Chapter 16 Injury Prevention
Decision Making, Safety, and Accident Avoidance
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Contributing to overall risk for injury is the growing feasibility of exploration by wilderness novices, children, elders, and persons with disabilities or chronic health issues by using off-road vehicles, watercraft, and aircraft or via improved access. For persons who venture into the wilderness, there are growing technologic advances in communications equipment, global positioning systems, sporting equipment design, water purification and disinfection, and food processing and preservation techniques, all of which extend the duration of expeditions and permit exploration of remote wilderness once accessed by only the most skilled and experienced persons. Environmental hazards, such as exposure to cold, heat, snow, or altitude, can be minimized through proper planning and training. Wilderness sports activities, such as hunting, snowmobiling, and backcountry ski touring, are safer today not only because of advances in technologic and safety equipment, but because of efforts to educate the public about associated risks and how to manage or reduce these risks and efforts to train the public in wilderness first-aid and medicine (Figure 16-1, online). Despite the growth in numbers of practitioners of wilderness medicine and improved ability to provide care for many injuries and illnesses in remote settings, evacuation of injured victims from the wilderness remains daunting and can turn a minor problem into a major medical situation with a protracted rescue.
There are 78 million hectares (193 million acres) of land in the U.S. National Forests and Grasslands. Thousands of rivers and lakes are parts of the National Forests, and there are 247,000 km (153,000 miles) of trails, primarily for nonmotorized use. It is estimated that 178 million people recreate each year in the national forests.152 Sixty-four percent of 446 million visits to national parks in 2009 were considered recreational, with 1.9 million categorized as backcountry overnight visits.97 The National Sporting Goods Association estimates that between 1994 and 2004, the number of Americans involved in backpacking and wilderness camping climbed from 10.2 million to 13.3 million. During the same time period, the number of hikers increased from 25 million to 29.8 million.98
With increased access comes the potential for higher numbers of injuries, illnesses, and fatalities. According to the Centers for Disease Control and Prevention (CDC), in 2005 a total of 173,753 injury-related deaths occurred in the United States, and during 2006 an estimated 29,821,159 persons with nonfatal injuries were treated in U.S. hospital emergency departments.26 The number of injuries and injury-related deaths as a result of wilderness activities is unknown and can only be extrapolated, particularly from National Park Service (NPS) data. Between 2003 and 2006, there were 12,337 search and rescue (SAR) operations in national parks, involving 15,537 visitors and involving 522 fatalities and 4860 ill or injured visitors.60 From a public health point of view, the physical, financial, and emotional consequences of injury can be wide ranging, devastating, and long lasting. The CDC’s National Center for Injury Prevention and Control (Injury Center) was formed partially as a result of a recommendation of the 1985 Institute of Medicine report Injury in America, which concluded that supporting injury research is necessary to substantially reduce injury rates.30 The Injury Center strives to prevent injury and reduce its consequences, using a public health approach that describes the problem, identifies risk and protective factors, develops and tests prevention interventions and strategies, and promotes widespread adoption of effective interventions and strategies. Although the Injury Center includes intentional as well as unintentional injuries in its focus on injury prevention, their efforts and approach may prove to be a model for future research and methods for injury reduction in the wilderness setting.
Principles of Wilderness Injury and Prevention
Conceptual Models
The following are the steps to complete Haddon’s matrix:
Haddon’s 10 Strategies for Reducing Injuries
Environmental, Educational, and Enforcement Approaches to Injury Prevention
Comprehensive injury prevention projects employ strategies that include all of these.
Environmental Approach
In classic injury epidemiology, environmental interventions refer to the following:
The following are key concepts for environmental modification:
Educational Approach
Three goals of educational interventions are as follows:
An educational approach may be appropriate in the following instances:
Limitations of the educational approach include the following:
Social-Ecologic Model
In addition to the classic epidemiology approach of host, agent, and environment enhanced by the stages of prevention and articulated by Haddon in his matrix, another conceptual model attempts to describe injury prevention but with more focus on the interplay of different factors. The social-ecologic model has its foundation in human development and has been refined to apply to injury prevention and epidemiology. The social-ecologic framework was created by Urie Bronfenbrenner19 in the context of understanding human development and is very compatible with a broader view of public health.76 Social-ecologic theory defines various levels of the social environment, depicting the nested roles of intrapersonal factors, interpersonal factors, institutional elements, and cultural elements. This social-ecologic framework enhances the standard public health model of agent-host-environment.88,120,135
Institutional elements are those that reflect organizations in which individuals function, for example, schools, places of worship, and workplaces. How these organizations promote or control activities and environments can affect injury risks. Work sites contain many hazards and adopt many types of safety practices, whereas places of worship may either encourage or discourage certain safe or unsafe practices. Prehospital trauma care and inpatient health care systems are institutions that affect injury outcomes.105
Active Versus Passive Injury Prevention Strategies
Before proceeding to implement methods of injury prevention, it is important to recognize that injury prevention strategies are either active or passive.112 Active injury prevention strategies require change in behaviors by individuals before or when exposed to risks.145 For example, individuals must be convinced that wearing seat belts reduces the risk for injury and then must take the action of buckling up. Passive injury prevention strategies are preferable because they require no action on the part of the individual.54,72 For example, recent advances in automotive safety have been gained by placement of air bags. A more classic passive approach has been referred to as environmental controls. An example of this is a fence placed around a pool to prevent entry of unsupervised children, thus reducing drowning incidents.
