We are not talking about the first-aid kit you carry in your truck to the job site. We are talking about the first-aid kit you carry aloft. Some safety standards in other countries recommend that climbers carry a first-aid kit with them. The Z133 Safety Requirements for Arboricultural Operations (2017) does not address this, but a personal first-aid kit is becoming more common among climbers in the U.S. You can find climber first-aid kits available online and in catalogs, and these carry an array of first-aid supplies.
Before going further, we want to make it clear we are not distinguishing between climbers and aerial-lift operators. We believe both groups should have a kit on their person before going aloft. They operate alone in a high-hazard environment, and self-first-aid is an important requirement of the job.
But what do you need to carry? What injury is going to require first aid? Let us look at one of the most common serious, nonfatal incidents aloft. No surprise, it is severe hemorrhaging from deep lacerations caused by a chain saw. The wound is frequently on the left forearm, although these also occur on the upper arm, usually left, or the upper leg. Chain-saw lacerations to the face and neck also occur, but these are usually fatal.
The amount of blood loss from chain-saw cuts can be significant. The typical adult male (175 pounds) has a total blood volume of about 10 to 12 pints. You cannot tolerate a loss of more than 20% of this volume, about two pints, over a short period (important note, you can donate one pint of blood over 15 to 20 minutes, so don’t sweat it when you give blood). Everyone knows that prompt and effective CPR can maintain blood flow and save lives. Stopping blood flow is equally important.
If you lose too much blood – more than two pints in a few minutes, you will suffer hypovolemic shock. This is a traumatic injury from low blood volume that causes inadequate profusion to critical organs. Your heart and brain require a constant flow of oxygen-rich blood, and a reduction can result in severe injury or death. A chain-saw laceration can result in a rapid blood loss of greater than two pints.
Lacerating the arm with a chain saw is likely to sever an artery. Arterial bleeding is bright red (since it is carrying the
oxygen-rich blood) and will spurt in time with the pulse. Venous bleeding, where you sever a vein, is darker red and flows steadily. The loss of blood from either an artery or vein is potentially life threating. The reason we regard arterial bleeding as more serious is because it is harder to stop.
Bleeding usually stops on its own in 10 minutes or less due to the body’s reaction and exposure to air. The cut ends of the blood vessels constrict, and exposure to air causes a clot to form. The greater pressure from arterial bleeding means it is harder to form a clot. Chain-saw lacerations are deep, wide and jagged, so it is hard for a clot to completely close these wounds.
If you are aloft when you are cut by the saw, first aid is up to you. The profession has seen many chain-saw incidents where climbers or aerial-lift operators were not able to stop the flow of blood and died before help could reach them. These incidents are more common with climbers than lift operators, due to the need for self-
rescue (many tree crews have only one climber). Rescues of climbers incapacitated by chain-saw lacerations have turned into recoveries as fire/rescue teams took too long, 30 minutes to more than an hour, to arrive on scene and reach the worker.
Why didn’t the injured climbers just come down on their own? First, if you’re the climber, the blood loss may be so severe that you lose consciousness quickly. Add this to the fact that it probably is going to happen when you do not have a straight descent to the ground. Instead, after you are cut, you must unclip a lanyard and pull yourself over a limb before descending, which means valuable seconds are lost and you become unconscious before even beginning the descent.
Aerial lifts can be operated by the lower controls if the operator aloft becomes incapacitated. But that is not always fast or easy. Working a boom into the interior of a large tree can involve a series of complex movements with both booms and the turret. Lowering an operator from a lift within a dense canopy may take several minutes, long enough for the operator to go into shock.
All these are good reasons to carry a personal first-aid kit to manage blood loss, whether you are a climber or an aerial-lift operator. As stated earlier, there are numerous personal first-aid kits on the market. But what should the kit contain? The supplies available to a tree worker in these kits range from a half-dozen small adhesive bandages to one with hemostatic agents and tourniquets.
