Emergency Medical Training for the Commercial Fishing Industry: An Expanded Role for Wilderness Medicine

Abstract

This article describes the conception, implementation and evaluation of a wilderness medicine based first aid class for the commercial fishing industry. Commercial fishing is a dangerous occupation in the United States. To date, commercial fishermen often have only access to basic first aid classes. Because of austere environments, hazardous conditions, and distance from definitive medical care—hallmarks of commercial fisheries—wilderness medicine offers a more appropriate approach to decreasing morbidity and mortality in the industry. A 2 d, 16 h pilot commercial fishermen wilderness medicine course, Fishermen First Aid and Safety Training (FFAST), conducted for Dungeness crab fishermen, was effective and well received, based on pre- and post-course knowledge, skill, and attitude surveys. FFAST has been approved by the Coast Guard and is being made more widely available to the commercial fishermen in the Pacific Northwest. The FFAST program offers an example of how wilderness medicine can improve safety and emergency medical response for a wide variety of austere environments not traditionally linked to the backcountry.

INTRODUCTION

Commercial Fishing – A Dangerous and Challenging Occupation

In the US, commercial fishing is one of the most dangerous occupations based on fatality rates. There are approximately 115,000 fishermen (harvesters) in the US fishing for different species and using different types of fishing gear and vessels. [1] A report from the US Bureau of Labor Statistics (BLS) describes the challenging working conditions of commercial fishing as strenuous with long hours and seasonal employment. Commercial fishermen can be at sea for extended periods of time, and depending on the harvest may have to work on deck with little or no sleep nor opportunity to rest. Fishermen are exposed to the elements, depending on the season, and work on vessels that are in constant motion due to wind and sea conditions. Their work platform is in constant motion and requires balance and skill to complete their work safely. [2]

The National Institute for Occupational Safety and Health (NIOSH) collects data on US commercial fishing fatalities and vessel disasters. The fatality rate of commercial fishermen is many times higher than all US workers. From 2000 to 2014, the most recent published data , the average annual fatality rate for commercial fishermen ranged from 21 to 147deaths per 100,000 full time equivalent workers. [3] While it is clear that continued attention is needed to reduce the risk of fatal injuries in commercial fishing, nonfatal injuries, which can be life threatening and result in permanent disability, have remained largely unaddressed. This is an opportunity for austere medicine practice.

From previous commercial fishing safety research on the US west coast, data on fatal injuries among Dungeness crab fishermen were obtained from the existing NIOSH surveillance system, while data on non-fatal injuries were manually abstracted from US Coast Guard (USCG) investigative reports. This study found that 28 fatal and 45 non-fatal injuries were reported between 2002 and 2014 in the Dungeness crab fleet. Most fatalities were due to vessel disasters, and many non-fatal injuries occurred on-deck when fishermen were working with gear, particularly when hauling the gear (47%). The most frequently reported non-fatal injuries affected the upper extremities (48%), and fractures were the most commonly reported injury type (40%). Injury severity while hauling gear was predominantly classified as moderate (n=10, 56%) or serious (n=5, 28%) using the abbreviated injury scale. [4]

In unpublished research by the same study team, data from USCG reports for all commercial fishing fleets during 2002 to 2014 in Washington, Oregon and California identified 208 non-fatal injury cases. Commercial fishermen are required by the USCG under 46 CFR §4.05-1 to report commercial fishing loss of life or injuries that require medical treatment beyond first aid. [5] The most frequent injury characteristics were: by nature – fracture (26%) and laceration/puncture (16%); by body part – upper extremities (40%) and head/neck (18%); and by event/exposure – contact with objects and equipment (57%) and falls/slips/trips (16%). The most frequently injured workers were deckhands (51%) and processors (on larger vessels) (24%). [6] This is not a comprehensive picture of all injuries as underreporting of work-related injuries is recognized across all industries as a problem [7] and is likely occurring in the commercial fishing industry. Given that these injuries may occur far from definitive care, first aid training specific to these injuries and settings may have substantial impact on long-term morbidity and disability.

Limited Emergency Medical Training and Resources

Adding to the challenges of these austere and hazardous conditions, to date, emergency medical training specifically for commercial fishermen is limited. Despite the high number of fatal injuries the US Coast Guard requires under 46 CFR § 28.210 only that one or more crew members (depending on total crew size) be first aid and CPR trained. [8] The training requirements are basic, covering both cardiopulmonary resuscitation (CPR) and generic first aid in 8 h. This rudimentary level of training clearly becomes a liability when vessels can be many miles offshore, in poor weather and rough sea conditions, and working long hours in physically demanding tasks. Commercial fishermen in Oregon had raised the issue to the authors that first aid courses offered locally are too generalized and not relevant for being out at sea for an extended period of time; the FFAST program described here was a direct response to that expressed need for more robust first aid courses tailored to commercial fishing settings.