Morbidity and Mortality Statistics for Wilderness Injury
The difficulties of obtaining data about injury prevention in the wilderness are the diversity of activities covered and lack of a single source for the data. As a result, data are often only for a selected activity and in a single location. Some data involve several activities. An example is a CDC study released in 2008 of nearly 213,000 people who had been treated each year in emergency departments for outdoor recreational injuries from 2004 to 2005.44 Of those injured, about 109,000 (51.5%) were young people between the ages of 10 and 24. For both men and women of all ages, the most common injuries were fractures (27.4%) and sprains (23.9%). Of these, most injuries were to the arms or legs (52%) or to the head or neck (23.3%). Overall, 6.5% of outdoor injuries treated were diagnosed as traumatic brain injury. Researchers found that snowboarding (25.5%), sledding (10.8%), and hiking (6.3%) were associated with the highest percentage of injuries requiring emergency department visits. The study points out that wilderness injury prevention begins with planning, preparation, and problem anticipation, which are discussed later in this chapter.
An example of event-specific data is for backpacking and camping. Data reveal that more than 11 million people participated in backpacking or wilderness camping in 1990. The morbidity and mortality figures from eight national parks in California between 1993 and 1995 are 1708 injuries and 78 fatalities.95 Another event-specific activity for which there are data is scuba diving. There are more than 9 million certified scuba divers in the United States, with approximately 650,000 annual certifications.35 The Divers Alert Network37 at Duke University Medical Center (Durham, NC) reported approximately 1000 serious diving-related injuries and approximately 90 diving-related fatalities annually between 1995 and 2002.
In addition to event-specific data, one can examine equipment-based data, which can include data based on certain types of vehicles. For example, from 1990 through 1995, an estimated 32,954 persons were involved in injuries related to personal watercraft.18
Lastly, one may search data to learn about specific types of injuries or deaths. An example of this type of data is a western Washington study of 40 pediatric wilderness-activity related deaths between 1987 and 1996.100 Ninety percent of the victims were male, and 83% were 13 to 19 years of age. The most common cause of death was drowning (55%), followed by closed head injury (26%). Injuries or deaths resulted from lack of preparation, lack of training for wilderness activities, and inadequate basic safety equipment; alcohol use and rescue delays were contributing factors. Of note, the presence of adults did not appear to be significant in reducing the incidence of mortality.
Putting Injury Prevention into Practice
Planning
At a minimum, one must address the following:
Preparation
Physical Preparation
Physical preparation includes maintaining excellent fitness and health in anticipation of the activity and the added stresses over daily activities. This may include conditioning, medical evaluation for physical abilities and health to undertake the activity, better medication adjustment for persons with chronic illness, and/or disability-specific planning for those with disabilities. In addition to general physical preparation there are unique considerations for physical preparation related to the genitourinary tract (see Injury Prevention for the Genitourinary Tract, later).
Physical Disabilities (see Chapter 102)
For persons with disabilities, it may be a great challenge to access wilderness. In federally designated wilderness areas, Congress reaffirms in the Americans with Disabilities Act that nothing in the Wilderness Act prohibits use of a wheelchair in the wilderness by a person whose disability requires its use. There are 54 million persons with disabilities in the United States, and this number is expected to grow. The challenge for the future will be ensuring that persons with disabilities have the same opportunity to participate in wilderness activities and programs as do persons without disabilities, without necessarily making wilderness access easier.153 The principles of injury prevention apply to people with disabilities who participate in wilderness activities. Their preparation, planning, and anticipation of problems must take into account the specific disability and unique physical and mental challenges of that disability.
