Abstract
Objective
To describe the rates, patterns, and likelihood of injuries in commercial whitewater rafting on the New and Gauley rivers, West Virginia.
Methods
Standardized injury report forms developed by the West Virginia Whitewater Commission were reviewed for years 2005–2010 to provide a statistical account of injuries reported by licensed commercial rafting outfitters operating on the New and Gauley rivers.
Results
Overall, musculoskeletal injuries (sprains/strains, 21.1%; dislocations, 13.8%; fractures, 12.2%) comprised the majority (47.4%) of incidents followed by injuries to soft tissue (lacerations, 29.0%; abrasions, 13.3%; contusions, 2.3%). Almost one half (44.3%) of injuries were to the head, neck, and shoulders followed by the lower extremities (foot/ankle/leg/knee/hip, 33.9%) and upper extremities (hand/wrist/arm, 14.3%). Data analyzed using the Somers’ D statistic revealed the likelihood of an injury occurring inside the raft is P = .55, and P = .39 when passengers are ejected from the raft into the river. The most likely injuries to occur to passengers are a laceration (P = .51) or a sprain (P = .20). The main probabilities for the risks of injuries were found to be to the head (P = .24), shoulder (P = .16), and face (P = .13) of the passenger.
Conclusions
By knowing what injuries are common, their likelihood of occurrence, and the settings in which they happen, commercial outfitters can initiate practices to reduce injury rates.
Keywords
Introduction
Commercial whitewater rafting is a popular and accessible type of outdoor recreation activity undertaken throughout the United States on rivers that offer excursions of various degrees of difficulty. 1 Outfitters offer opportunities for guests to participate in guided whitewater rafting by providing various outings based on previous customer experience, varying the length of the trip, difficulty of whitewater, and access. Motivations for participation in whitewater rafting vary with experience. Guests with no rafting experience are more likely to focus on the novelty of the experience and the willingness to take risks, whereas experienced whitewater rafters tend to be more relaxed, interested in being with friends or family, and recreating in a natural setting. 2 In general, the risk associated with whitewater rafting varies with the level of whitewater, weather, the health of the participant, the experience of the guide, and other factors. Although considered to be an extreme activity, commercial whitewater rafting has a low mortality and morbidity rate.
Our objectives in performing this case study are to provide an accident analysis program that includes 1) identifying the types and locations on the body of injuries that occurred during commercially guided rafting trips, 2) calculating the probabilities for each particular injury that may occur during a commercially guided rafting trip, and 3) from the resulting likelihoods of the occurrences of injuries, providing advice on the remedial preventive actions that commercial outfitters might take to reduce the identifiable injuries.
Methods
Study Areas
This study was based on injured guests reported by licensed commercial rafting outfitters operating on the New and Gauley rivers, West Virginia, during the years 2005–2010. Both rivers are located in south central West Virginia. The New River is the major feature located in the 70,000-acre New River Gorge National River, managed by the Department of Interior, National Park Service. The 53-mile stretch of river located within the jurisdiction of the National River contains more than 80 rapids, with more than one fourth rated Class III to Class V, making it one of the most popular whitewater rivers in the United States and one of West Virginia’s biggest tourist venues, attracting more than 150,000 commercial whitewater rafters each year. 3 The New River’s southern or upper segment consists largely of long pools and rapids up to Class III. The lower or northern segment, including the New River Gorge, has some of the region’s most demanding whitewater, ranging in difficulty from Class III to Class V.
The Gauley River, managed by the National Park Service, is the primary recreation resource in the Gauley River National Recreation Area, attracting more than 60,000 commercial whitewater rafters each year. 3 The Gauley River drops 668 feet over 28 miles and contains more than 50 named rapids, some of which are rated Class V rapids, making the Gauley a highly sought out whitewater experience.
Data Collection
Injuries and illnesses are reported by river guides on standardized injury report forms developed by the West Virginia Whitewater Commission. Commercial guides operating on the New and Gauley rivers (along with 3 other West Virginia rivers) are required by West Virginia Legislative Rule §58-12-11 to complete the form whenever a guest reports an injury or illness, when the guide is aware of an injury or accident that requires medical attention at a medical facility, and the injury or accident occurs during the duration of the trip, including the put-in. 4 The form requires that the guide include demographic information on the patient; identify the type and anatomical location of injury, the circumstances leading to the injury, the day, time, and geographic location (rapid) of the incident; and provide a brief description of how the injury occurred and other relevant information.
The West Virginia Whitewater Commission provided Injury Report Forms (n = 221) to the researchers for years 2005–2010. Sixteen reports were omitted from analysis because they involved guides (n = 9) and fatalities (n = 7), leaving a total of 205 reports with which to analyze the rates, patterns, and the likelihood of injuries in commercial whitewater rafting on the New and Gauley rivers. For confidentiality purposes the patient’s name and address were hidden from the researchers. Information from each form was coded and entered into a Microsoft Excel spreadsheet (version 14.0.0 for Mac 2011, Microsoft Corp, Redmond, WA).