Role of Wilderness Medicine in Improving Safety and Emergency Medical Response for Commercial Fishing Industry

The waters, conditions, and overall environment in which commercial fishers work clearly fall within the scope of wilderness medicine. However, despite the sobering statistics and obvious overlap, to date the practice of wilderness medicine has not included expertise on commercial fishing safety or off shore emergency medical response. There are trainings and curricula for a number of specific environments, for example from the (for sailing, mountaineering, and desert environments) and for disasters. Trainings for specific occupational groups are available, for example through private companies, such as for the energy and mining industry, but until recently nothing has been offered for the commercial fishing industry.

COMMERCIAL FISHERMEN FIRST AID AND SAFETY TRAINING DEVELOPMENT

Background

To address the hazardous conditions and the need for more robust training a new course, Fishermen First Aid and Safety Training (FFAST) was developed. This was supported by the Fishermen Led Injury Prevention Program (FLIPP), a translational research project being conducted by Oregon State University College of Public Health and Human Sciences and the Oregon Sea Grant. The goal of FLIPP is to understand factors related to non-fatal injuries in the Dungeness crab fishery and to test ideas to reduce or prevent these injuries. FLIPP researchers partnered with the University of Colorado’s Department of Emergency Medicine, to develop the FFAST course.

In 2015, FLIPP held focus groups along the West Coast with crab fishermen to help design a survey to collect self-reported injury and safety perception information. In Washington, Oregon and Northern California, 426 fishermen filled in the survey in the fall of 2015 season. FLIPP survey results showed respondents thought awareness and drills/preparation were among the most common strategies for staying safe while commercial fishing (S Pillai, unpublished data, 2018). The idea for a commercial fisherman-specific first aid training came from fishermen who indicated that the community first aid classes offered were not relevant for at-sea emergencies.

Designing the FFAST Curriculum

Starting from a wilderness/austere environment perspective, rather than traditional first aid training based on “street medicine” and a setting in which emergency medical responders are not immediately available , we developed a commercial fishing industry-specific first-aid/CPR training, FFAST. FFAST was adapted from the lead author’s experience in wilderness medicine training. The topics included in FFAST were from standard wilderness first aid curriculum with the setting and working conditions adapted, and informed by the injury epidemiological data available.

The curriculum was designed around the extremes of a vessel-based marine environment and on injury data gathered from US Coast Guard reports and the FLIPP survey. The goal was to customize the training and better prepare fishermen to prevent and treat injuries likely to be encountered. To encourage participation, the curriculum was also designed to meet the minimum US Coast Guard requirements for on-board first aid training. The training was contextualized to the relatively small crews, common injuries, fishing boats, cold water, rough seas, and delayed emergency response times typical to North Pacific fisheries. Because of the experiential and skill-based nature of the class, the curriculum was designed for groups of twenty or fewer participants.

FFAST Curriculum

The FFAST curriculum consists of 16 h of training over 2 d, including basic CPR. It includes lecture, hands-on skill development, and scenarios in which knowledge and skills are put together to respond to a simulated accident or illness. The curriculum focuses on preparing participants to respond to common fishery injuries and illnesses ranging from the mild, such as sea sickness or chapped hands, to life threatening injuries including fall or crush injuries. Table 1 provides the main subject areas and an example for each of commercial fishing-specific topics covered.

Table 1.

