Watch Your Step

EMS response to construction accidents

• Cameron Bucek, AS, EMT-P
• December 2008 JEMS Vol. 33 No. 12
• 2008 Dec 1

Look to the skyline of any large city, and you might feel like our country is being invaded by cranes, scaffolding, aerial lifts and other construction equipment. As our population continues to grow and the price per acre continues to climb, buildings and cities continue to expand outward and upward. And this expansion has another cost—injury. 

Across the U.S., construction ranks among the most dangerous industries, representing about 20% of all work-related fatalities, and an even larger number of non-fatal injuries, most of them affecting exterior building contractors, according to 2006 federal statistics.Most recently, New York, California and Florida have had the highest numbers of injuries and fatalities related to the building boom.

In addition to the increase in construction, a deadly mix of untrained immigrant workers and lax attention to safety regulations can mean EMS is called to an even greater number of sites. Let’s consider how the influx of construction brings with it unusual EMS responses and how to handle them.

Make an Appearance
As construction starts in your area, it would be beneficial for your crews to visit the site and meet with the project manager. Be prepared to ask questions, take notes and exchange contact information. Your questions should include: 

>> What kind of construction is this?

>> What stage of the construction process are you at?

>> Are you using any specialized construction equipment?

>> Are there collapse zones?

>> Do you have any on-site utilities?

During your visit, you should also determine the route of initial access to the scene and egress, as well as what rescue resources would be needed during an emergency. 

You may also need to have the crew physically sketch the development and involved streets. New neighborhoods in your response area mean new street names in different subdivisions, and new addresses may not be contained within your map book or mobile data terminal. Most newer CAD systems can be updated, but older systems may not be as easily appended. 

In addition to site visits to preplan access and egress, be sure to train on rescue operations if it’s within the scope for your agency. (For more training photos, view this article on  jems.com.)

En Route & On Scene
As an emergency responder, you must be fully prepared for the type of incident you’re responding to. Falls are the leading cause of injury/fatality at construction sites. Other common injuries include burns, lacerations, impalements, amputations, crush injuries, head injuries and fractures/dislocations. En route, try to learn the type of injury or illness; the patient’s condition; and, most important, the location and direct-access route to the patient. 

Based on dispatch information, you should consider responding with specialized equipment and/or request a helicopter be placed on standby for aeromedical transport. Also among initial concerns is the appropriate level of PPE based on possible structural or environmental hazards, as well as emergency egress from the scene in case of secondary collapse. 

Depending on the stage of construction, most sites have a sand perimeter, which makes it almost impossible to access the scene with your stretcher. Instead, you can utilize a backboard or Stokes-type basket to transport your equipment to the scene. The Stokes or backboard can be easily maneuvered through the construction site without your equipment falling off. Use the backboard straps to secure your equipment and prevent unnecessary damage. 

As you walk toward the scene, consider lighting, fall protection and the ever-present hard-hat areas. All construction sites are hard-hat areas, and we should treat them as such. Do you require your crews to wear steel-toe boots with a puncture-resistant sole, or do they wear comfortable tennis shoes? If we become injured, who will treat the patient?

On arrival to the patient, pay particular attention to the immediate surroundings. If it’s a trauma call, look for all the mechanisms related to the patient’s injury. As you remember from your basic EMT education, mechanism of injury (MOI) describes the process of assessment related to how kinetic energy was transmitted through the body and which organ systems were most likely affected. Kinetic energy is the most frequent source of injury related to construction accidents, so this step is critical. The cornerstone of trauma assessment is early consideration of kinematics to predict hidden injury. Remember, kinematics is the branch of physics that studies the motion of a body or system of bodies without consideration given to its mass or the forces acting on it.

The basic concepts to keep in mind when assessing MOI at a construction site are the anatomy of the area affected by the trauma, the type of surface density that was struck and the distance of the fall (if relevant). Remember, the greater the height of the fall, the greater the potential for injury.

Scorekeeping
As in every standard trauma treatment protocol, initial assessment includes the primary survey with the addition of neurological status. This is a good time to use a trauma scorecard with the Glasgow Coma Scale. The trauma triage criteria listed in Figure 1 is Palm Beach County (Fla.) Fire Rescue’s version of the trauma scorecard. 

Using this scorecard,if the patient is identified by the EMT or paramedic as meeting certain criteria, a trauma alert will be directed to an appropriate trauma receiving hospital. The trauma triage criteria are divided into red and blue categories for both adult and pediatric. If the patient exhibits any signs or symptoms related to any one criterion in the red category, it’s an immediate "Trauma Alert." If the patient doesn’t meet any of the red criteria, the provider must assess for any two criteria of the blue category. 

The triage criteria also states, "Any patient may be transported as a ‘Trauma Alert’ if local criteria are met, or if in the judgment of the EMT or Paramedic should be transported as a ‘Trauma Alert.’" This statement is the catch-all when you’re on scene with a certain patient who just doesn’t meet trauma triage criteria but should be taken to an appropriate trauma receiving hospital. 

For example, I recently responded to a residential construction site to a 35-year-old male patient who had fallen. On arrival, I found the patient supine, lying in an unfinished sand and gravel driveway. Bystanders on scene reported the subject was working on the roof when all of a sudden he was gone. 

