CPR is best performed with compressions and rescue breaths. Photo courtesy of John Ball.

Arborists have their Z133 Safety Requirements for Arboricultural Operations. This industry consensus standard provides them with the safety recommendations and requirements for performing their work. The Z is revised about every five or six years to reflect changes in the tools and techniques used in the tree care profession.

Arborists are not alone in having standards that are periodically reviewed and revised. The American Heart Association (AHA) and the American Red Cross have recently revised their guidelines for first aid and cardiopulmonary resuscitation (CPR) training. The guideline revisions were based upon current evidence and patient impact. These first-aid/CPR revisions are important to arborists. One Z133 requirement under 3.2 Emergency Procedures and Readiness is that there shall be two workers trained in first aid and CPR on every crew of two or more. These two workers must have valid certificates from AHA, Red Cross or other training organizations. These certificates must be renewed every two years to be sure that first-aid providers are staying current with first-aid/CPR guidelines.

The AHA and Red Cross first-aid/CPR training is not specific to any industry. The information and skills arborists learn in their first-aid/CPR class may be called upon to care for a neighbor, family member or the public, as well as a co-worker. This article will highlight guidelines that pertain to arboricultural-operations injuries. Readers will learn about other guideline revisions during their next first-aid/CPR class.

Determining the need for medical assistance

This is not a new guideline but is included, as the decision to act is the first step in first aid. This means being aware of your own safety and that of other potential rescuers. Are you or other workers at risk of being injured as well? Is there an electrical hazard? Is the tree unstable? Once a rapid survey is completed, based on the first-aid needs of the injured worker, do you call 911? A key emphasis to the guidelines is determining whether an injury can be treated on site or requires professional assistance.

Signs to contact emergency medical services (EMS) are when the injured worker is unresponsive, has abnormal breathing (absent, too low or too high), has severe bleeding or suffers severe chest or abdominal pain. Additional signs to contact EMS are allergic reaction resulting in facial swelling or difficulty breathing, traumatic head injuries, suspected limb fractures and vision loss, among others. Delaying first aid for these potentially life-threatening injuries can have grave consequences.

Bleeding control

Uncontrolled bleeding is a major trauma injury that can result in death before emergency medical services arrive on scene. These account for about one-third of the preventable trauma fatalities, and arborists are among these fatalities. We perform a wide array of tasks, such as chain-saw operations, that – if improperly performed – can result in incidents involving severe bleeding. The bleeding from a deep, ragged laceration from rotating chain-saw teeth can become fatal in two to four minutes if left uncontrolled.

Arborists need to practice the proper placement of tourniquets. Photo courtesy of John Ball.

Direct pressure is the first aid for managing external bleeding. Every first-aid kid must have dressing and roller bandages for pressure dressing. But severe arterial bleeding, due to its higher pressure, may not slow from dressing alone. Direct pressure also may be difficult to maintain. These are situations when the use of hemostatic dressing may be useful as adjuncts to pressure. These dressings contain blood-clotting agents – chitosan, kaolin or calcium alginate – among others. But these do not replace the need for direct pressure, nor with severe bleeding, the application of a manufactured tourniquet.

Manufactured tourniquets are becoming a means of controlling blood loss. They are most appropriate for controlling blood loss from deep, ragged lacerations to extremities, such as to the thigh from the rotating teeth of a chain saw. They are applied “high or die” at the proximal end of the injured extremity. This means for a deep forearm cut, the tourniquet is placed on the upper arm near the shoulder.

Tourniquets are tightened with a strap, then the windlass twisted until bleeding stops. The pressure can be painful for the patient, but it is necessary to control the bleeding. While the use of manufactured tourniquets has not been linked to loss of limb function or amputation, their use can increase the risk of nerve compression injury. This risk is reduced by using wide-cuff tourniquets that require less pressure.

Once a tourniquet is applied, it remains tightened until EMS arrives. If properly installed, tourniquets can be left on for two hours without any ill effects (though the patient may find the tourniquet extremely painful). The time when the tourniquet was applied also should be recorded. Many manufactured tourniquets have a tab to write the time on with a Sharpie or other marker. If a tab is not on a tourniquet, a Sharpie can be used to write it on an exposed extremity or even the patient’s forehead. The purpose of writing the time of application is that there is a window in which EMS may decide to replace the tourniquet with pressure dressing.

Fractures

First-aid training includes the use and placement of SAM splints. Photo courtesy of John Ball.

Long-bone fractures – broken arm and leg bones – are a common arborist injury, especially to climbers who suffer from fractures as they bounce off branches during a fall. These fractures can be associated with significant, and sometimes life-threatening, blood loss. The use of direct pressure and hemostatic dressing may be necessary to control external bleeding associated with a suspected fracture.