Fishermen First Aid and Safety Training (FFAST) Content Examples

Subject Area	Example Commercial Fishing-Specific Topic
Response and Assessment	The scene safety assessment must consider the waves, vessel (stability and flooding), gear, machinery (cranes/winches) and catch in addition to more typical austere hazards.
Orthopedic Injuries (Cumulative and Traumatic)	Commercial fishing can involve prolonged exposure to forceful and repetitive motions while standing on slick decks. Discussion of preventative measures of micro-breaks/rest and proper footwear/anti-slip mats is included.
Soft Tissue Injuries	The use of bleach to clean gear and buoys is common, which can result in chemical burns. Discussion of preventative measures such as substitution with less hazardous cleaners, use of appropriate personal protective gear, and best practices for minimizing exposure both pre-season and on vessels is included.
Epidemiology and Hazard Assessment	Sharing results of injury epidemiological studies specific to commercial fishing fleets can help fishermen consider what needs to be prevented. A hazard assessment tool is taught to help fishermen break a work task down to consider how they could reduce the risk of injury. Fishermen are great problem solvers.
Head and Spinal Injuries	Head and spinal injuries need to be properly assessed within the at-sea context. This determines immobilization and the need for an evacuation. Evacuation at sea involves calling the Coast Guard.
Environmental Hazards	Understanding the prevention, signs, symptoms and treatment of hypothermia and other cold injuries is important due to the marine environment. Likewise, heat stress/strain due to heavy physical labor is also a concern.
Abdominal Injuries and Illnesses	Abdominal illnesses such as diarrhea, cramping, and seasickness can all be common ailments at sea.
Patient Packaging and Carrying	Moving patients on board a commercial fishing vessel can be challenging. The spaces are tight and ladders are steep.
Drowning	Vessel disasters and falls overboard are a major concern for commercial fishermen. Prevention strategies and personal floatation devices specific to working on vessels must be discussed along with treatment onboard vessels.
First Aid Kits	Having an appropriately stocked first aid kit can make treating injuries at sea more effective.
Respiratory and Cardiac Issues	Respiratory and cardiac issues are life threatening conditions that are more common as the workforce ages. Practicing and considering the vessel environment for delivering CPR is important.

In addition to providing details of skills for what to do during an event, FFAST also includes information about what can be done before an incident happens. This includes injury and prevention strategies, informed by discussing the injury statistics for commercial fishermen and considering the factors relating to those injuries. This conversation identified common tasks and associated hazards, and led fishermen to consider what controls or prevention strategies could be implemented. The scenarios and hands-on activities also were based on actual injury reports allowing for the instructor to discuss how the injury could have been prevented. An example scenario for reinforcing hypothermia treatment is shown in Figure 1.

Figure 1.

Cold crewman example scenario for hypothermia.

To pass the course and receive certification, students must demonstrate basic skill and scenario proficiency and pass a final exam with a minimum score of 70%. FFAST compliments another US Coast Guard required training commonly known as the drill conductor course, where fishermen learn how to conduct safety drills on a regular basis to prepare the crew for emergencies.

FFAST Pilot Methods

The FLIPP project offered pilot FFAST classes in 2016 in two locations: Newport, Oregon and Astoria, Oregon. These ports are the largest commercial fishing ports in Oregon and have active Dungeness crab fishing and resident Sea Grant staff. In 2017 a FFAST training was again held in Newport, Oregon. Classes were held just before Dungeness crab openings, when fishermen were preparing for the season but still available. Volunteer participants were recruited through the connections of Oregon Sea Grant with the commercial fishing communities in these locations via posted fliers at fishing docks, social media and targeted phone calls. The pilot classes were offered at no cost to the participants.

Participants were asked multiple choice questions on first aid knowledge and skills before (10 questions) and after the training (including the 10 pre-training questions, embedded in a more comprehensive 34 item assessment). The questions were taken from wilderness first aid trainings led by the lead author and had been used in previous courses. Participants were also asked to rate the training. Ratings were based on a scale of 1 to 5 (l=best, 5= worst): “How do you rate the information in today’s training?”, “Would you recommend this training to other fishermen?”, and “How useful for your work will the information you learned today be?”. Additional feedback was collected using open-ended questions regarding the training: “What did you like best?”, “What could be removed?”, and “What would you add?”. Descriptive statistics were calculated and data are presented as mean ± standard deviation with the range, as appropriate. All study procedures were approved by Oregon State University’s institutional review board, and all participants gave informed consent.

FFAST PILOT RESULTS

FFAST Pilot Participants

Between the three FFAST trainings, there were forty-eight participants; two women and forty-six men. The mean age (± standard deviation, range) of participants was 39.0 ± 13.4 (21-68) years. Thirteen of the participants were captains, nineteen were deckhands, and sixteen did not indicate a crew position. Two-thirds of participants had previously taken a first-aid training. Participants had been fishing for 16.0 ± 11.9 (1-40) years and fishing for Dungeness crab for 10.6 ± 9.7 (040) years. Participants were predominantly White, non-Hispanic.

FFAST Pilot Training Results

Results of the pilot programs demonstrated substantial participant learning. On the ten question pre-test the mean score was 55% ± 22.5 (20-100%) ± sd (range); on the final post-class test (thirty-four questions) the mean score was 86% ± 8.5 (64-100%), indicating the fishermen learned key concepts. Results for the 10 embedded items were nearly identical to the 34 item findings.

