Trauma in the Agricultural Setting 25

25

Trauma in the Agricultural Setting

G IDEON L ETZ AND J AMES E. L ESSENGER

Key words: mechanisms of injury, agents of injury, prehospital care, trauma care systems

By the very nature of the industry, traumatic injuries in agriculture are com- mon and difficult to treat. In the agricultural environment, the worker is exposed to a number of hazards, well documented in other chapters of this book. The work is hard and demanding and often carried out under unfa- vorable and harsh weather conditions.

This chapter will document the scope of injuries in worldwide agriculture, roadblocks to timely and competent treatment, systems for medical response to traumatic injuries, and systems for returning the injured worker back to the workplace. Prevention of injuries is discussed in Chapters 4, 5, and 6.

Extent of Trauma Injuries

The numbers of agriculture related injuries and deaths vary from country to country based upon several factors, including the type of work done in that country, preventive measures, the health and nutritional status of the work- ers, and the medical response to injuries. Tables 25.1 and 25.2 compare agri- cultural injury and death rates in several countries (1–5).

In many countries, the reporting system for agricultural injuries and deaths is incomplete due to apathy, lack of funds or facilities, or political factors.

Many companies and countries don’t want the precise numbers known in order to hide the need for preventive measures and safety controls. In Pak- istan, for example, official apathy is such that the newspapers provide a more realistic measure of injury and death than does the public health system (16).

As discussed in detail in Chapter 12, children are at greater risk for agri- culture injury and death, especially by trauma. Tables 25.3 and 25.4 show the injury and death rates among children in several countries, many of which have aggressive prevention and safety programs (17–20).

339

T

25.2. Trauma fatalities in adult agricultural workers.

Location Rate / 100,000 workers

United States (2000) 22

India (2000) 22

United States (1989 to 1992) 3.2

New Zealand (1989 to 1992) 4.9

Australia (1989 to 1992) 3.8

United States (1992 to 1996) 2.1

Canada (1991 to 1995) 1.6

Alaska commercial fishing (1991–1992) 200

Source: Data Rautianinen and Reynolds (4), Mag and Nag (12), Feyer et al. (13), Adekoya and Myers (14), and Pickett et al. (15).

T

25.1. Extent of agricultural injuries.

Location Costs Rate

California (2002) 8.2/100 workers/year

Iowa (2002) US$51,764/ injury 42/100 person/years

Ontario, Canada (1995 to 1996) US$19 million/yr

United States (1990 to 2000) 0.5 to 16.6/100 workers/year United States (1992) $3.14 to $13.99 billion/yr

India (one state) (2000) $27 million/yr 1.23/1000 workers/year

Australia (1989 to 1992) 20.6/100,000 workers/year

China (1997–1998) 33% of the workforce/year

Denmark (1998) 32% of full-time workers/year

Ohio (1995) 5/100 person/years

Source: Data from McCurdy et al. (1), Rautiainen et al. (2), Locker et al. (3), Rautianinen and Reynolds (4), Leigh et al. (6), Tiwari et al. (7), Franklin et al. (8), Xiang et al. (9), Rasmussen et al. (10), and Crawford et al. (11).

T

25.4. Extent of agriculture trauma fatalities in U.S. youth.

Time period Rate /100,000 persons in age groups

1979 to 1981 9.3/100,000

1990 to 1993 8/100,000

Source: Data from Goldcamp et al. (21) and Lilley et al. (22).

T

25.3. Extent of agricultural injuries in youth.

Location Rate

Kentucky (1994 to 1995) 2.8/100

California (1998) 3.8/100

Minnesota (2000) 1,683/100,000

United States (1990 to 1993) 1717/100,000 farm residents

Source: Data Browning et al. (17), McCurdy and Carroll (18), Gerberich et al. (19), and

Rivara (20).

Mechanisms, Agents, Types of Trauma

The mechanisms of trauma, or the way that the person is injured, vary from country to country based upon the type of crops grown and the methods used to grow them. For example, in California falling ladders are a risk to people harvesting oranges, yet in the Pacific Islands, falling coconuts are a hazard to people harvesting the product. The resulting injury may be the same in both cultures. Table 25.5 compares the major mechanisms of injury in agriculture, the typical agents where the mechanisms occur, and the typi- cal resulting injuries.

