Safety from Falls, Falling Objects and Crush Injuries
The Arrive Alive website regularly receives reports of pedestrians and other road users injured in some sort of “Fall”. This includes incidents where objects fall onto them as well as themselves falling from heights.Falls and the trauma caused by falling are a significant part of paramedic studies. It involves several aspects of EMS like scene safety, mechanism of injury and several other dynamic factors, which are specific to each incident.
Falling can be separated into two categories:
Falling or tripping from a standing position on the ground and falling from a height (like from a ladder or building etc). This is separate from falling objects, which is effectively blunt force trauma to the body. There could also be a combination of the two forces, depending on the incident.
We decided to gain more insights from our EMS services and create awareness on how to respond to these incidents.
What is the nature of injuries usually expected when responding to a fall of objects onto a victim/ patient i.e. a wall falling over, a tree or gate etc falling onto a person or an object such as a vehicle found on top of a person?
Generally, the type of injuries we will see are “Crush” injuries.
What is a “Crush” Injury?
Crush injuries are common in car accidents, falls and in other situations where an injury is caused because of a structure collapsing.
Nature of Injury from a crushing incident
- There are varying degrees of crush injuries, from slamming a finger in a door to limbs being trapped and crushed for an extended period. Depending on the severity of the crush injury, the symptoms will differ.
- Injuries can range from anything as minor as a sprained ankle to severe crushing injuries, depending on the nature of the call. We've had fractures, head injuries, facial trauma, severe lacerations, blunt force chest- and abdominal trauma etc.
- For a minor injury, there can be bruising, lacerations and moderate pain. However, the recovery time is significantly shorter than a major crush injury, as is the degree of the symptoms.
- A crush injury will often cut off the flow of blood in the damaged appendage, leading to serious muscle and tissue damage, as well as numbness and possible paralysis.
- In the case of a major crush injury, there is often serious damage below the skin, including tissues, organs, muscles and bones.
- These injuries are often significant as they involve significant force that is transferred on the victim and then it is possible that the victim, becomes entrapped by what fell on them.
- Injuries we expect are injuries associated with blunt force trauma, which causes damage to the bodies internal organs and structures.
- There can also be fractures. cuts and lacerations do occur but most of the trauma is internal and is not obvious to people without medical training. (i.e. ruptured internal organs, collapsed lung, internal bleeding, closed fractures).
- If the person is entrapped or pinned down by the object (this is often the case with large objects) it then often requires the use of rescue tools to free the person.
- The extrication needs to be done in a controlled matter, while paramedics constantly treat and reassess the patient. The object can’t simply be lifted off quickly.
- There is also often difficulty in breathing due to an object falling on the chest, which is generally the biggest part of your body.
What are the first steps to be taken by bystanders?
- Safety First!!
- Focus on safety of the scene and remember own safety first.
- This is especially important with falling objects and industrial incidents.
- Keep in mind the risk that someone still in the area could be injured.
- Properly assess the situation and then call for help in the form of ambulances, rescue etc
- Accurate information for these types of calls is critical as specialist equipment might be needed in some cases that are not normally dispatched as a first- turnout.
What should bystanders NOT be doing?
- Don’t Panic! This creates a tense situation for all and especially the patient that is already under a lot of stress.
- Do not act instinctively, trying to be a hero and doing more harm than good in the end.
- Never put your own life at risk. Rather call for help immediately.
- Do NOT enter an area that is not safe.
- Do NOT unnecessarily move the patient. First aiders should be wary of moving a patient if he is trapped beneath a heavy object.
- If the object is unstable, moving it could apply more weight to the patient or injure the patient further. If you are unsure, calling an emergency service for further advice is always a good call.
To move or not to move the victim/ patient? What are the considerations as to whether to move the victim/ patient?
- In most incidents, it is best not to move the person. The victim may have sustained injuries, which could be worsened if moved.
- Moving a patient unnecessarily could cause further spinal or other damage depending on the nature of the injury.
- Moving heavy items from patients that are trapped could cause the patient to go into shock and subsequently cardiac arrest if the necessary precautions have not been taken by paramedics before moving.
- As a rule, the victim should not be moved if the scene is safe and there is no life-threatening danger for the patient.
- However, there is a principle, which is “life, over limb” which means that if the person’s life is in danger by remaining there then its best to move the patient to a safe area.
- Examples of Immediate danger would be fire, further collapse, drowning etc.
- Extra caution is required if you are not qualified in first aid or similar and do not have the right equipment available.
Does the age of the victim influence the injuries expected or treatment considered?
- Age is a factor in traumatic injuries as elderly patients are much more fragile.
- Old age brings factors such as osteoporosis, causing fractures to occur easier even from small falls normally due to the weakening of the bones.
- Younger / fitter patients also handle injury much better than older / unfit persons. Younger persons normally also have fewer co-morbidities i.e. cardiac, pulmonary, gastrointestinal conditions that further contribute to the condition of the patient.
- The elderly unfortunately does not recover from these injuries as well as the younger generations do.
- Young children ages 1 month to 1 year tend to decompensate much faster than adults.
- In children, who’s bones are still growing, we often saw what are called, “greenstick “ fractures, which is an incomplete break of the bone, due to the bones being less brittle.
- For children to have a complete fracture we can suspect that it was caused by significant trauma.
The person's age irrespective of the incident is something we always take into consideration when treating patients, especially babies and children when compared to adults:
- as they have different body size to weight ratios.
