1. Kulesa, Marjorie G. RN, BS, ONC, CNOR

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Living in the northeast, each year we anxiously look forward to good weather. The flowers start to bloom, days are longer, winter coats are shed, and we are able to get back outside and enjoy summer recreational activities. As I see boats come out of storage; motorcycles appearing on the highways; all terrain vehicles (ATVs) in the sandlots; people out on their bikes, scooters, and skates; and parents/communities erecting play sets, I start to be wary. My years in the operating room make me see how the fun in these activities can turn to sorrow so quickly. It is these thoughts as well as personal and professional experience that drew me to this topic of accidents related to recreational activities. The reason behind this is not to disturb but to explore the statistics of these accidents; view our thoughts and feelings about prevention; and as orthopaedic nurses, who have firsthand knowledge of the consequences, see how we can effect change.

Figure. Marjorie G. ... - Click to enlarge in new windowFigure. Marjorie G. Kulesa

Playground Injuries

What fun it is when parents, the local community, or the school erects a great playground for their children to play on. Children eagerly await the words "It's OK to go on it!!" For the past 10 years, the National Association of Orthopaedic Nurses (NAON) nurses have worked with the American Academy of Orthopaedic Surgeons (AAOS) and KaBOOM members to build accessible and safe playgrounds. According to the AAOS Web site, more than 500,000 children are treated in hospital emergency rooms and doctors' offices each year because of injuries sustained on playground equipment. These injuries include severe fractures, internal injuries, concussions, dislocations, amputations, and death by fall to the surface or by strangulation. According to the Centers for Disease Control and Prevention, most of the injuries are on public playgrounds; however, the more serious injuries occurred on home playgrounds. As the granny of 4 little girls, I love to take them to the playground, have them swing on the swings, slide the slide, and just have fun. So, what should I look for at those playgrounds? The U.S. Consumer Product Safety Commission (CPSC) makes the following recommendations to help prevent injuries from falls and other hazards on playgrounds:


1. Never attach ropes, jump ropes, clotheslines, or pet leashes to the equipment. This can present a serious strangulation hazard to children.


2. Make sure children remove their bike or other sports helmets before playing on the playground. Helmets can become entrapped in playground equipment, posing a strangulation hazard.


3. Purchase play equipment that meets the latest safety standards.


4. Smooth sharp points or edges; close open "S" hooks; and cover protruding bolts.


5. Check for openings in guardrails or between ladder rungs. Spaces should be either less than 31/2 in (9 cm) or more than 9 in (23 cm) so that they do not present an entrapment hazard.


6. Always supervise young children to make sure that they are safe.


7. Install and maintain at least 9 in (23 cm) of wood chips, mulch, or shredded rubber (for equipment up to 8 ft [2.5 m] high) or sand or pea gravel (for equipment less than 5 ft [1.5 m] high) as shock-absorbing material under the playground. (Dirt and grass, which are the most prevalent surfaces under home playground equipment, do not adequately protect children from serious head injuries.)


8. Install protective surfacing at least 6 ft (1.8 m) in all directions from play equipment. For swings, the surface should extend, in back and front, twice the height (




The CPSC warns that in-line skating can be hazardous if skaters do not wear helmets and other safety gear or do not learn to skate and stop safely. The CPSC estimates that approximately 100,000 consumers annually receive hospital emergency room treatment for injuries associated with in-line skates.


Most injuries were to wrists, arms, and legs. The CPSC recommends the use of safety gear to help prevent injuries with in-line skates. A helmet, elbow pads, knee pads, wrist guards, and gloves should always be worn. My girls are so geared to wearing their helmets and pads that it has just become part of the sport.


Additional safety tips are as follows:


1. Get instructions and learn to stop safely.


2. Skate on smooth, paved surfaces without any traffic. Avoid skating on streets, driveways, or surfaces with water, sand, gravel, or dirt.


3. Do not skate at night-others cannot see you and you cannot see obstacles or other skaters.



Foot- and Motor-Propelled Scooters

Scooters have become very popular as they are lightweight and can be stored easily. However, as more are sold, the injuries increase proportionately.


Again, injuries are preventable with keeping safety tips in mind:


1. Children under age 8 should not use scooters.


2. Learn the basic skills of the sport.


3. Understand how the steering and brakes operate.


4. Wear a helmet, wrist protectors, and knee and elbow pads.


5. Wear proper shoes.


6. Avoid riding downhill on steep hills, slippery/uneven surfaces, and crowded walkways/streets.


7. Do not operate a scooter at night.


8. Avoid tricks and stunts.




Knowing how to ride a bicycle is the easy part. Being safe takes skill-knowing the rules of the road, being conscious of motorists who may not be conscious of you, using safety equipment, the correct shoes, and so forth, though seemingly obvious, all lead to safe riding. A very dear friend of mine was out for a Sunday ride on her bicycle. She was doing all the right things-wearing a helmet and observing traffic patterns and laws, but says today, "I was not looking at the condition of the road"-over the handlebars and many facial reconstruction surgeries later, her message is "Know the roads and be safe!!" (


Some suggestions for safety are as follows:


1. Make sure the bicycle is of the proper size.


2. Wear bright, fluorescent colors, and avoid biking at night. If this is necessary, make sure that the bike has rear reflectors.


