Head Injuries and Concussion on the Job

Why this matters

Field techs hit their heads constantly: standing up under an attic truss, catching a soffit corner coming off a ladder, a wrench slipping on a stuck fitting overhead. Almost all of those are nothing. The few that are something tend to look like nothing for the first twenty minutes, and the decisions that go wrong are made in those twenty minutes: the tech finishes the call, drives the van home, or climbs back onto the roof.

This card covers what a responder watches for after a head strike, the signs that make it a 911 call, why a person with a possible concussion does not drive or return to work that day, and what follow-up looks like. It aligns with current CDC concussion guidance and American Red Cross first aid teaching. It is not training: hands-on first aid certification is what makes a responder, and nothing here is a diagnosis. You describe what you see; a clinician decides what it means.

The vocabulary, and why timing is the whole problem

A concussion is a mild traumatic brain injury: a blow or jolt that makes the brain move inside the skull and briefly disturbs how it works. "Mild" describes how it usually turns out, not how it should be treated on the day. Most people do not pass out. Many feel fine at first.

The reason a responder keeps watching is that a head injury can evolve. Symptoms of a concussion can show up or worsen over hours. Less commonly, a blood vessel inside the skull is torn, and pressure builds slowly. A person in that situation can talk normally for a while after the hit and then decline, which emergency clinicians sometimes describe as a lucid interval. You cannot tell the two apart on a job site, and nobody is asking you to. What you can do is notice change, because change is what the red flags describe.

So the job of whoever is with the injured person is not to decide whether it is a concussion. It is to watch for the signs on the list below for as long as they are together, and to keep that person off the road, off the ladder and away from machinery until a clinician has seen them.

The red flags: these mean 911

Call 911 if, after a blow to the head, the person shows any of these. The list follows CDC's danger signs for adults; you do not need two of them.

• Passed out, even for a few seconds, or nobody saw the hit and they were found down.
• A headache that gets worse and does not go away.
• Vomiting more than once, or repeated nausea.
• Confusion, restlessness or agitation; not knowing where they are; asking the same question again a few minutes after you answered it.
• One pupil larger than the other.
• Slurred speech, weakness, numbness or loss of coordination, especially on one side.
• Drowsiness they cannot shake, or they cannot be woken.
• A seizure.
• Unusual behavior their partner would recognize as not like them.

Two more conditions send the person to the emergency department even with no symptoms: they take a blood thinner, or they are 65 or older. Both raise the chance of bleeding inside the skull from a hit that would be minor for someone else; CDC flags blood thinners specifically, and emergency clinicians treat age 65 and over as a risk factor on its own. Ask about blood thinners in the first minute, because the person may not volunteer it.

A head hit from a fall is also a possible neck injury. If the strike came from a fall from a ladder, a roof or a stair, or the person has neck pain, numbness or tingling in the arms or legs, do not move them; keep their head still and call 911. See related: Falls From Ladders and Possible Spinal Injury.

What the responder actually does

Stop the work and sit them down. Somewhere flat and shaded, not at the top of a ladder or on a roof edge. If they are in an attic and alert, steady and free of neck pain, help them down the access with one person below guiding their feet. If they are dizzy, confused or nauseated, they stay put on the attic platform, someone stays with them, and you tell 911 dispatch the person is in an attic, because getting a dizzy adult down a pull-down stair is a fall waiting to happen and responders have the equipment to do it.

Ask three questions and remember the answers. Where are we? What were you doing just before you got hit? What day is it? You are not scoring a test. You are setting a baseline so that ten minutes later you can tell whether the answers changed.

Look and listen. Pupils equal? Speech the same as usual? Can they walk a straight line without reaching for the wall? Write down the time of the hit and anything you see, with times. The ER will ask, and the person who was hit is the worst witness to their own first half hour.

Bleeding from the scalp looks alarming because the scalp bleeds heavily. Press a clean pad on it. Do not press hard on a spot that feels soft, sunken or uneven, which can mean the skull itself is damaged; cover it lightly and treat that as a 911 call. Clear fluid from the nose or ears after a head strike is also a 911 sign.

Ice, not medicine. A cold pack wrapped in cloth on the bump is fine. Do not hand out pain relievers from the kit; some affect bleeding, and a clinician should decide.

Why they do not drive or go back to work that day

Every shop has heard "I'm fine, I'll drive myself to urgent care." The answer is no, for three reasons that do not depend on how they feel.

Reaction time and judgment are the first things a concussion degrades, and the person is the last to notice. A concussed driver may feel normal and still brake late.

Symptoms can appear hours later. A tech who seemed fine at 2:00 and was alone in a van at 3:30 is the case nobody is there to see get worse.

