The spectrum of agricultural trauma

TheJournal of Emergency Medrone, Vol. 3, pp 205-210. 1985 Prlnted in the USA ??CopyrIght 0 1985 Pergamon PressLtd

THE SPECTRUM Thomas

H. Cogbill,

OF AGRICULTURAL

TRAUMA*

MD,f and Henry M. Busch, Jr., MD*

tchairman, Trauma, Department of Surgery, +Chlef Resident, Department of Surgery, Gundersen Clinic/La Crosse Lutheran Hospital, La Crosse, Wisconsin Reprinnt address: Thomas H. Cogbill, MD, Department of Surgery, Gundersen Clinic, Ltd., 1836 South Avenue, La Crosse, WI 54601

0 Abstract-During the past 6 years, 375 patients were hospitalized with injuries resulting from farm accidents. The mechanism of injury was farm animal in 135 patients (360/o), tractor in 89 (24S), corn picker or auger in 57 (15%), power take-off in 29 (8Vo), other farm machinery in 50 (13%), and miscellaneous in 15 (4%). Injury severity score (ISS) of 25 or greater was calculated for 29 individuals (8?70).Eleven groups of surgical subspecialists performed 539 procedures. Eight patients (2.1%) died as a result of their injuries. All eight deaths occurred after tractor accidents secondary to pelvic fractures, head and spinal cord injury, or blunt chest trauma. Thirty-nine patients (10%) were left with serious permanent disability. Unnecessary morbidity and mortality in many cases were attributed to excessive prehospital care times within a hugely rural atea. Better prevention by farmer education and the initiation of mandatory safety devices on agricultural equipment may lower the incidence of farm accidents. Major agrk~ltural trauma ls frequent and diverse and is optimally managed in a regional trauma center. 0 Keywords-agriculture; rural trauma; injury severity score; farm accidents; trauma centers

*Presented at the 16th Annual Meeting of the Western Trauma Association, Snowbird, Utah, March 6, 1985.

Introduction As an industry, agriculture ranks first in the United States in work injury death rate; accounting for 61 fatalities per 100,000 workers in 1980.’ This compares with an overall figure of 13 per 100,000 workers in all occupations combined. In addition, a much larger number of farmers and farm workers are injured with subsequent physical disabilities. The resultant social and economic ramifications are far reaching. Little attention has been focused on this aspect of rural trauma. This study was undertaken to better define the spectrum., management, and prevention of agricultural injuries.

Materials and Methods During the 6-year period ending December 1983, 375 consecutive patients were ,admitted to the La Crosse Lutheran Hospital for treatment of injuries resulting from agricultural trauma. Hunting, logging, swimming, household, and passenger vehicle accidents occurring on the farm were excluded from study. There were 307 males (82%) and 68 females. Age ranged from 11 months to 89 years (mean = 34.6 years). The distribution of patients by age was nearly even through-

RECEIVED:1 May 1985; ACCEPTED: 19 June 1985 205

0736-4679185 $3.00 +, .OO

206

Thomas H. Cogbill and Henry M. Busch, Jr.

Table 1. Age Distribution of 375 Patients with Agricultural Injuries Age (yr) o-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 260

Number

:: 59 56 54 49 34 13 2

Table 2. Mechanism of Injury in 375 Farm Accidents Farm animal Tractor Corn picker, auger Power take-off Other farm machinery Miscellaneous

Results The mechanism of injury was farm animal in 133 patients (36Vo), tractor in 89 (24%), corn picker or auger in 57 (15%), power take-off in 29 (S%), other farm machinery in 50 (13Oro),and miscellaneous in 15 (4%) (Table 2). Obvious seasonal variation in the incidence of farm accidents was apparent with 288 individuals (77%) injured between May 1 and November 30. Nineteen patients (5%) arrived at our emergency department in shock (systolic

(36%) (24%) (KY (130:) (4%)