3. Obey all rules of the road.


4. Do not ride double or attempt stunts.



All Terrain Vehicles

The NAON has a position statement on ATVs. Many of you may have these vehicles and we ask you to look at the safety in them. Remembering that they can involve high speed on a heavy machine, the riding can be risky. Also review your state's positions on ATV safety regulations as it relates to helmets and the age of riders.


Safety tips for ATVs include the following:


1. Get trained-these vehicles take skill and knowledge to use.


2. Always wear protective gear.


3. Remember that the majority are designed to carry only 1 passenger-so, do not drive with a passenger or ride as one.


4. Do not drive on paved roads-it is difficult to control an AVT on paved roads, and many accidents are fatal when there is a collision with a car.


5. Do not allow children on adult ATVs. Children under the age of 16 lack the developmental skills to safely drive adult ATVs that have the capability of going 70 mph and weigh hundreds of pounds.


6. Children under the age of 6 should never ride on an ATV (



Another dear friend of mine, a NAON nurse, has told her story over and over again of her little neighbor who lost his life on an ATV; how precious that little boy was to her; and how sad for all who loved him so much. A minute of fun turned to sorrow.



Every operating room/emergency room nurse has his or her own feelings about motorcycles. The Sunday groups that are out to share the roads, enjoy their times together, and be in community are not my concern. It is those fast-riding, pop-a-wheelie people who ride on the center white line between the cars who give me the chills. In 2006, in the United States, 4,810 motorcyclists died and approximately 88,000 were injured in highway crashes. Head injury is the leading cause of death in motorcycle crashes. The National Highway Traffic Safety Administration estimates that motorcycle helmets reduce the likeliness of a crash fatality by 37%. I live in New York. New York has a helmet law-wear it. However, helmet laws vary from state to state. As of January 2008, 20 states had mandatory helmet laws for all ages, with 27 requiring for a specific segment of riders, usually those under 18. Although there is an argument that the choice should be left to individual's compliance, after the initiation of the universal helmet law, there were fewer fatalities and severe injuries. Individual state's laws can be found online (



I live in a community that is close to the sea. It is beautiful and peaceful, and each year, many of my neighbors take their boats out of storage, and off to the waters they go. Each year there are at least one if not two fatal accidents on the seas off our community. According to the U.S. Coast Guard, more than 70,000,000 Americans enjoy recreational boating each year. Annual boat registrations have increased steadily from just over 10 million in 1988 to 12.7 million in 2006. During this same period, boating-related fatalities have decreased, due in part to increased use of life jackets or personal flotation devices. The U.S. Coast Guard received reports for 4,967 boating incidents; 3,474 boaters were reported injured and 710 died in boating incidents in 2006. Overall, 70% of fatal boating accident victims drowned in 2006-about a 15% decline from the 82% of victims who died from drowning in 1990. The remaining boating fatalities were due to trauma, hypothermia, carbon monoxide poisoning, or other causes. It is estimated that 423 lives could have been saved in 2006 if all boaters had worn life jackets. Alcohol involvement was the leading contributing factor in fatal boating accidents, contributing to about one in five reported boating-related deaths. Open motorboats were involved in 45% of all reported incidents and personal watercrafts were involved in another 24%. In 2006, there was an increase in the number of reported fatalities associated with the use of canoes/kayaks. The number of deaths associated with these types of crafts increased from 78 in 2005 to 99 in 2006 ( (


The U.S. Coast Guard recommends


1. That all passengers wear life jackets or PFDs.


2. Avoiding alcoholic beverages while boating.


3. Completing a boating education course and a Vessel Safety Check Program (


4. That you become aware of the regulations in your state for boating for operator age and safety equipment. These can be found on the National Association of State Boating Law Administrators' Web site.


5. Awareness of the risk of carbon monoxide poisoning, provision of proper ventilation in cabins, and use of a carbon monoxide detector.



Each of us sees different issues within these recreational activities and the potential for injuries associated with them. For some of us, our call to action is based on a personal experience; for some, a professional experience that has been life changing; or for some, just a personal conviction. How do we respond? Where can we make that difference? Know the statistics; become familiar with safety issues so that you can share the information. Should we write letters to our local newspapers and elected officials about the issues? Is there an opportunity for you to bring these issues forward to your respective hospitals to sponsor a safety day? If you are already doing this, share it with your NAON community!! Are you comfortable speaking to religious, secular, school, or scout groups? Perhaps, you are most comfortable just having a conversation with a neighbor over the fence or on the sidelines of your children's games. Who better to give this information than orthopaedic nurses? Nurses who have seen the effects of injuries and can tell the stories to encourage others to be safe. Your decision is your decision led by personal and professional opinions, feelings, and experiences.


My wish for us all is a renewing summer, time spent with family and friends, and most of all, safe and happy times.


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