Whether a bone is fractured or the injury is a dislocation, sprain or stress is not easy to determine in the field. An injury may require an x-ray to confirm a fracture. Unless it is an open fracture, where a bone is piecing the skin, the mechanism of injury – a fall from three times the patient’s height, for example – provides the suspicion of a fracture.

Color changes to the skin over the suspected fracture are indications that a fracture may have occurred. The injured extremity turning blue or pale is a sign that blood circulation may be compromised. People with dark pigmented skin should have their hand palm or feet soles, areas with minimal melanotic pigmentation, inspected for cyanosis. Any color change is serious and requires professional care.

Splinting also may be beneficial for reducing pain and risk of further injuries. But a splint can increase nerve injury if done improperly. The splinting must be done in the position found; never attempt to move the limb.

Spinal-motion restrictions

Spinal immobilization was the standard first aid for anyone experiencing a back or neck injury. The rationale was that any movement could result in spinal-cord injury. This led to the routine use of backboards and cervical collars for EMS. Arborists produced their own devices, including the thought of using boots to fashion a collar, which should never be done! Immobilization is best left to the professionals.

But the evidence is not clear on the benefit of backboards and collars for EMS. They have even been shown to increase mortality with some traumatic injuries. Now the recommendation is to have the person with the suspected spine or neck injury remain as still as possible while awaiting EMS. Once they arrive, EMS may decide spinal immobilization is necessary, but first-aid providers should not employ collars or backboards. The use of these may be required for a rescue, but this is a decision for EMS.

Bee and wasp stings

Bee and wasp stings can trigger anaphylactic shock, making quick recognition, epinephrine use and EMS response critical. Photo courtesy of Richard Schramm.

There are more than 50 incidents each year in the United States of people suffering fatal anaphylactic shock from a bee or wasp sting. At least one of these incidents is to an arborist who dies following bee or wasp stings.

Anaphylactic shock is due to the body’s reaction to the venom, not the venom itself. A severe reaction causes blood vessels to dilate while the airway passages are constricted. The person experiences facial swelling, throat tightening and dizziness, among other things. Anaphylactic shock can be fatal if left untreated.

Individuals with known allergies often carry epinephrine autoinjectors. These inject epinephrine into the muscle of the outer side of the thigh. If the person to which the autoinjector is prescribed can self-administrate the device, they should do so at the first sign of an allergic reaction. If they cannot, a first-aid provider can assist.

The epinephrine will relax the airway muscles and tighten blood vessels. The injector can reverse the reaction very quickly, but the effect may only last minutes. About a fifth of the time, the second autoinjector may be needed, hence the reason they come in packages of two. The second autoinjector can be used if symptoms have returned and EMS has not yet arrived. Any time the autoinjector is used, the first-aid provider should contact EMS. The person may require further treatment after the first or second injection.

Temperature extremities

Heatstroke occurs when people are doing heavy work in hot, humid environments. This describes the summer environment for many arborists. One group of arborists that are vulnerable to heat-related injuries is chipper operators. One of the worst jobs on a crew is dragging and feeding brush into a chipper on hot and humid days.

Heat-related injuries occur when the body cannot shed heat. We depend on the evaporative cooling of sweat to regulate our temperature. If someone is dehydrated on a muggy day, they are not sweating as much as they should be. If the humidity is high, the sweat remains on the skin rather than evaporating.

This also is an injury that coworkers often miss – until it is too late. We have several fatalities each year of arborists working in the heat and feeling sick, then told to sit in the shade for a few minutes, only to be found dead when a co-worker later checks on them.

Some common symptoms associated with heat exhaustion are dizziness, heavy sweating and cool, clammy skin. Workers with these symptoms must be moved to a cooler environment such as an air-conditioned building or even the cab of a truck with the air-conditioner running. Clothing traps heat, so as much as is practical, remove their outer clothing. The overheated person should be given cool liquid, but only if they are not in danger of becoming unresponsive and not being able to swallow. A 4% to 9% carbohydrate-electrolyte drink is better than water.

Heat exhaustion can become heatstroke if left untreated. Heatstroke occurs when the body temperature exceeds 104ºF. Heatstroke is a serious medical condition that can become fatal if not managed. Some common symptoms of heatstroke are confusion, lack of sweating and hot, dry skin.

This is one of those times that emergency medical services need to be contacted. The first-aid treatment that provides the fastest cooling is water immersion – from the neck down – while awaiting EMS. The water temperature is not a factor; anywhere from 36ºF to 79ºF is acceptable. Water immersion works faster than ice packs placed in the groin and armpit areas. If placing the injured worker in water is not possible, soaking them with cool water can be done.

This is a brief overview of some of the revisions in the latest standards for first aid/CPR. Everyone will hear about these revisions (and more) when they take their next first-aid/CPR class.

John Ball, Ph.D., BCMA, CTSP, A-NREMT (Advanced-National Registry of Emergency Medical Technicians), is a professor of forestry at South Dakota State University.