- different vital signs.
- there are different injury patients that occur (due to their smaller body size) (i.e. a car bumper that would strike an adult on the leg, would hit a small child in the abdomen and chest).
- There are many differences between and adult and a child that we take into consideration when treating, way too many to mention here.
What are the most important steps taken by emergency services on the scene of a fall incident?
- Irrespective of the nature of the emergency and especially if there are multiple patients, our approach is always the same.
- Scene safety. Even with EMS the first assessment we undertake, even before we get on scene, is about the safety of the scene and we implement measures if possible to make the scene safe or request further assistance.
- One of the first steps is to make sure that the emergency workers are kept safe. From there, we will stabilise the object, making sure that no further harm can come to the patient.
- In structural collapses, the scene needs to be stabilised with specialist equipment to prevent further collapse if there are still unstable structures present.
- We assess if we will need further assistance, this could range from requesting more paramedics to attend or requesting rescue services or police.
- We determine how many patients there are, where they are located and what their injuries are. We use this to determine which patients we treated first.
- It is vital to allocate the correct personnel/level of care to the correct patient. It is also important to assess if more / additional specialist equipment or services will be required to complete the task at hand.
- While treating patients we decide which patients need to be transported first from the scene and the level of the hospital which the patient requires being transferred to.
- The priority with the patient is to maintain airway breathing and circulation.
What are the most important steps to be taken in the event of a trench collapse and how does this differ from other objects falling on a victim?
A trench collapse is a very dangerous, if not one of the most dangerous types of rescue situations.
Trench collapses, in general, are technically complex calls to attend to, requiring specialist personnel and equipment.
There is always the risk of further collapse or entrapment. Compacted soil as an example also exerts a much greater force on the human body than a single item falling on a specific area of the body.
Considerations such a suffocation/difficulty in breathing must be considered in a trench collapse as the body might by completely covered in material.
Many paramedics, especially those who have not had rescue training (some paramedics don’t have the combined medical and rescue training), don’t even realise the dangers involved in a trench rescue.
The dangers include:
- The unstable trench
- The risk of further collapse
- The weight of the soil
- Other objects like pipes in the trench
- Many paramedics and bystanders often not realise these risks and just jump into the trench to start trying to help
Aspects that make trench rescue difficult as well as dangerous (continued) include
- The confined space the rescue
- The rescue could be taking pace several meters under the surface.
- Harmful gases in the trench
- During trench rescue boards need to be lowered into the trench and secured against the walls, using pneumatic struts to prevent the walls collapsing. This is often time-consuming and complicated depending on the type of trench, how deep the trench is and how much of the trench has collapsed.
- The height is taken into consideration and whether the entrapped patient can breathe. The time limit is vital as well as resources available to rescue team workers.
As always, the safety of the emergency workers and patient is paramount. In a trench rescue, rescue services will make sure that no further collapse will happen, which can cause more injury to the patient, as well as cause the paramedics to become entrapped.
What are the major differences between the injuries sustained and treatment required when a person [pedestrian] falls from a height as to when an object falls onto him?
- The injuries may differ quite a bit.
- Injuries from a fall from a height will most likely impact injuries whereas objects falling on patients will most likely result in crush injuries.
- Both incidents may result in general fractures as well as general soft tissue injuries.
- Paramedics will assess the patient and treat his injuries symptomatically.
- In falls we expect to see fractures- to the legs, arms and spine as well as head and spinal injuries.
- When falling items cause injuries it may range from local trauma at the site, to the person becoming trapped under the object, depending on the size.
- Much depends on the height the patient fell from, on what service the patient landed.
- In the case of falling from heights your whole body can be injured, in the case of a pedestrian accident the point of impact can be on part of the body, that can accrue in spinal injuries. Common injuries suspected can be head injuries and spinal injuries.
Any advice you would like to offer to a parent and the public on the response to falls?
- Prevention is better than cure.
- Please remember own safety first, don’t walk on uneven grounds, be careful always.
- The most important advice is to remain calm and make sure once emergency services are called, that accurate and correct information is given for emergency workers to give the best possible care.
- Take extreme caution with small children where a hazard exists that can cause falling from a height i.e. an open/unprotected window on a second story, open balcony etc.
- Also, teach children not to play at or on dangerous structures such as gates or in trenches that could possibly collapse.
- This covers many safety aspects which can be implemented to try and prevent someone from falling in the first place, in the home, office and industrial site:
- slippery floors are a big risk, clean standing water on floors and door mats can prevent excess water being carried onto interior floors.
- stairs must have a railing and preferably a non-slip edge.
- Safety precautions of equipment must be adhered to, irrespective of the equipment being used
- Safety equipment like hard hats and fall harnesses are very important
- Scaffolding needs to used according to spec and safety checked before people climb on it.
Many fall cases involve people who have fallen off a ladder when using a ladder.
- Make sure the ground is firm and level
- Don’t take distractions, like cell phones up the ladder
- Don’t climb all the way to the top of the ladder as it becomes unstable, a longer ladder is then needed
- Don’t stretch or lean while on the ladder
- Have someone hold the ladder at the bottom.
[A word of appreciation to the following people for the assistance with this Q&A]
Robert McKenzie, KZN EMS
Russel Meiring, ER24
Ruan Vermaak, CrisisOnCall
Stanley Schimper, Trauma Response Africa