The patient reported he had slipped off the roof and fallen two stories to the ground below, landing on his left side, and that he was in moderate pain. The patient complained of left arm pain, left-sided abdominal pain and left hip pain. On further assessment, I discovered a broken left forearm with bone protrusion as well as a tender left-sided abdominal wall, and finally left hip pain with some crepitus noted. Vital signs were: P 110, BP 100/70, RR 24, GCS 15. Did this patient meet trauma alert criteria, or was it a case of paramedic discretion?

Fluid Theories
Most of your construction cases will fall under the "load-and-go" principle, limiting on-scene time to 10 minutes. However, some incidents that involve extended extrication or patient removal will lend themselves to on-scene treatment, which may involve advanced airways and IV access. 

Many studies have tried to settle the debate on early versus late use of fluids for resuscitation. Currently, the best data available demonstrate that there’s no difference in mortality outcomes in relation to fluids when surgical intervention is immediately available. However, the Advanced Trauma Life Support protocol of the American College of Surgeons recommends the liberal use of isotonic crystalloid to correct hypotension in bleeding trauma patients. 

The new theory in trauma-related fluid administration is called "permissive hypotension," which is when restrictive fluid resuscitation increases systemic pressure without reaching normotension. In non-compressible bleeding (i.e., can’t be stopped in the field) regardless of the cause, permissive hypotension is preferred. In this case, the decrease in blood pressure may assist in the formation of clots, whereas aggressive fluid resuscitation to increase blood pressure could "pop" clots that may have formed.

With permissive hypotension, the goal in the adult patient is simply maintenance of a peripheral pulse or systolic blood pressure between 80–90 mmHg. It’s important to remember that it takes 3 mL of fluid to replace 1 mL of lost blood because two-thirds of infused fluid will leave the vascular space within an hour. Although it’s a good principle to begin with 20 mL/kg of fluid as a starting point, the final amount will vary depending on the situation. Two large-bore IV catheters should be chosen for trauma patients. In cases of severe hypotension or shock and the inability to rapidly establish vascular access, intraosseus access should be established. 

Your Toolbox
Expect extended operations for any situation that involves extrication, elevated victim rescue, patient removal from entanglements or impalements, or collapse. The limited resources on most EMS response units include only a small toolbox. Be sure you carry at least the following: a hammer, screwdrivers, pliers, a ratchet set, channel locks, an adjustable wrench, a razor knife and a hacksaw.Luxury tools include cordless power tools, such as a drill, a reciprocating saw and an angle grinder with a metal cutting blade. 

If you need to extricate and package a patient impaled by an object, the first priority is to stabilize the scene by securing a safe perimeter around the patient. This may entail lock-out/tag-out of equipment, scene tape and even law enforcement. 

Second, stabilize the patient and ensure they’re supported and aren’t putting unnecessary pressure on the impaled object. Use a ladder, rope system or other practical means to reduce movement of the object and to comfort the patient. 

The next step is to remove (i.e., disentangle from the surroundings), cut and/or secure the impaled object. Some methods of cutting can result in further injury. A reciprocating saw will cause excessive vibration, and a hydraulic cutter tends to torque the object. The practical method for removal is to utilize hand tools, such as a hacksaw or an angle grinder with a metal cutting blade. Be aware of the heat generated by cutting metal, and assess the patient and object for heat transfer.

Once the object is free and the patient is in the position of comfort, secure the object from unnecessary movement and prepare the patient for transport. Remember this isn’t the "cookbook approach," but it’s a good start for you and your crews. 

Conclusion
It’s no secret that construction accidents are becoming more prevalent. Preplanning for construction calls, becoming familiar with construction projects in your area and visiting the sites will improve your response to these incidents. Considering dispatch information and using the scorecard methodology are crucial to quickly get the needed resources to the scene and make the appropriate decisions to treat and transport. For the future, we should continue to watch for new research about permissive hypotension and patient outcomes. I hope you’ll go out to your truck and check your toolbox for what’s missing or for tools you need to train on. Remember, don’t train until you get it right—train until you can’t get it wrong.  JEMS

Cameron Bucek, AS, EMT-P, is an EMS captain with Palm Beach County (Fla.) Fire Rescue. He has 18 years of fire and rescue experience. His certifications include fire officer, fire inspector and live-fire instructor, and he also instructs for Palm Beach Community College Fire and EMS Programs. Contact him at cbucek@pbcgov.com.

References
1. Bureau of Labor Standards and Statistics: "Injuries, Illnesses and Fatalities: 2006 Injury/Fatality Reports." www.bls.gov/iif

2. James SD: "Construction worker deaths spike."
ABC News. Jan. 16, 2008. www.abcnews.go.com/US/Story?id=4139502&page=1

3. Meyer SW, Pegula SM, Bureau of Labor Standards and Statistics: "Injuries, illness and fatalities in construction, 2004." www.bls.gov/opub/cwc/sh20060519ar01p1.htm

4. Palm Beach County Fire Rescue, Rescue Division: "Trauma Triage Criteria." www.pbcfr.org

5. Rushing GD, Britt LD: "Reperfusion injury after hemorrhage: A collective review." Annals of Surgery. 247(6):929–937, 2008.

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