A second blow before the first has healed can make the injury worse and recovery longer, according to CDC. Field work is full of second blows: ladders, attics, crawlspaces, tools overhead. Balance is commonly affected for days, which is the faculty a ladder relies on.

So the rule is the same for everyone: after any head strike with symptoms, someone else drives, the person goes off the tools for the rest of the day, and they return only on a clinician's say-so. Where the person goes depends on what you saw. Any red flag is 911. Symptoms without a red flag (a headache, a fogginess, nausea once) still get a same-day clinician evaluation; an emergency department is the safer door because it can scan if needed. See related: When to Go to the ER Versus Urgent Care.

Follow-up and the return to work

Follow the clinician's written instructions, which commonly include having someone stay with the person the first night and a list of signs that mean go back to the ER. Concussion symptoms (headache, light or noise sensitivity, trouble concentrating, irritability, poor sleep) usually ease over days to a couple of weeks for most adults, and some people take longer; the clinician, not the calendar, decides when they are cleared.

The shop's part is a graduated return: office work, shop work or ride-along duty first, with no ladders, roofs, attics, driving or powered tools until the clinician releases those specifically. Ask for the work-status note to say which tasks are allowed, not just "light duty," because a field tech's light duty can still include a 12-foot ladder.

The office has two recordkeeping calls. Under OSHA's recordkeeping rule for employers that must keep the injury log, a work injury involving loss of consciousness is recordable (29 CFR 1904.7), as is one that causes days away or restricted work. And an in-patient hospital admission must be reported to OSHA within 24 hours under 29 CFR 1904.39; an ER visit with release the same day is not an admission. See related: Accident and Incident Reporting SOP.

The worked example: the truss that seemed like nothing

A two-person crew is replacing an attic air handler in a 1990s house in late spring. At 1:40 pm the tech stands up too fast and drives the top of his head into the bottom of a roof truss. He swears, sits down on the plywood platform, and says he is fine. No visible cut. His partner, the lead, stops the work.

1:41. The lead asks the three questions. "The Nguyen house. Pulling the old coil. Thursday." All right. Pupils look equal by flashlight. He takes no medications. The lead writes "1:40 head strike on truss, no LOC seen, answers OK" on the back of the work order. The tech wants to finish the coil.

The first call. No red flag yet, but a headache started within a minute and he says he feels "a bit off." That is a symptom without a red flag: same-day evaluation, someone else drives, no more attic today. The lead decides to get him down first. He is alert, steady and has no neck pain, so the lead goes down the pull-down stair first and guides his feet. The lead calls the office to send someone to finish and to tell the customer.

1:58. At the truck, the tech asks, "Did we already pull the coil?" The lead answered that question 17 minutes earlier. Asking the same question again is on the red flag list. At 2:02 he vomits beside the truck; at 2:05, again. Vomiting more than once is a second red flag.

2:05, the plan changes. The lead had been about to drive him to the ER himself. With two red flags, that becomes a 911 call, because a patient who gets worse in the passenger seat gets a driver watching the road. The lead calls 911 from the driveway, gives the street address and cross street, says "head strike 25 minutes ago, now confused and has vomited twice," sits him down in the shade, and keeps watching. The customer meets the ambulance at the curb.

What the record showed afterward. Responders arrived at 2:16. The lead handed them the work order with the strike time, the first answers, the repeated question at 1:58 and the vomiting at 2:02 and 2:05. The ER kept him for observation and released him that evening with a no-driving, no-work note for the next two days and a follow-up visit. He returned to ride-along duty on day three and full duty when the follow-up clinician cleared him.

What would have gone wrong without the watching. At 1:41 every observable thing was normal. If the lead had let him finish and drive home, the repeated question and the vomiting would have happened alone in a van on the highway. Nothing the lead did required medical knowledge; it required writing down the 1:41 answers so that the 1:58 question registered as a change.

What would have changed the answer at 1:41. If he had said he takes a blood thinner, the plan at 1:41 would have been the ER regardless of symptoms. If he had fallen off the attic platform rather than standing into the truss, he would not have been moved at all.

How to tell you handled it right

• The strike time and the first answers were written down within a few minutes, and the record shows the times of every change.
• The injured person did not drive, did not go back up, and did not use powered tools that day.
• Every red flag led to a 911 call, not a ride.
• Return to field work followed a written clinician release that named ladders and driving.

References

• CDC, HEADS UP concussion information and danger signs for adults.
• American Red Cross, First Aid/CPR/AED participant materials (current edition).
• 29 CFR 1904.7 (general recording criteria) and 29 CFR 1904.39 (reporting in-patient hospitalization).
• See related: The First Five Minutes After Someone Is Hurt; Falls From Ladders and Possible Spinal Injury; When to Go to the ER Versus Urgent Care; Accident and Incident Reporting SOP.