Too many people die each year during arboricultural operations. While even one death is too many, the number we seem to have in all-industry statistics is disproportionate to the number of workers we have. While fatal injuries garner the most attention in the tree care industry, we also suffer a disproportionate number of severe non-fatal injuries. We tend to forget about this – they don’t make the news – but they can have life-altering consequences.
We often say that the older workers are the ones to die, but the reverse is that the younger workers are more often injured. What this means is that everyone has incidents, regardless of age, but it’s the outcome that’s different.
The definition of a traumatic injury is a physical injury of sudden onset. It’s the result of an outside force (i.e., not an internal illness) that’s beyond the body’s level of tolerance. If you are struck on your head with a rolled newspaper, your body can probably tolerate the force, and there is no injury. If your head is struck with a metal bat, that force is beyond your level of tolerance, and a traumatic injury will occur. Whether you die from this traumatic injury depends upon your level of tolerance, and to a large degree, that relates to your age.
We have thousands of minor injuries, i.e., those that require only a band-aid, though some require a quick trip to an urgent- care facility or even the emergency room of the local hospital. We have about a thousand or so severe injuries every year. Severe means they result in at least one day of in-patient hospitalization, not out-patient where you are treated and released.
The one-day hospital stay does not sound too serious, but how long are you out of work? Unfortunately, it’s usually a long time. More than a quarter (25%) of severe injuries result in at least 30 days’ lost time. Some are so severe that the injured worker will never return to work again. A few are even left paralyzed by the incident.
The severity of the injury depends on the magnitude of the force and the body’s level of tolerance. However, the outcome is dependent on the quality of the first aid provided on site and the speedy arrival of professional emergency medical services.
Let’s start with the emergency medical services (EMS). Speedy does not mean how fast EMS rushes to the site – in the EMS world, we don’t want to drive any faster to a scene than we have to; lights and sirens are not a prerequisite for every run. Instead, speedy is how fast you contact EMS. Too often, the crew waits before calling EMS. The injured worker, let’s call him Pat, didn’t “seem” that hurt when the falling branch bounced off his shoulder. Just have him rest for a bit, you think. Thirty minutes later, Pat is nauseous and his skin is cool and clammy. Pat is going into shock, you did not recognize the seriousness of the situation and now the call to EMS may be too late.
In the EMS world, we talk about the “golden period.” This was once referred to as the “golden hour,” but we wanted to get away from an exact timeframe. The term was coined by Dr. R. Adams Cowley, a military surgeon who wrote that a rapid response to a traumatic incident was a key factor in the long-term outcome of the patient. The concept has been criticized by the medical profession, but the basic point is valid, assuming the quality of care is the same – sooner care is better care.
Once the incident occurs, the first step is to assess the situation. What happened? Once you have that information – and assuming the incident warrants EMS – call 911. This is probably one of the best uses of your first-aid training, the ability to assess the situation and injuries and determine whether they require professional medical assistance.
When you call 911, it helps if you are prepared with some basic information. The first is, what happened? Be brief – did the climber fall, was a worker struck by a falling branch or was it some other incident? Next, know your location. Do not assume that your phone’s GPS will provide the precise location. It might, but there have been times when it’s off by a few blocks or more.
Another value to your first-aid training is being able to communicate some information about the injury, known as the LOC and the ABCs. You are the eyes and ears of the first responders prior to their arrival. LOC means level of consciousness. Is the worker conscious and oriented as to who they are and/or where they are, conscious but not behaving normally, or worse, unconscious?
The ABCs refer to the following:
A – airway. Do they have an open airway? If he or she cannot breathe, they are going to die very quickly, within minutes. The easiest way to check airway is by answering a simple question, can they talk? If they are conscious and talking in complete sentences, they have an open airway and they are breathing normally.
If the person is unconscious, they aren’t talking, so we move to B – breathing. Place your ear near their face and listen for breaths or watch the rise and fall of the chest. The average adult is breathing 12 to 20 times a minute. Incidentally, you are going to need to control your breathing during this, because it’s hard to hear their breaths if you are huffing and puffing.
After the A and B, we move to C – circulation. This assessment used to involve checking the pulse, but this has been mostly discarded, as few people can accurately take a pulse. Instead, we look for coarse bleeding. Can you see blood oozing out of the clothing? Is the blood bright red and spurting? Lots of bleeding is serious, as you can lose more than a quart of blood in a short time, an event that will result in shock. If the blood is bright red, it’s arterial, which means the bleed has higher pressure and will be more difficult to stop.
If the injured worker is not breathing or is breathing only with great difficulty, this life-threating condition requires prompt attention from EMS. The care may be beyond the first-aid capabilities – both training and supplies – of the crew. Uncontrolled bleeding is also life threatening, but there are means of controlling bleeding that are within the capability of a crew trained in first aid.
Lacerations, particularly jagged cuts, are most often responsible for hemorrhaging, or bleeding. The most common serious laceration is a chain saw cut, and, perhaps no surprise to readers, it is often because the worker was operating the saw one-handed, since most of the cuts are on the left forearm. Most crews also disregard the ability for modern handsaws to do prolific damage and cause severe bleeding. So just because it’s a handsaw injury doesn’t change the response.
The rapid blood loss from a deep laceration from a chain saw has killed tree workers, with most of these fatalities occurring while the worker was aloft. Direct pressure with dressings is the basic first-aid response to lacerations, but this alone may not be sufficient to control the bleeding. “Stop the bleed,” a recent national-awareness campaign in response to the proliferation of mass-casualty shootings, provides information, supplies and training for managing severe blood loss. In addition to direct pressure – compress and control – this training includes the use of tourniquets and hemostatic gauze that is packed into the cut, and these materials are now found in trauma first-aid kits.
Generally, the preferred option for severe bleeding of an extremity, i.e., an arm or a leg, is the wide-band tourniquet, sometimes called a soft tourniquet. However, if not available or the laceration is on the neck or shoulder – two other common sites for chain saw injuries – the hemostatic gauze can be used. The gauze is packed into the open wound and then direct pressure is maintained until EMS arrives and takes over care. If the gauze or dressing becomes soaked with blood, resist the urge to remove and replace it with new gauze; instead, just keep packing on more and more.
Many injures are serious but not life threatening, so while they still warrant a call to EMS, the initial first aid that the crew provides is essential to a good outcome. The ABCs extend further into the alphabet with D, disability. The most common severe injury is a fracture. Perhaps not too surprisingly, most of these fractures occur to climbers. They either break a lower leg or ankle when they impact the ground or the upper leg as they tumble through the canopy on a pinball- like path to the ground.
The open fractures are usually obvious and alarming – the bone is sticking out of the skin. The closed ones are more difficult to see. The basic “rule” is, if you suspect they may have broken a bone – a reasonable suspicion for a fall of more than 15 feet, assume it’s broken until proven otherwise, and the proof may be an X-ray.
So treat the injury, which may be just a sprain or strain, as a fracture by following RICE:
Rest – Do not move or straighten the injured area. Immobilize the injured area by holding – only splint if they have to be moved. Cold – Place ice in a plastic bag and hold to the injury for 20 minutes. Elevate – Raise the injured area to reduce swelling, but do not move to elevate if it causes more pain.
Bleeding from lacerations and fractures are two of the most common traumatic injuries to tree workers, and everyone should know how to treat these conditions. The best means of knowing what to do and how to do it is to take a first-aid/CPR course and practice these skills at least quarterly. You don’t want the first time you have to help an injured co-worker be the first time you’ve performed the skills!
John Ball, Ph.D., CTSP, and Travis Vickerson, CTSP, QC L, are both Advanced Emergency Medical Technicians.