The training was very well received by participants. The following ratings are based on a scale of 1 to 5 (1=best, 5= worst). When asked to rate the information, the mean rating was 1.5 ± 0.8 (15). When asked if they would recommend the training, the mean rating was 1.5± 0.6 (1-3). When asked how useful the information was for their work, the mean rating was 1.3± 0.5 (1-2). When fishermen were asked what they liked most about the FFAST training, a common answer was that they appreciated the hands-on element of training. When participants were asked what they would change about the FFAST training a common answer was that they would like to have the training on a vessel so that scenarios are more realistic. Table 2 shows the open-ended questions and unique responses (if the same comment was repeated, it is only listed once in the table).

Table 2.

Participant responses to FFAST training reaction questions.

FFAST training reaction	Participant responses
What did you like best?	• Touches on all types of injuries that might be seen while fishing
	• Two-day format
	• Peace of mind that I won’t be helpless if someone is injured
	• Learning about acronyms and what they represent
	• Scenarios with hands on training prepares for real thing
	• Conducted so people can share and learn from other’s experience
	• Informal style, good for creating a comfortable learning environment for a bunch of dirty crabbers
	• How knowledgeable the teacher was
	• Evaluating situations
	• Gives a plan- A,B,C,D,E
	• Certain things were repeated various times
	• I learned more than [land-based first aid] training
	• How to move someone that’s hurt
	• Learning new and creative ways to treat injuries
What could be removed?	• Too much lecturing
	• We could have gotten a lot from a video
	• Long video on CPR (note: this is required for certification)
	• Time is long (note: this is required for certification)
What would you add?	• On-vessel scenarios
	• Talk from coast guard representative about how we could help them
	• More education on shock, stroke, heart failure, seizures
	• More stories of injuries on the water and how fishermen adapted
	• Combine more with marine safety
	• Take home/ to-the-boat laminated index cards with response checklists, reminders of evaluation procedures in different situations, CPR instructions.
	• Add boat-specific situations regarding engine rooms, fish holds, and first aid in life rafts
	• Simulate calls to coast guard to gain a better understanding of the scenarios we worked through
	• Maybe train people to stitch and cut (suturing)
	• Maybe what to do if someone falls overboard

NEXT STEPS

The FFAST curriculum is finalized and has gone through the formal approval process with the USCG and is now registered as course OREG197, meeting all USCG requirements for first aid and CPR training. Our team has received funding to train local first aid instructors, and/or motivated commercial fishermen, to become familiar with austere medicine. Through a FFAST instructor course, they will be certified wilderness first aid instructors and can use the FFAST materials to lead courses. In this way the training can be offered to more of the thousands who commercially fish the Pacific Northwest, and eventually to commercial fisherman on all coasts. By offering “train the trainer” programs, the cost of the classes will become affordable, and classes will be available in more locations. As more FFAST courses are offered, the team will expand its evaluation beyond knowledge and skill assessment, important though they are. With time and increased participants, we will be able to assess downstream process (e.g. changes in first aid readiness, responses to emergencies at sea) and outcome (e.g. treatments provided, injury status) variables.

DISCUSSION

Specific and relevant first aid and safety training for the commercial fishery industry could go a long way towards reducing the number and severity of injuries, and to saving lives, in one of the most dangerous occupations in the country. With FFAST addressing the first aid and CPR requirements, it complements the other marine and survival training programs and courses that commercial fishermen already have access to. The FFAST program demonstrates the utility of austere emergency medicine training for specific environments and activities not previously addressed nor commonly thought of as being part of the wilderness medicine field. It is a reminder that the knowledge, skills, and experiences of wilderness medicine go beyond the traditional backcountry venues many people think about, including even experienced wilderness practitioners.

The FFSAT curriculum includes CPR to meet USCG requirements. Prolonged transport times are common and decrease the utility of CPR for commercial fishermen working at sea. Despite this, a number of situations such as close access to a medical facility while at the docks or drowning incidents support the inclusion of CPR in the curriculum. The decision to initiate and continue CPR in the remote setting is a complex topic beyond the scope of this article.

The initial success of FFAST suggests other occupations could benefit from the field of wilderness medicine: logging, rural farming, or wildland firefighting. Wilderness medicine can and should play a bigger role in assuring workers are less likely to suffer debilitating injuries, even in high risk occupations.