Table 3. Injury Severity Score for 375 Farm Injuries

ISS

out each of the first seven decades of life (Table 1). Hospital charts for all individuals were reviewed and injury severity scores (ISS) were calculated for each using the method of Baker et a1.2,3Long-term disability was determined by reviewing the patients’ outpatient clinic records. The La Crosse Lutheran HospitaVGundersen Clinic is a level II trauma center situated in rural western Wisconsin. The hospital serves as a referral center for parts of Wisconsin, Iowa, and Minnesota. Patients in this series were often stabilized at small community hospitals before transfer to La Crosse. Upon arrival in our emergency department, assessment and resuscitation were initiated by emergency medicine physicians and nurses, surgical residents, and a general surgery attending physician. The attached Gundersen Clinic is staffed by 190 full-time medical and surgical subspecialists.

135 89 57 29 50 15

l-9 1O-24 225

ISS, injury

Number of Patients (O/O) 297 49 29 375

(79%) (13%)

(8%)

severity score.

Table 4. 539 Procedures Performed in 297 Patients Orthopedic Hand Maxillofacial Thoracostomy Peritoneal lavage Laparotomy Neurosurgical Urologic Vascular Other

226 188 42 19 16 14 14 8 6 3

blood pressure of 80 mm Hg or less). The calculated ISS was 10 or greater in 78 patients (21%) and 25 or greater in 29 individuals (8%) (Table 3). The most frequently injured organ systems were orthopedic, 184 patients; hand, 97; neurologic, 61; abdominal, 52; thoracic, 48; and maxillofacial, 41. A total of 539 procedures were performed in 297 patients. Most common procedures were orthopedic, 226; hand, 188; maxillofacial, 36; abdominal, 30; thoracic, 19, and neurosurgical, 14 (Table 4). Fourteen patients underwent laparotomy for the repair of five liver lacerations, five splenic tears, two duodenal lacerations, two bladder ruptures, one pancreas injury, one small-bowel mesentery tear, one colon injury, and two iliac artery lacerations.

Agricultural

207

Trauma

Table 5. Clinical Data of Eight Fatalities after Agricultural Trauma Patient

Sex

Age

Mechanism

Injuries

Shock

ISS

1

M

61

Tractor rollover

Yes

57

2 3

M M

71 71

Tractor rollover Tractor rollover

No Yes

9 25

4

M

89

Fell off tractor

No

38

5

M

65

Pinned by tractor

No

18

6

M

27

Crushed by tractor

Yes

36

7

M

52

Pinned beneath tractor wagon

Yes

41

8

M

4

Run over by tractor wheel

lntracerebral hematoma, flail chest, cardiac contusion, splenic tear clavicle Fx, scapula Fx L2 spine Fx, pulmonary embolus Odontoid Fx with quadraplegia, myocardial infarct Thoracic aorta laceration, bilateral hemothorax, concussion Severe pelvic fractures, retroperitoneal hematoma, pulmonary embolus Severe pelvic fractures, vascular lacerations X2, spinal cord compression Cerebral edema, left shoulder dislocation, intestinal necrosis, hypothermia Massive skull fractures, with subdural hemorrhage

No

25

--

ISS,injury severity score.

The mean hospital stay was 8.4 days (range = 1 to 115 days). Sixty patients (16%) were admitted to an intensive care unit for an average 4.3 days. Eight patients (2.1 Vo) died as a result of their injuries (Table 5). All eight deaths occurred in patients involved in tractor accidents. ISS was greater than or equal to 25 in six of these patients. The other two individuals died from massive pulmonary embolus. Significant hospital morbidity was observed in 75 patients (20%); this included respiratory complications in 22, bony nonunion in 14, wound infection in 14, and neuropraxia in 4. Longterm disability was assessed for 39 individuals (10%). Serious impairment was observed following 14 (58%) mangling corn-picker accidents and 6 (21%) power take-off injuries (Table 6).

