By Rabbi Yair Hoffman for 5tjt.com]

STABBINGS

In light of the recent shootings in Bnei Brak and stabbings in Be’er Sheva and in Hadeira,r”l – a halachic question arises:

IS THERE AN OBLIGATION TO LEARN FIRST AID?

Is there an obligation to actually learn how to treat a gunshot and stabbing victim?
This article is going to take a view that is different than what seems to be the accepted halachic position in some of the contemporary Poskim.

RAV FEINSTEIN’S VIEW ON MEDICAL SCHOOL AND KOHANIM

In a response dealing with Kohanim studying medicine, Rav Moshe Feinstein zt”l (Igros Moshe YD II #151 and YD III #155) writes that the parameters of Pikuach Nefesh do not require someone to go out and gain new knowledge at a medical school. Rav Feinstein writes that only if one knows what to do must one stop whatever he is doing to save a life. However, there is no obligation to actually go out and learn and acquire new knowledge that can be applied into the future. Some contemporary Poskim have applied Rav Moshe’s psak to other forms of medical training as well.

DOES IT APPLY TO FIRST AID TOO?

The application of this ruling of Rav Feinstein to first aid, however, may not be the case. Rav Feinstein also brings up the notion that there are enough doctors in the world. Our situation, however, may be vastly different. For stabbing victims, seconds count, and there are actually not enough trained people out there to know what to do until medical assistance arrives.

PROOFS

With due respect, I would like to suggest that there may be a significant distinction between a long medical course of study and a shorter course of study for basic first aid. There are also a number of other Mitzvos that could and should be fulfilled in learning first aid procedures. There may also be a fascinating Kal VaChomer, fortiori argument, from a halacha in Shulchan Aruch.

The Shulchan Aruch (OC 328:2) writes in regard to whether a life-saving procedure is permitted on the Shabbos, “Hashoel – harei zeh megunah – one who asks a question – this is a disgusting thing.” The guilt and blame is also ascribed to the Rabbi, who should have taught the laws of what may or not be done on the Shabbos. Regardless, we see that there is an obligation to teach the halachos of what may or not be done. Would it not be a kal vachomer that if the actual procedures of what can be done were just as easily taught – that one would be obligated to do so?

The possible arguments to this are:

A] The obligation here in the Shulchan Aruch (OC 328:2) is a form of Torah instruction – the actual first aid knowledge, however, is not Torah.
B] It could be that the first aid knowledge is more complex than the halachic knowledge that is under discussion.

There is significant room, however, to disagree with these arguments.

The author of Hatzalah K’halacha (Siman 1) cites the Rambam in Hilchos Deos (4:23) writes that it is forbidden for a Talmid Chochom to reside in an area where there is no doctor. It may be conjectured that there, in fact, might be an obligation to go beyond the general knowledge that an individual may have – at least in terms of choosing where one will reside. The Sefer Chassidim (#1669) also cites the rationale that had a certain son studied what needed to be done for his father, his father would have been alive.

There are also some subtle proofs from the Acharonim as well, that there is an obligation to actively go out and learn something. Rabbi Yechezkel Landau, author of the Noda Biyehudah writes (MT YD 210) that it is forbidden to perform an autopsy to learn medicine in order to cure sick people who are not physically in front of us. The implication is that if they were physicially in front of us, we would be required to study it – that is something new. The same implication may be drawn from the response of the Chsam Sofer (YD 336).

OTHER MITZVOS TOO

In learning this type of first aid, a person will be in a position to fulfill other Mitzvos as well.

Let’s also realize that the Talmud Yerushalmi tells us, “whomsoever saves one life it is as if he has saved the entire world.”

The other Mitzvos are:

Vahasheivoso Lo. The verse in Parashas Ki Teitzei (Devarim 22:2) discusses the mitzvah of hashavas aveidah, returning an object with the words, “Vahasheivoso lo—and you shall return it to him.” The Gemara in Sanhedrin (73a), however, includes within its understanding of these words the obligation of returning “his own life to him as well.” For example, if thieves are threatening to pounce upon him, there is an obligation of “Vahasheivoso lo.” This verse is the source for the mitzvah of saving someone’s life. It is highly probable that it is to this general mitzvah that the Shulchan Aruch refers to in Shulchan Aruch, Orech Chaim 325.

V’chai Achicha Imach. The Sheiltos (Sheilta #37), based upon the Gemara in Bava Metzia 62a, understands these words to indicate an obligation to save others with you. The Netziv in his HeEmek Sheailah understands it as a full-fledged obligation according to all opinions. He writes that he must exert every effort to save his friend’s life, until it becomes pikuach nefesh for himself.

V’ahavta L’reyacha Kamocha. The Ramban, Toras haAdam Shaar HaSakana (p42-43) understands the verse of “And love thy neighbor as yourself” as a directive to save him from medical danger as well.

