Falls From Ladders and Possible Spinal Injury

Why this matters

When a coworker comes off a ladder, every instinct in the people around them says help them up. That instinct is the one thing most likely to turn a broken vertebra into a damaged spinal cord. The bone can heal; the cord mostly does not. The first few minutes after a fall are about doing less, not more: keeping the person still, getting the right help moving, and watching their breathing while you wait.

This card is about the fall itself and the possibility of a spine injury. The general order of a first response (scene, call, the few actions that matter) is owned by its own card, as is the 911 call. See related: The First Five Minutes After Someone Is Hurt, and Calling 911 From a Job Site So They Find You. This is not training: a hands-on first aid course is what makes a responder, and the American Red Cross and American Heart Association guidance this card follows is taught properly there.

Before you reach them: what put them on the ground

Look before you go to the person, because the fall may have a cause that is still active.

• Electricity. A ladder that touched a service drop or a tech who took a shock at the top may still be in contact with an energized conductor or a ladder that is. Do not touch the person or the ladder until the source is confirmed off or the person is clearly clear of it; if a line is down, keep everyone back and tell the dispatcher. See related: Electrical Shock First Response.
• The ladder and the load. A ladder still leaning, a bucket or a gutter section still overhead, a roof edge someone else is standing on. Clear or steady them.
• The ground. A wet slope, a pool deck, a driveway with traffic. If a car may come up the driveway, put a person or a vehicle between it and the patient.

Only a danger you cannot remove (fire, a gas smell, rising water, energized metal you cannot de-energize, traffic you cannot stop) justifies moving a person who may have a spine injury.

Who to treat as a possible spine injury

You cannot diagnose a spine injury and you should not try. Treat it as possible, and keep the person still, when any of these is true:

• The mechanism: a fall from higher than the person's own height, a fall onto the head, or a fall that ended on something hard, an edge, or a rail.
• What they report: neck or back pain, numbness, tingling or "pins and needles" in the arms or legs, weakness, or a limb that will not move.
• What you see: a head injury, confusion, unconsciousness, a person who cannot tell you what happened, or an unusual position of the head or neck.
• What they cannot do: an intoxicated person, someone in shock, or someone with another painful injury may not feel or report neck pain. The absence of a complaint is not clearance.

A tech who walks around after a fall is not cleared either. People with unstable spinal fractures have walked into emergency departments.

The hold: what you actually do

Tell them not to move. Say it plainly and early: "Don't move your head. Stay exactly how you are." A conscious person who tries to sit up is the most common way the situation gets worse.

Steady the head in the position you found it. Kneel or lie at the top of their head, place your hands on both sides of the head over the ears, and hold it still. Do not pull, straighten or turn it. Your job is to stop movement, not to correct the position. If holding gets tiring, swap with another person hand over hand without letting go.

Call 911 early. A fall with any of the signs above is a 911 call, not a ride in a truck to urgent care. Have someone else make the call while you hold the head, and put the phone on speaker beside you so you hear the dispatcher's instructions.

Watch breathing and keep watching. Look at the chest and listen. Breathing takes priority over the spine: if the person stops breathing normally, the dispatcher will coach CPR, and you start it. A person who is breathing but vomiting, or whose airway is filling, needs to be rolled onto their side with several helpers keeping head, neck and back in line as one unit (a log roll); the dispatcher can talk you through it.

Keep them warm and talk to them. Cover them with a jacket or blanket without lifting them. Note anything that changes: they were talking and stop, they could move their feet and now cannot. Responders will ask.

What not to do, and why each one is tempting

A worked case: the extension ladder on the driveway

A gutter crew of two is working a two-story house. At 1:40 pm the lead tech, standing about 14 feet up on a 24-foot extension ladder, reaches past the rail, the ladder feet slide on a dusty concrete driveway, and he comes down with the ladder, landing on his back with his head striking the concrete. The helper, Dana, was at the truck.

Scene, first 15 seconds. Dana looks up before running. The ladder top had been against the gutter, nowhere near the service drop on the far side of the house. The ladder is lying across the tech's legs. Nothing is overhead. The driveway is private and no car is moving. The scene is clear except for the ladder.