Farm-Animal-Related injuries A total of 135 patients sustained injuries involving farm animals, which included 48 falls from horses, 40 animal kicks, 39 animal assaults, and 8 animal-drawn-vehicle accidents. The peak incidence of these injuries occurred between March 1 and No-

vember 30 each year. Horse falls resulted in 14 head injuries and 15 upper extremity fractures. Animal assaults accounted for the most seriously injured patients in this group as the result of severe thoraco-abdominal trauma. Six patients (15%) in this group had injuries with ISS of 25 or greater. Multiple-system trauma was al.so observed in the victims of animal-drawn-vehicle mishaps. Injuries that occurred from animal kicks were nearly all maxillofacial and leg fractures. Twenty-five of 30 patients (83’-70)kicked by cows sustained leg or facial trauma.

Farm Tractor Accidents The mechanism of injury in this group of 89 patients was tractor rollover in 3 1 (35%), run over by tractor in 21 (24%), fall from tractor in 19 (2lVo), and miscellaneous in 18 (20%). Peak incidence occurred from May 1 to November 30. All eight deaths in the overall series of farm accidents occurred in this group. The mortality of farm tractor accidents was, therefore, 9%. The mean ISS in this group was 13.3. Most common injuries were rib fractures (22), pelvic frac-

208

Thomas H. Cogbill and Henry M. Busch, Jr.

Table 6. Mechanism of Injury for 39 Survivors with Severe LongTerm Disability Farm animal Tractor Auger Power take-off Corn picker Other farm machinery Miscellaneous Overall

: 5 6 14 4 0 39

I;:;;

bility was significant, tients (21 (r/o).

occurring in 6 pa-

Discussion

[::q ‘9::; 0 (10%)

tures (15),

pulmonary contusion (14), renal contusion (12), facial fractures (1 I), pneumothorax (12), and closed head injury (12). Of the 3 1 tractor rollover victims, eight arrived at the emergency department in shock; the average time in the field was 1 hour and 40 minutes.

Corn Picker Accidents Twenty-seven patients (49Vo) were injured during October and November. The usual mechanism of injury involved an attempt to unjam the rollers of a machine by removing bound corn stalks without first turning the machine off. All but four of these injuries involved the upper extremities with components of laceration, crush, fractures, and burn with massive contamination. No amputated digits could be replanted. There were no deaths but 58% of patients were left with serious permanent disability.

Power Take-Off Injuries The peak incidence of power take-off accidents was between October 1 and January 31 of each year. The mechanism of injury nearly always involved a piece of loose-fitting or bulky clothing getting caught by a poorly shielded rotating shaft. Hand and arm injuries predominated, with four traumatic amputations and five brachial plexus injuries. One patient sustained a degloving urogenital injury, and there were two near stranglings. Serious permanent disa-

Agricultural workers are constantly exposed to a surprisingly high risk of personal injury. More than 62 patients per year were admitted to our institution as the result of farm accidents. A relatively large number of these patients were critically injured. The ISS was 10 or greater for 78 injuries (21070) and 25 or greater in 29 individuals (8%). A score of 25 or greater has been classified as indicative of a life-threatening injury with uncertain outcome.2.3 Mortality in this group is age dependent and has been reported from 20% to 60% .2,4Six of the eight deaths in our series occurred with injuries equivalent to ISS of 25 or greater. The mortality for injuries with ISS of 25 or greater was, therefore, 21%. The mean ISS for the eight fatal accidents was 3 1. Another indication of injury severity was that urgent laparotomy was necessary for 14 patients and tube thoracostomy for 19 individuals. Overall mortality in this series of 375 patients was only 2.1%. However, victims who were pronounced dead at the scene or at small community hospitals within our referral area were not included in the study. The magnitude of fatal farm accidents has, however, been well documented, with 384 individuals killed on Wisconsin farms from 1976 to 1980.5 Agricultural trauma occurs in all age groups from early childhood through age 65 in nearly equal numbers.5 This even distribution was evident in our series. Thirtynine children 9 years old and younger and 15 adults 70 years old and older were included in this series. Paralleling most other forms of trauma, the male : female incidence ratio was greater than 4 : 1. Clear seasonal variation was apparent, with 77% of individuals injured between May 1 and November 30, corresponding to the most active farming months in the north central United States.