Data were analyzed using Microsoft Excel for descriptive analysis and the Stata 9 version of Somersd (Stata Corp, College Station, TX) 5 to determine the probabilities for each injury, anatomical location of injury, and the setting (raft, water, shore) where injuries occurred. The Somers’ D statistic is a nonparametric, directional estimator of the ordinal association between 2 variables that allowed us to designate one variable as the response variable (injury) and the other as the predictor variable (injury location). 5 Somers’ D is a preferred extension of Gamma statistic, which is based on Kendall’s coefficient but adjusts for ties. The asymmetric form of Somers’s D statistic is Dyx and correctly represents the degree of association between the outcomes (y), designated as the response variable, and the estimated probability (x), designated as the predictor variable.
Results
Demographics and Background Information
During the 6-year period 2005–2010, a total of 205 guests were injured on commercial whitewater rafting trips on both the New and Gauley rivers. More than one half (56.5%) of the injured were reported on the New River. Males accounted for more than one half (53%) of the injured. Almost one half of the injured (44%) were aged 40 and older. Eleven percent of the incidents involved individuals younger than 20 years of age, and the median age was 34.3 years (range, 8 to 78 years). Sixty-one percent had taken at least 1 commercial rafting trip before the trip on which they were injured.
More injuries occurred during the summer (52%) than in the fall (36.5%) or spring (11%). Injuries occurred more often on weekends (51% on Saturdays and Sundays alone) than on weekdays (49% on Mondays through Fridays). Time of injury peaked between the hours of 12:01
Injury Type and Anatomical Location of Injury
Overall, musculoskeletal injuries (sprains/strains, 21.1%; dislocations, 13.8%; fractures, 12.2%) comprised the majority (47.4%) of incidents followed by soft tissue injury (lacerations, 29.0%; abrasions, 13.3%; contusions, 2.3%). Types of injuries are included in Table 1.
Distribution of injury by river
Anatomically almost one half (44.3%) of injuries were to the head, neck, and shoulders followed by the lower extremities (foot/ankle/leg/knee/hip, 33.9%). These were followed by injuries to the upper extremities (hand/wrist/arm, 14.3%). Anatomical location of injuries can be found in Table 2.
Anatomical location of injuries
Injury Probability
We supply the probabilities from Table 3 in parentheses as to the likely occurrences of injuries. We are 95% confident that the probability of an injury occurring in the raft is .55, and .39 injury will occur in the river. The probability of an injury on shore is statistically insignificant. What this finding suggests is that if a guest experiences a reportable injury while on a commercial raft trip, there is a .55 probability (more than one half of the time) the injury will occur in the raft and a .39 probability (more than one third of the time) that the injury will occur in the river. The most likely injuries to occur to passengers are a laceration (P = .51), sprain (P = .20), and dislocation (P = .20). The main probabilities of the risks of injuries are to the head (P = .24), shoulder (P = .16), ankle (P = .11), and face (P = .13) of the passenger.
Somers’ D results of response variables to commercial rafting injuries (2005–2010)
Coefficients are interpreted as the probabilities of their occurrences from reported river accidents.
These items are statistically significant at the .05 level.
Discussion
During the period 2005–2010, more than one million (n = 1,020,974) clients participated in a commercial raft trip on the New and Gauley rivers.
3
A higher number of injured guests were reported for weekends, peak months of the season (summer), and time of day (12:01
Nationwide, the number of fatalities on guided whitewater trips has ranged between 6 and 10 per year for an estimated 2.5 million user-days. The incidence of commercially guided rafting fatalities is estimated at 1 death per 312,500 user-days. 6 In comparison, researchers in New Zealand 7 estimated a total of 200,000 commercial whitewater rafters annually, reporting 2.5 fatalities and 15.4 hospital visits. Whisman and Hollenhorst, 8 in their examination of mortality and morbidity rates on 5 West Virginia rivers, including the New and Gauley rivers, estimated an injury rate of 26.3 per 100,000 commercial rafters.