T

25.5. Mechanisms and agents of injuries, with examples of associated injuries.

Mechanism Agent Injury examples

Fall from a height Farm animals Fractures

Overexertion Lifting boxes Lumbar strain

Repetitive motion Sorting fruit Carpal tunnel syndrome

Sprains and strains Jumping from a tractor Sprained ankle

Lacerations Pruning knives Lacerated hand

Scalp avulsions Long hair caught in machinery Partial or complete scalp laceration

Engulfment Falling into grain elevators or Asphyxiation manure pits

Rollovers Tractors and self propelled machines Head injuries Spinal injuries Multiple trauma

Collisions Vehicles Head injuries

Spinal injuries Multiple trauma Blasts Explosion of pressurized tanks Multiple trauma

Amputations

Burns Combustibles such as gasoline Burns

Shrapnel Exploding fuel tanks Lacerations

Multiple organ trauma

War Combat “collateral” injuries Amputations

Unexploded ordnance Multiple trauma

Land mines Lacerations

Burns

Falling objects Trees Head and spinal trauma

Coconuts Ladders

Penetration Animal horns Pneumothorax

Abdominal trauma

Tree branches Eye injuries

Auger injuries Augers for transporting grain or Amputations of hands crushing wine grapes

Source: Data from Centers for Disease Control (23), Pros and Vrtiskova (24), Karaman et al.

(25), Alexe et al. (26), Kirkhorn and Schenker (27), and Stiernstrom et al. (28).

Mechanized countries may have more injuries from limb entrapments in machines, while countries dependent upon animals will have more injuries from animals, such as stomping and kicking injuries or injuries from falls.

The nature and extent of injuries are complicated by the pre-injury health and age of the worker, pregnancy, the potential for secondary gain through litigation, and whether personal protective equipment was used (see Chap- ter 6) (23–28).

Roadblocks to Treatment

With exceptions, such as ornamental horticulture, most agricultural enter- prises are carried out in rural areas, far from doctors’ offices, clinics, trauma hospitals, and rehabilitation facilities. Many countries, such as Bangladesh, Pakistan, Afghanistan, and countries in equatorial Africa or Central America, have minimal medical care and may not have facilities to effectively treat farm trauma except in the large cities. Many countries lack any prehospital care at all and the populace may have poor training in first aid (29).

Along with the lack of facilities, many parts of the world lack trained med- ical personnel and surgeons to effectively treat trauma. Especially important is the “golden hour” in trauma patients, the hour when effective treatment of shock and rapid control of bleeding is so important to the preservation of life and limb (29).

Even in the so-called “wealthy” countries, sheer distances may complicate treatment. For example, in Tulare County, California, it may take an ambu- lance traveling at high speeds over an hour to reach some remote places. The terrain, lack of effective roads and transportation, and swollen rivers or marshes create roadblocks to obtaining effective medical help. Weather con- ditions, such as blizzards, ice storms, and floods provide effective barriers to medical transportation.

War presents a major challenge to people in agriculture. Combat places farmworkers in harm’s way and at risk for war-related trauma. Blockage of roads, minefields, crowded hospitals, and overworked ambulances result from combat, making it difficult to evacuate and treat farm injuries. In the after- math of war, unexploded ordnance and landmines maim hundreds, if not thousands, of people on farms each year (30–33).

Many of the roadblocks come down to lack of money and, more impor-

tant, commitment. The two must go hand in hand because without one, the

other will be useless. With a commitment to effective trauma care, profes-

sionals can organize a system of evacuation and treatment geared to the local

terrain and weather barriers. Professionals can also lobby for money to

implement such a program.

Systems for Medical Response

Pre-Hospital Options

First aid

Many organizations, including the Red Cross, Red Crescent, and Scouts, teach basic and advanced first aid courses. Because of the long distances to medical services, some states train farm families in advanced first aid techniques.

First aid courses concentrate on control of bleeding, control of the airway, covering the wound, splinting, preventing shock, and evacuation techniques.

Ireland equips rural physicians with portable trauma kits to provide advanced trauma life support. The Donegal Pre-hospital Emergency Care Project equipped general practioners with the kits and found a significant improvement in pre-hospital survival (34).

Emergency Medical Systems

Volunteer or professional emergency medical systems (EMS) follow one of five models: hospital based, municipal, private, volunteer, and complex.

These organizations vary in training, equipment, and their ability to reach the injured person. More advanced units utilize highly trained personnel and sophisticated treatment protocols and equipment. Also important is advanced training in machinery extraction, tractor rollovers, and enclosed space rescue (35–37).