Agricultural

209

Trauma

Though overall mortality was gratifyingly low in this series of 375 patients, improved outcomes may have been obtained by decreasing the length of prehospital care time. The average length of time in the field for tractor rollover victims was greater than one hour and 40 minutes. This excessive time results from several factors. Many farmers work alone so that an accident may go undiscovered for hours if the farmer is trapped or unconscious. Extraction from heavy farm machinery may be time consuming. Finally, these accidents occur within a rural area where response times and transport times may be very long. Regional emergency medical services must be well organized in these areas, with rapid communication and response. Primary transport to a regional trauma center may not be reasonable because of the long distances involved. Often the severely injured patient is better managed by transport to a nearby smaller community hospital for rapid evaluation, advanced airway management, and the initiation of volume replacement.6 Immediate transfer to the regional trauma center for definitive care is then accomplished according to well-established protocols outlined by the American College of Surgeons.’ Specific agricultural worker educational programs must be initiated with medical personnel participation to stress prevention of farm accidents. Analysis of our results has yielded several specific recommendations. Protective headgear should be worn by novice equestrians. Constant caution and respect should be shown around the large farm animals, and professional help should be sought for the examination of

sick animals. Proper operation and maintenance of tractors are important, as most tractor accidents occur with older equipment.8.9 Precautions must be taken when plowing on soft ground or along the side of a hill. Farmers should be encoura.ged to have someone periodically check on them while working. In addition, the insti.tution of mandatory safety features on tractors such as crushproof cabs and rollover bars has been strongly recommended.8-‘0 Extensive farmer education concerning the proper use and maintenance of corn pickers, augers, and power take-gffs should reduce needless disabling injuries. Carelessness and failure to use protective shields have been implicated as the most common cause of farm equipment accidents.10-‘3 Agricultural trauma is frequent and diverse, with many mechanisms of injury. Life-threatening injuries are often seen, and permanent disability is common. Decreased morbidity and mortality may follow improvements in prehospital care, farmer education, and the institution of mandatory safety features on agricultural equipment. Full multispecialty support from resuscitation in the emergency department to rehabilitation is vital to provide definitive care for a wide variety of organ system injuries. Optimal management is achieved in a regional trauma center with established transfer protocols from smaller community hospitals.

authors gratefully acknowledge the financial support of the Gundersen Medical Foundation.

Acknowledgment-The

REFERENCES 1. Accident Facts. Chicago, National Safety Coun-

cil, 1981. 2. Baker SP, O’NeillB, Haddon W, et al: The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14:187-196. 3. Baker SP, O’Neill B: The injury severity score: An update. J Trauma 1976; 16:882-885.

4. Mayer T, Matlak ME, Johnson DG, et al: The modified injury severity scale in pediatric multiple trauma patients. JPediatr Surg 1980; 15:719726. 5. Fatal Farm Accidents in Wisconsin 1976 to 1980. Madison, Wisconsin Division of Health, Department of Health and Social Services, 1981. 6. Krob MJ, Cram AE, Vargish T, et al: Rural trau-

210

ma care: A study of trauma care in a rural emergency medical services region. Ann Emerg Med 1984; 13:891-895. 7. American College of Surgeons Committee on Trauma: Interhospital transfer of patients. Bull Am CON Surg 1984; 69~29-32. 8. Smith JD, Rogers DL, Sikes RK: Farm-tractor associated deaths-Georgia. MMWR 1983; 32:481482. 9. Karlson T, Noren J: Farm tractor fatalities: The failure of voluntary safety standards. Am J Public

Thomas H. Cogbill and Henry M. Busch, Jr.

Health 1979; 69~146-149.

10. Simpson SC: Farm machinery injuries. J Trauma 1984; 24:150-152.

11. Melvin PM: Corn picker injuries of the hand. Arch Surg 1972; 104:26-29. 12. McElfresh EC: Power take-off injuries. J Trauma 1973; 13:775-782. 13. Campbell DC, Bryan RS, Cooney WP, et al: Mechanical corn picker hand injuries. J Trauma 1979; 19:678-681.