Lo Suchal L’hisalaym. There is yet another negative commandment associated with the positive commandment of hashavas aveidah, and that is the verse in Devarim (22:3), “You cannot shut your eyes to it.” This verse comes directly after the mitzvah of hashavas aveidah. The Netziv (HeEmek Sheailah) refers to this mitzvah as well. If we do not have a number of people readily available who can handle such emergencies until help arrives, and it is something that can be easily learned, are we not “shutting our eyes?”

Lo Saamod Al Dam Reyacha. There is a negative mitzvah of not standing idly by your brother’s blood as well. This is mentioned in Shulchan Aruch (CM 426:1) and in the Rambam. If the solution is easily accomplished, are we not in some manner or form violating this Mitzvah if we do not educate ourselves and others in this minor area?

CONCLUSION

It is this author’s view that in fact there is an obligation to have a basic understanding of simple first aid techniques. We also see this in the obligation to understand what constitutes a physical danger as well, which is outlined in Choshain Mishpat. Thus, we should know that not cleaning out lint filter in a dryer causes many fires and deaths. We should educate ourselves and our children that we cannot mix bleach and ammonia house cleaners or it can cause death from poison gas. And we should learn basic first aid techniques as well.

The rest of this article contains much of the information that is necessary to best deal with a stab wound for a layperson. The first priority of course is to get the proper personnel there to take care of the victim. The information below is for what to do until the emergency medical personnel arrive or what to do if there are no such personnel present. The information has been adapted from WikiHow.com.

There are 18 paragraphs – chai. Remember, v’chai bahem – we must live by the Torah.

How To Treat a Stabbing Victim

1. Survey the area. A stabbing often occurs during a volatile incident and the terrorist may still be in the area. Only approach the victim once you have determined it is safe for you to do so. Although waiting until the assailants have left the scene entails lost precious time for the stabbing victim, having more people injured is worse.

2. Call for emergency help immediately. If the person has been stabbed, it is critical to call emergency services as soon as possible. If you are the only person around, use your phone to call for priority assistance. If you don’t have a phone with you, try to find a passersby or a nearby shop. You want to help the person as quickly as you can, but the most helpful thing you can do is get professional medical help to the victim as soon as possible. If the assailants are still nearby and you are unable to safely approach the victim, use that time to call emergency services.

3. Lay the person down. Before you do anything to attend to the stab wound, get the person to lie down on the ground. This will make it easier to help stabilize the victim, particularly if he starts to get dizzy or fall unconscious. You don’t want the person to risk making things worse if he falls while fainting. For comfort, place a jacket or backpack under the victim’s head. Or, if there are other people around, ask one of them to sit with the person’s head in their lap and talk to him. This will be soothing to the victim and help keep him calm.

4. Examine the person and determine the extent of the injury. Is there more than one stab wound? Are there slashes? Where is the blood coming from? Is it on the front or back of the body? You will probably have to part the person’s clothing to properly identify the wound(s). Try to look for and identify all wounds before starting your treatment. However, if you notice one obviously severe wound that needs urgent treatment, you should deal with this immediately. A severe wound would be one that is bleeding steadily and profusely or one that it spurting out blood like a geyser. Spurting blood is usually a sign that the wound has hit an artery.

5. Attending to the Stab Wound – Put on disposable gloves if you have them. Alternatively, you can also put some plastic bags over your hands. Though this step is not required in order to tend to the stab wound, it is important in order to protect yourself reduce the risk of infection to you or the victim. If available, nitrile or other non-latex gloves are preferable. Sometimes there are allergic reactions to latex, which can complicate treatment. If you don’t have gloves, try to wash your hands or even use a hand sanitizer quickly. If you have nothing available, use layers of cloth to keep a barrier between yourself and the victim’s blood.

6. Check the victim’s ABCs, Airway, Breathing, and Circulation. Make sure the person’s airway remains unobstructed. Listen for the sound of breathing and watch the person’s chest for movement. Check the victim’s pulse to make sure the heart is still beating. If the victim has stopped breathing, perform CPR. If the person is conscious, begin working but also talk with him to keep him calm and help slow his heart rate. If possible, try to keep the victim’s eyes averted so he cannot see the wound.

7. Remove the victim’s clothing around the affected area. This will enable you identify the precise location of the stab wound and then apply treatment. Stab wounds can sometimes be obscured by both clothing and blood or other fluids and even dirt or mud, depending on where the victim is found. Use care in removing the victim’s clothing since he or she is likely in considerable pain.

8. Do not remove the stabbing object if it is embedded. Leave the object in the wound if it is still there and be very careful not to move it, which may cause further damage. The object is actually helping to stem the blood flow. Pulling it out will likely increase blood loss, while pushing it in may cause further injury to the internal organs. You’ll need to apply pressure and dress the wound around the object as best you can. Medical professionals will be better able to remove the object without damaging any internal organs or causing massive blood loss in the process.