Individual Factors and Injury Prevention
Specific Tools for Planning and Preparation in the Wilderness
Maps and Orienteering
People should have the ability to tell where they are and where they are going. A single wrong turn can have disastrous consequences. Maps are useful tools for planning, and the Global Positioning System (GPS) gives an accurate determination of actual location. Traditional two-dimensional maps, such as road maps, identify a sampling of features on the ground, with symbols to represent physical objects. Topographic maps, also known as “topo” maps or contour maps, use contour lines or shaded relief to represent the shape of land surface. Contour lines connect contiguous points at the same altitude. Topo maps usually depict significant bodies of water, forest cover, or other features and are prepared using interpretation of aerial photography or remote sensing techniques. The U.S. Geological Survey (USGS) produces several series of national topographic maps, the largest and best known of which is the 7.5 minute, 1:24,000 scale, quadrangle nonmetric scale map, each of which covers an area of 0.125° latitude by 0.125° longitude spaced 7.5 minutes apart (an area of about 49 to 64 square miles). The 7.5 minute series of maps has been abandoned recently in favor of The National Map, a collaborative effort of the USGS and federal, state, and local agencies to improve topographic information in the United States and contributing to the development of a new generation of digital topographic maps.141
Communication Devices
Traditionally, emergency communications from wilderness settings have been limited to signaling with devices such as a mirror or other reflector, whistle, fire, smoke, or flare (Figure 16-2). Newer laser devices encased in waterproof housings have been found to be very effective in identifying people during aerial searches, particularly at night. Commercially available “rescue laser flares” are small, lightweight, and rugged handheld laser devices that project a wide line, rather than the pinpoint light normally associated with a laser. They allow the user to sweep across an area with a dispersed red or green light beam that can be seen from up to 30 miles away (3 miles in daylight). The device is powered by lithium batteries that when used continuously will last for up to 72 hours, depending on the model.111 The international distress signal (SOS), which can be used with many signaling devices, consists of three short signals, followed by three long signals, and then three short signals, repeated at intervals. Signals may communicate the general location of an injured person, but to provide more detailed information about injuries or illness, some form of vocal or written communication is needed. Vocal communication allows rescuers to obtain an accurate, on-site victim report with descriptions of injuries, mechanism of injury and the specific location of the victim. Ongoing communications with a reporting party can help guide rescuers to the victim and allow them to provide advice about first aid before their arrival.
(A to D courtesy Eunice Singletary; E copyright Greatland Laser, Anchorage, Alaska. http://www.greatlandlaser.com.)
Cell phone technology is useful only when travel is within an area with cell phone relay stations, making its use limited in the wilderness. Wireless access for cell phone use is becoming more common inside U.S. national parks but is limited to the more populated areas where the park service often provides audio tours. Signals may be weak or unreliable. Cell phones in national parks are controversial: Conservationists argue that parks run the risk of becoming too civilized. Critics argue that the presence of cell phone towers in wilderness areas and national parks creates a false sense of security. Despite the controversies, cell phones are being used increasingly within national parks to notify authorities of mountaineering and recreational accidents. If a cell phone is used within a park, it is best to program in the direct number for park dispatch, because dialing 9-1-1 will often reach a county sheriff, who must then relay the call. Once dispatch is reached, state your location and call-back number early in the conversation in case of connection failure. A member of a party may need to hike to the nearest trailhead to obtain cell phone service. Completion of a standard incident report form before leaving the scene will allow the caller to provide critical information about the nature of the incident, location, and initial care provided. Cell phones with GPS (E911) technology can be useful for providing the location of an injured person. As a result of a mountaineering accident with three fatalities on Mt Hood in 2007, the Oregon state legislature proposed bills that mandate electronic signaling devices (personal locator beacons, mountain locator beacon, GPS receiver with cell phone/two-way radio) for all climbs above 3048 m (10,000 feet) on Mt Hood. Although local rescue personnel and climbers are reported to encourage the use of such equipment, they do not believe its use should be required.127 One survey of climbers found that 14% of them always carry a cell phone. Twenty-one percent of climbers who reported carrying a cell phone indicated that they had used it to report an accident.8 If a cell phone or GPS unit is carried into the wilderness, consider using a waterproof box or case to prevent damage from crushing, dropping, or water, along with a backup battery. In most cases, portable radios serve as a good choice for communication between party members. When carrying a portable radio, determine which frequencies are allowed for personal use and which frequencies are monitored in your area.