There are three basic treatment philosophies in operating EMS systems:

1. Scoop and swoop: This system utilizes minimal or no stabilization of the injured person at the scene of the accident, evacuating the person to a hos- pital as quickly as possible.

2. Treat and swoop: These systems engage in advanced treatment at the injury site, including intravenous fluids, advanced airway control, antishock suits, and chest tubes. Some systems utilize physicians to perform advanced pro- cedures on injured people in the field.

3. A combination of the two. Most systems use a combination of the two EMS systems depending upon the level of training of the response per- sonnel and the complexity of equipment they are provided with (38,39).

Helicopters and “flying squads” have provided a new dimension to EMS

services. Not only can they rapidly evacuate injured persons over difficult ter-

rain but they can utilize aircraft to transport injured persons to specialty hos-

pitals in other areas, even on other continents (40).

Physicians’ Offices and Clinics

In many parts of the world, and especially in rural areas, physicians’ offices are the first stop for agricultural trauma patients. They provide the advan- tages of availability, less crowding, and less expense than hospital emergency departments. They also may have less bureaucratic burden of regulation and paperwork. Some physicians’ offices and clinics are equipped to manage major trauma and life support, but most treat minor injuries such as lacera- tions, minor burns, and fractures.

Emergency Departments and Hospitals

Around the world, there is a vast range of availability, training, and equip- ment among hospitals and emergency departments. Using protocols and training in Basic Trauma Life Support and Advanced Trauma Life Support, the management of agriculture trauma has improved in many countries.

Rapid intubation, fluid resuscitation, control of hypothermia, and control of bleeding are the hallmarks of trauma support in emergency departments.

Precise and rapid diagnosis using radiographs is possible in most countries, but ultrasound machines, CT scanners, and MRI units are not available in many countries. In many locations, physicians must rely on their clinical judg- ment to diagnose and treat trauma patients (41,42).

Advanced surgical techniques in limb re-implantation, head injury surgery, spinal salvage, and microvascular surgery have improved the salvage rates for limbs, spinal, and head injuries. Any advanced surgical program requires advanced training for surgeons, nurses, and other personnel, adequate equip- ment and supplies, and proper facilities.

Coordination

Training physicians who work in emergency departments in the techniques of

Advance Trauma Life Support is not enough. A training program in Jamaica

did not improve life and limb salvage because it was not integrated into the

prehospital and surgical treatment programs. Integration of pre-hospital,

clinical, emergency department, and surgical programs into one seamless sys-

tem is the goal of any trauma system. Major items such as protocols and

training can be standardized by a coordinating organization such as a munic-

ipality or hospital. Ironically, sometimes the little things are what really mat-

ter, such as compatibility of EKG machine lead attachments with machines

in the ambulance, emergency department and operating room. The need to

place and replace EKG leads or IV equipment from one component to the

other wastes money and time that can be better spent in patient treatment

(41,42,43).

Returning the Injured to the Workplace

Impairment is the physical inability to perform a certain function, such as the loss of an arm or vision in one eye. Disability is the social restriction upon the injured person brought by a specific impairment. An example of a dis- ability would be the inability of a person to harvest fruit with the loss of vision in both eyes or the inability of a person to continue to sort fruit after the loss of an arm (44,45).

Rapid Return to Work

Most agriculture trauma is minor, and injured workers can and should be sent back to work in some capacity as soon as possible. A rapid return to work takes advantage of the “healthy worker effect,” i.e., people get better faster if they are returned to work (44–47).

Not all employees can be immediately returned to work at full duty; yet there is some work they can do. Many injured employees can be placed on modified duty so they can be returned to work to take advantage of the healthy worker effect and at the same time earn a living. Many employers have modified duty programs for injured workers and it is important for the employer and physician to work in concert to develop a return to work pro- gram (46–48).

Rehabilitation Services

Major trauma often requires major rehabilitation to return the employee to work. Rehabilitation services include:

1. Reconstructive surgery 2. Provision of prostheses 3. Training

4. Special equipment for return-to-work, such as specially equipped vehicles 5. Assistance with activities of daily living, especially important in-head and

spinal cord injuries

6. Provision of personal assist devices such as wheelchairs, canes, and crutches

7. Vocational counseling services 8. Psychological counseling services

Coordination of services is just as important in rehabilitation and return

to duty as coordination of the trauma treatment. Typically, one physician is

responsible for the certification of necessity for the services and the provision

of the various components. However, a collegial, committee approach allows

input from the various specialty professions involved in the rehabilitative process (49,50).

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