9. Stop the bleeding. Apply pressure on the wound with a clean and absorbent material (like a shirt or towel), or preferably, a clean dressing such as sterile gauze. If the object is still in the wound, press firmly around it. Applying pressure to the wound will help to slow the flow of blood. Some first aid training suggests using the edge of a credit card to “seal” the wound, an item that’s handy because so many people have one on them. Not only does this stem blood flow, but it may also prevent lung collapse (by keeping air out of the wound) if the wound is in the chest. If the wound is bleeding profusely, apply pressure to the major artery leading to the area with your hand, while your other hand continues to apply pressure on the wound. These areas are called “pressure points.” For example, to slow bleeding in the arm, press the inside of the arm just above the elbow or just below the armpit. If the wound is on the leg, press just behind the knee or in the groin.

10. Reposition the victim so the wound is above the heart. This will help reduce blood loss. If the victim can sit, get him to move himself into an upright position; if not, then help the victim if possible.

11. Cover the dressing. If you have first aid materials with you, fasten the dressing in place using a bandage or tape. Do not lift or remove the dressing as this will disrupt clot formation and re-start the bleeding. If the dressing becomes soaked with blood, add more cloth material on top of it. If you don’t have any materials to fasten the dressing in place, simply continue to apply pressure. This will help the blood clot. For a chest wound, be careful. Cover the wound with something like kitchen foil, a plastic bag or cling-film and only cover three sides of the wound and leave one un-taped or bandaged down. Air needs to be able to escape from one side of the bandage to prevent it from entering the pleural cavity in the chest. If air enters the pleural cavity, the lungs can collapse. Never use a tourniquet except as the last resort to save a life. Know how and when to use a tourniquet. If a tourniquet is applied incorrectly, it may lead to an unnecessary serious injury to or loss of the affected limb.

12. Continue to apply pressure to the wound until help arrives. While waiting for emergency help, continue to monitor the ABCs: airway, breathing, and circulation. Look for and treat symptoms of shock. Symptoms of shock include cool, clammy skin, paleness, rapid pulse or breathing, nausea or vomiting, dizziness or fainting, and increased anxiety or agitation. If you suspect the victim may be in shock, loosen any tight clothing and cover her with a blanket to warm her. Try to get the victim to stay still.

13. Check the victim’s consciousness. If the victim falls unconscious, you’ll need to act quickly. Place the victim in the recovery position, on his side with the head tilted back and the hand further away from the ground under the head and the arm closest to the ground either bent or straight out. The leg further away from the ground (the top leg) should be bent for stability and to keep the victim from rolling forward. Do not put someone in the recovery position if you suspect he has a spinal or neck injury. Monitor the person’s breathing. If the unconscious victim stops breathing, place the victim on his back and perform CPR.

14. Keep the victim warm and comfortable. Both shock and loss of blood can cause the victim to suffer from lowered body temperature. Throw a blanket, coat, or some other warm item over the victim to keep her warm. Keep the victim as still as possible. Whether lying or sitting down, the person should be kept still and calm. It is important that someone remains with the person constantly to both reassure her and to monitor her condition.

15. Cleaning and Closing a Stab Wound – Begin cleaning the wound. If you are isolated and not able to call emergency services, you should clean the wound once you have some control over the bleeding. In normal circumstances, this would be the job of emergency personnel, but there may be times when you need to do this yourself. Remove any debris from the wound if present. Keep in mind, however, that even a wound without debris has had an object jabbed in it and there’s no way of knowing how clean that item was. In other words, every wound should be cleaned properly. Saline is the best to irrigate the wound. Fresh, clean water is best if there is no saline on-hand. You can also make a salt solution. Mix of 1 tablespoon of salt to 1 cup of warm water. The victim will likely experience pain when the wound is being cleaned so if the person is conscious, give him warning.

16. Pack the wound. A dirty wound should not be closed, and any stabbing is considered dirty. Packing the wound should help to avoid any contamination from outside materials, like dirt, which could cause an infection. Stab wounds should be packed with saline and gauze and cover with tape relatively loosely. In this case, you are covering the wound, not binding it, as you wait for it to clot. If you have some medical training or you are certain the wound is clean, you may wish to close the wound. Make sure the wound is dry first. If you have some glue, apply it to the edges of skin around the wound (not on the wound). Apply a strip of tape to one edge of the wound, close the skin gap with your hand, and apply the other side of the tape. Cover the wound with clean cloth, duct tape, or whatever else you have on hand that can keep dirt and other infectious materials out of the wound. The wound should be repacked daily. If a wound will not cease bleeding, do NOT close it.

17. Apply antibiotic treatment, if available. If you have any antibiotic ointments, apply periodically to the wound. This will also help avoid any infection from setting in.

18. Check that the bandage is not too tight. Check the area furthest away from the heart for each limb that has a bandage on it. For example, if the person has an arm wound, examine his fingers. If the person has a leg wound, check his toes. If a bandage is too tight, it may cut off blood flow to the area below it, which is dangerous and can permanently damage the tissue. You can tell if this is happening because these areas will become discolored (blue or dark-colored). Loosen the bandage if you notice this happening and see emergency assistance as soon as possible.

The author can be reached at [email protected]