Direct pressure is the first step to stopping blood flow and is usually all that is required for shallow wounds. However, here the focus is stopping severe blood loss due to a chain-saw cut. If you suffer a severe chain-saw laceration in a tree, you may have only seconds to make decisions as to how to treat the wound. You need more than a Band-Aid or even direct pressure with gauze in these instances. And you probably are only going to use your right hand to apply first aid, as blood is spurting from your left arm. The two first-aid supplies often mentioned for managing severe bleeding are hemostatic agents and tourniquets.
Hemostatic agents are chemical compounds that assist in clot formation. These come in two forms, a granular powder that is poured into the wound or an agent already impregnated into gauze that can be wrapped or packed into the wound. The gauze-impregnated agents are particularly adapted for deep, jagged wounds such as chain-saw lacerations, where they can be packed into the open cut.
Some hemostatic agents contain a clay material that absorbs water (blood is mostly water) and causes rapid clotting. The first clay material used, zeolite, caused a thermal reaction when mixed with blood. The temperature generated by the reaction of these compounds reached 140 F or higher, which could result in thermal injury or burns. Since 2016, there has been a switch to kaolin, another clay material, to eliminate the thermal reaction. Quikclot, a common commercial hemostatic product, switched to kaolin years ago.
Other hemostatic agents are chitosan-
based such as Celox. These promote clot formation through red-cell bonding. These compounds do not have a thermal reaction, but chitosan is derived from shellfish. There is a possibility that patients with a shellfish allergy may have a reaction to these products, however, no reactions have been reported.
Hemostatic agents can result in clots that move, causing distal thrombosis. They also can be difficult to remove at the time of surgery. All these precautions do not outweigh their benefit. Using hemostatic agents, in combination with first aid, should not be performed without previous training in their application.
This is especially critical for the gauze products. These must be packed into the wound. Many come in 12-foot rolls. The trauma trainer that comes in the Stop the Bleed kit is a cylinder that represents a thigh, and your goal is to pack all the gauze into the wound. This may sound impossible, but with just a little practice, you will be surprised how much gauze can be placed in the long, open slit. If you are a climber or lift operator, practice packing the gauze into the trainer using only one hand – this may be the real situation you are faced with.
Tourniquets have been used for centuries to stop the flow of blood. However, their use has been controversial and often discouraged for first-aid providers. Tourniquets can cause complications including increasing hemorrhaging. But with recent advances in tourniquet design and training, these have become acceptable in initial care when direct pressure is not feasible or enough to slow bleeding.
The tourniquet that comes in first-aid kits, such as the Combat Application Tourniquet (CAT), has a band wider than one-half inch and provides a windlass to tighten the band around the injured extremity. The windlass can be tightened with one hand, and there is a triangle attachment to hold it in place. Just as with hemostatic gauze, the application of a tourniquet should be practiced one-handed. The first time you use it should not be when you need it.
The key to using a tourniquet is to place it as distal as possible on the extremity, but at least 2 inches above the laceration and never over a joint. It also needs to be tight – tight enough that it stops the bleeding. The tourniquet should never be loosened or removed once it is placed. It can be left on for at least two hours without complications. By this time, professional rescue/medical personnel should be available.
As a final note, do not assume that if you can slow the bleeding and get to the nearest trauma center, you are going to have your limb function completely restored. The chain rotating into your arm is not only cutting through arteries and veins but also nerves. Severing nerves can result in loss of feeling in the fingers and thumbs. This nerve damage may be temporary, as surgeons can reconnect strands and nerve pathways do regenerate over time. Still, the numbness and loss of sensation, such as touch, is more than annoying. How do you climb a line if you cannot feel it?
John Ball, BCMA, CTSP, A-NREMT (Advanced National Registry Emergency Medical Technician), is a professor of forestry at South Dakota State University in Brookings, South Dakota.
Christopher Stimson, RN (registered nurse), CEN (certified emergency nurse), is a clinical improvement nurse at Sparrow Hospital Trauma Services in Lansing, Michigan.
Mitchell Sangl, Certified Arborist, is a graduate student at South Dakota State University and an arborist with Glacial Lakes Tree Service in Brookings, S.D.