Reaching him. He is conscious, groaning, and starting to push up on one elbow. Dana's first words are the most important thing she does in the whole event: "Don't move. Stay flat. You fell off the ladder." She kneels at his head and holds it between her hands. The homeowner comes out and offers to help get him onto the porch; Dana asks her instead to lift the ladder straight up off his legs, without dragging it, and lay it on the lawn. Then she asks her to call 911 and put the phone on speaker.

What she tells the dispatcher, and what she hears back:

DISPATCH: Is he awake and breathing?
DANA:     Awake, talking, breathing fine. He fell
          about fourteen feet off a ladder onto
          concrete and hit his head.
DISPATCH: Does he have pain anywhere?
TECH:     My neck. And my hands feel buzzy.
DISPATCH: Okay. Keep him still, don't let him
          move his head. Is anyone holding it?
DANA:     I am. Hands on both sides.
DISPATCH: Good. Don't give him anything to drink.
          If he vomits, tell me right away and
          I'll walk you through rolling him.

The tingling in his hands matters. It is a reported sign, it points toward the cervical spine, and Dana repeats it to the paramedics when they arrive.

The wait. The ambulance arrives at 1:53, 13 minutes after the fall. In that time the tech tries twice to sit up, says his back is fine and his neck is "just stiff," and asks for water. Dana keeps her hands where they are, keeps telling him to stay still, and declines the water. The homeowner brings a blanket, and Dana has her lay it over him without lifting anything. At 1:48 he says the tingling has spread to his left foot. Dana repeats it to the dispatcher, who stays on the line.

Hand-off. Paramedics take over the head hold before Dana lets go. She gives them, in order: the height, the surface, that he struck his head, the neck pain, the tingling in both hands from the start, the spread to the left foot at 1:48, and that he has had nothing by mouth.

What would have gone wrong. The homeowner's offer was the dangerous moment. Walking him to the porch would have taken about a minute and felt like care. With a cervical fracture and symptoms already in his hands, that minute is exactly the movement the hold exists to prevent.

What changes the answer

The scene is dangerous. If the ladder had brought the tech into contact with an energized line, or a gas meter had been struck and was hissing, the order flips: the rescuer does not approach until the hazard is controlled, and if the person must be moved to survive, the move is made with the head and neck supported in line, as one unit, by as many people as are available. See related: Rescuing Without Becoming the Second Victim.

The person is not breathing. Airway and breathing outrank the spine. A pulseless or non-breathing person gets rolled onto their back as carefully as you can and gets CPR, with an AED if one is on the truck. See related: First Aid + AED on the Jobsite.

The person is stuck at height. A tech caught on a roof or hanging in a harness is a fire department rescue. Do not climb the same ladder that failed to bring them down. For a tech suspended in a harness, the plan has to exist before the fall; that belongs in your fall protection program.

The fall was short and nothing points to the spine. A tech who stepped off the bottom rung, landed on their feet, and has an ankle injury with no head strike, no neck or back pain and no tingling does not need a head hold. They still need the ankle seen. See related: When to Go to the ER Versus Urgent Care.

After the ambulance leaves

The ladder that failed is evidence. Tag it out of service and keep it as it is. The fall goes into your incident report the same day, and a hospitalization of an employee is reportable to OSHA within 24 hours under 29 CFR 1904.39 (federal rule; a state plan may set its own process). See related: Accident and Incident Reporting SOP. The crew's next ladder setup at that house gets the feet secured or footed before anyone climbs.

How to verify you got this right

Run a tabletop at your next huddle. Lay a coworker on the shop floor and have each tech, one at a time, say their first sentence to the "patient," take the head hold, and tell a "dispatcher" what they see. Check three things: the first words were "don't move," hands went on the head before anything else, and nobody offered water or help sitting up. Do not call 911 for the drill; use a coworker as the dispatcher.

References

• American Red Cross First Aid/CPR/AED guidance on head, neck and spinal injuries
• American Heart Association and American Red Cross Guidelines for First Aid
• 29 CFR 1904.39, OSHA reporting of fatalities, hospitalizations, amputations and eye loss
• See related: The First Five Minutes After Someone Is Hurt
• See related: Head Injuries and Concussion on the Job