Radiofrequency interference from transmitting cell phones (code division multiple access [CDMA]) or two-way radios can cause interference with some avalanche beacons. Playing an iPod at close range has also been found to cause radio frequency interference in all beacons.38 A common intermediate (processing) frequency for cell phones or digital cameras is 455 kHz, which is very close to the 457 kHz radio frequency of avalanche beacons. In addition, false signals may be produced in some beacons from cell phones cycling their transmission to “handshake” with their cell. To ensure there is no radio frequency interference, electronic equipment, including cell phones and digital cameras, should be turned off while doing an avalanche transceiver search with any brand of digital or analog transceiver.149 Satellite phones connect with orbiting satellites and have the potential to be used worldwide. The size and weight of early “sat phones” once limited their use in the wilderness, but current versions are as small as a “smartphone” or mobile PDA (Figure 16-3, online). The cost of newer satellite phones can top $1000, prohibiting their use by many wilderness adventurers. In addition, most satellite phones will only work with a corresponding network and cannot be used if the network is switched.
Depending on the type of satellite phone service used, there may be a delay in transmission of voice or data. Geostationary satellite phone systems depend on line of sight for service. Low-Earth-orbit systems (<2000 km [1243 miles] above the earth’s surface) depend less on line of sight. Two such systems in the United States are Globalstar (http://www.GlobalstarUSA.com) and Iridium (http://www.Iridium.com). Globalstar does not provide coverage of the polar caps because of the inclination of their orbiting satellites; Iridium claims worldwide coverage. Satellite phones are banned in a number of countries, such as North Korea and Myanmar, because their use bypasses local telecommunication systems, hindering efforts at censorship. In disaster situations, large spikes in call volumes may lead to cascading failures of a network, similar to cell phone network failures noted in past disasters.
Protective Gear
Clothing
Waterproof and breathable fabrics, sealed seams, lightweight high-loft insulation, quick-dry material, and material with sun-blocking properties have been at the forefront of outdoor clothing offerings. Sometimes referred to as technical clothing, these fabrics have temperature regulation properties embedded in the yarns and retained with washing. Microfiber materials are used as an alternative to down for insulation in sleeping bags and clothing, because they retain heat when damp or wet. Microfiber material wicks moisture and sweat away from the body and keeping wearers drier and warmer in cold weather and cooler in hot weather. A combination of yarn selection, fabric construction, and finishes is used to create sun-blocking protection, which is often rated with the Ultraviolet Protection Factor (UPF) system.7 A rating of 15 earns a product a rating of “good”; a rating of 30, “very good”; and a rating of 40 or 50+, “excellent.”
Foot and Hand Wear
Mechanical injuries to the toes can be avoided with shoes or boots with integrated steel caps and soles. Sole design can prevent slippage; the design should be based on the intended use. Materials with good friction at moderate temperatures tend to become hard with cold temperatures and to lose their grip. On wet ice, virtually all shoe materials become slippery. Insulation is an important factor with low ambient temperatures. Adding heat sources such as disposable chemical foot and toe warmers, warm air or water circulation, or battery powered electrical heaters can reduce heat loss. Additional heat sources generally reduce volume inside the shoe or boot, potentially compromising fit and maneuverability, and also add weight. A 100-g (3.5 oz) increase in the weight of footwear has been shown to increase oxygen consumption by 0.7 to 1.0%, the equivalent of adding five times that weight carried on the torso.70,71,83
Insulating qualities of footwear largely depend on air being trapped inside the fabric of the shoe and between the sole of the foot and the shoe, and can be increased by addition of socks, so long as the footwear is large enough to accommodate the socks without becoming too tight.78 Socks play a large role in moisture management by absorbing sweat. Sweat rates vary widely in the foot, with lower rates in cold weather of 3 g/hr at rest. Newer synthetic materials, such as polypropylene, Capilene, and Thermax, wick moisture quickly, making them good choices for an inner layer. Pile or fleece socks do not wick moisture very well. Wool offers many advantages. It is warm in winter, cool in summer, absorbs and wicks sweat, and keeps the feet warm when wet. Furthermore, during long trips, it rinses well in cold stream water, can be worn for days at a time without wear, and does not mat down like cotton socks with terry loop liners.
Impermeable or semipermeable footwear materials prevent external moisture from entering footwear and wetting insulation. Moisture from sweat inside a shoe reduces insulation qualities and increases heat loss by 5%. Walking and the subsequent pumping effect of moving air in footwear removes moisture and in ordinary shoes removes about 40% of humidity.78 Footwear requires drying to retain insulation and protect feet from the cold. Moist socks and insoles should be changed, and shoes with removable liners should have the liners removed. Placing footwear in a warm, well-ventilated location will assist with drying.
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