit. 3owever, the actual number of bo"es required will be determined on the basis of the needs assessment made by the employer. In some countries the number of containers required, as well as their contents, has been established by law. Au&iliary kits .mall first aid kits should always be available where workers are away from the establishment in such sectors as lumbering, agricultural work or construction where they work alone, in small groups or in isolated locations where work involves travelling to remote areas or where very dangerous tools or pieces of machinery are used. The contents of such kits, which should also be readily available to self-employed persons, will vary according to circumstances, but they should always include< = a few medium-si%ed dressings = a bandage = a triangular bandage = safety pins. &pecialized equipment and supplies Further equipment may be needed for the provision of first aid where there are unusual or specific risks. For e"ample, if poisonings are a possibility, antidotes must be immediately available in a separate container, though it must be made clear that their administration is subject to medical instruction. 1ong lists of antidotes e"ist, many for specific situations. Eotential risks will determine which antidotes are needed. .peciali%ed equipment and material should always be located near the sites of potential accidents and in the first aid room. Transporting the equipment from a central location such as an occupational health service

facility to the site of the accident may take too long. 'escue equipment In some emergency situations, speciali%ed rescue equipment to remove or disentangle an accident victim may be necessary. 7lthough it may not be easy to predict, certain work situations !such as working in confined spaces, at heights or above water# may have a high potential for this type of incident. 8escue equipment may include items such as protective clothing, blankets for fire-fighting, fire e"tinguishers, respirators, self-contained breathing apparatus, cutting devices and mechanical or hydraulic jacks, as well as equipment such as ropes, harnesses and speciali%ed stretchers to move the victim. It must also include any other equipment required to protect the first aid personnel against becoming casualties themselves in the course of delivering first aid. 7lthough initial first aid should be given before moving the patient, simple means should also be provided for transporting an injured or sick person from the scene of the accident to the first aid facility. .tretchers should always be accessible. The first aid room 7 room or a corner, prepared for administering first aid, should be available. .uch facilities are required by regulations in many countries. 4ormally, first aid rooms are mandatory when there are more than +** workers at work or when there is a potentially high or specific risk at work. In other cases, some facility must be available, even though this may not be a separate room-for e"ample, a prepared corner with at least the minimum furnishings of a full-scale first aid room, or even a corner of an office with a seat, washing facilities and a first aid bo" in the case of a small enterprise. Ideally, a first aid room should< = be accessible to stretchers and must have access to an ambulance or other means of transportation to a hospital = be large enough to hold a couch, with space for people to work around it = be kept clean, well ventilated, well lit and maintained in good order = be reserved for the administration of first aid = be clearly identified as a first aid facility, be appropriately marked and be under the responsibility of first aid personnel = have clean running water, preferably both hot and cold, soap and a nail brush. If running water is not available, water should be kept in disposable containers near the first aid bo" for eye washing and irrigation = include towels, pillows and blankets, clean clothing for use by the first aid personnel, and a refuse container. Comm$nication and Referral Systems (eans for communicating the alert Following an accident or sudden illness, it is important that immediate contact be made with first aid personnel. This requires means of communication between work areas, the first aid personnel and the first aid room. $ommunications by telephone may be preferable, especially if distances are more than A** metres, but this will not be possible in all establishments. 7coustic means of communication, such as a hooter or bu%%er, may serve as a substitute as long as it can be assured that the first aid personnel arrive at the scene of the accident rapidly. 1ines of communication should be pre-established. 8equests for advanced or speciali%ed medical care, or an ambulance or emergency service, are normally made by telephone. The employer should ensure that all relevant addresses, names and telephone numbers are clearly posted throughout the enterprise and in the first aid room, and that they are always available to the first aid personnel. Access to additional care The need for a referral of the victim to more advanced or speciali%ed medical care must always be foreseen. The employer should have plans for such a referral, so that when the case arises everybody involved will know e"actly what to do. In some cases the referral systems will be rather simple, but in others they may be elaborate, especially where unusual or special risks are involved at work. In the construction industry, for instance, referral may be required after serious falls or crushings, and the end point of referral will most probably be a general hospital, with adequate orthopaedic or surgical facilities. In the case of a chemical works, the end point of referral will be a poison centre or a hospital with adequate facilities for the treatment of poisoning. 4o uniform pattern e"ists. /ach referral plan will be tailored to the needs of the enterprise under consideration, especially if higher, specific or unusual risks are involved. This referral plan is an important part of the enterprise0s emergency plan.

The referral plan must be supported by a system of communication and means for transporting the casualty. In some cases, this may involve communication and transport systems organi%ed by the enterprise itself, especially in the case of larger or more comple" enterprises. In smaller enterprises, transport of the casualty may need to rely on outside capacity such as public transport systems, public ambulance services, ta"is and so on. .tand-by or alternative systems should be set up. The procedures for emergency conditions must be communicated to everyone< workers !as part of their overall briefing on health and safety#, first-aiders, safety officers, occupational health services, health facilities to which a casualty may be referred, and institutions which play a role in communications and the transport of the casualty !e.g., telephone services, ambulance services, ta"i companies and so on#.