Based on the analysis of the data, the injuries and anatomical locations for injury that occurred during commercially guided raft trips on the New and Gauley rivers are consistent with those reported in the literature. For example, Whisman and Hollenhorst 8 noted that almost half of the injuries sustained by commercial whitewater rafters were musculoskeletal (fractures, sprains/strains, dislocations), or soft tissue (abrasions, contusions, lacerations), with the face being the most common site of injury. Musculoskeletal injuries accounted for more than half of the injuries reported among commercial whitewater rafters in New Zealand. 7 Most fractures were to the foot, followed by the face, arm, or hand. Sprains and strains were common to the knee or leg, and dislocations occurred most often to the shoulder. The majority of the injuries reported on the Arkansas River, Colorado, were soft tissue related, followed by musculoskeletal injuries and hypothermia. 9
Similar acute injuries were reported by whitewater kayakers and canoeists and involved sprains/strains, fractures, and dislocations, followed by lacerations, contusions, and abrasions. The shoulder and upper extremities (wrist/hand, elbow/forearm) were the most common sites of injury. 10
The injuries associated with commercial whitewater rafting are much like those reported in other adventure recreation activities. Hospital emergency rooms treated more than 213,000 Americans for injuries received during snowboarding (25.5%), sledding (10.8%), and hiking (6.3%). 11 Researchers examining the case incident report files from 8 California National Parks during a 3-year period calculated a rate of 9.2 accidents per 100,000 visitors. Musculoskeletal or soft tissue injury accounted for more than 70% of all nonfatal incidents. The most frequently involved anatomical areas were the lower extremities (38%). 12 Similar injuries were reported for a college outdoor education program, where the majority of injuries reported were sprains or strains to the ankle, wrist, and hand. 13
In our analysis we found that the most likely injuries to occur are lacerations, sprains, and dislocations, with the head, shoulder, ankle, and face being the most likely anatomical locations for injury. Because musculoskeletal injuries comprised the majority (47.4%) of incidents reported, guides should be skilled at treating these types of injuries, especially the knee and ankle. To prevent, recognize, and treat injury, all river guides receive (or should receive) advanced training in wilderness medicine and carry with them the appropriate first aid equipment and supplies to treat these injuries. Guides should also be encouraged to make guests aware as to where and why injuries occur on raft trips. This knowledge may help reduce injuries or at the least could enhance the guest’s experience.
Our findings also suggested that there was a good probability that if a guest was injured, the injury occurred in the raft. Whisman and Hollenhorst 8 noted similar results and suggested that injuries sustained while passengers remained in the raft were usually a result of collisions with other passengers or being struck by a paddle or other piece of equipment in the raft.
Data also revealed that injuries occurred when passengers were thrown from the raft into the river and subjected to the forces of high-volume, turbulent water in which the guest, while swimming, could encounter hydraulics, foot entrapments, impact with rocks, floating debris, or other hazards. 8
By knowing beforehand the probability for injury, guides can better prepare their guests by reminding them to stay in control of their equipment or positioning themselves in the raft in such a way to minimize potential for injury. The focus on injury prevention could also incorporate additional preventive measures such as attaching face protection to helmets, encouraging the use of mouthguards to protect teeth, creating rubber or flexible “T grips” on paddles, modifying ways to exit the raft, or carrying fewer passengers per raft. In their whitewater injury survey, Schoen and Stano 10 reported that a helmet with a face guard was used by 11% of whitewater paddlers, of which 69% noted the face guard protected their face from injury. Researchers in New Zealand recommended that the design of the raft be modified to prevent overturning and that guests be trained in strategies to prevent overturning and what actions should be taken or modified once guests find themselves in the water. 7 Although these measures may seem logical solutions for injury prevention, they may not be cost effective or without undesirable consequences. Further discussion and investigation is warranted before pursuing any of these preventive measures.
There were a number of rapids on both rivers where the incidence of reported injury was higher than most. Many of the injuries in this study were documented on Class III to Class V rapids. This finding is supported by Hunter, 14 who noted passengers tend to be ejected from the raft at higher rates in Class IV whitewater mainly because of limited skill and experience or because guides tend to choose more aggressive and more challenging routes through the rapids or intentionally flip the raft for more fun and excitement. (The International Whitewater Classification System is a subjective scale designed to rate rivers based on danger and paddling difficulty. Ratings range from Class I [slow-moving water with little turbulence, and small waves with little to no danger to swimmers] to Class VI [dangerous rapids that are considered unrunnable by commercial outfitters]).
The Class III to Class V rapids on the New and Gauley rivers where more injuries were reported are popular surfing or play locations or require focused maneuvering by guests to successfully complete the run. While this information is valuable, it would be more valuable to note why these rapids record high injury rates. For example, Greyhound Bus Stopper on the New River has a high injury rate even though it is only a Class III rapid. Is this because it is a popular surfing location and injuries are more likely to happen while surfing rather than running through the rapid, or are there specific patterns of guest or guide behavior (eg, routes run, maneuvers used, guide attitudes and dispositions toward safety, etc.) or other variables involved? Without this information, it would be difficult to make reasonable decisions about ways to reduce injury at these locations. One way to get a better understanding of what mechanisms or behaviors cause injury at these sites would be to place trained observers at each rapid with a high injury rate to record the circumstances contributing to the incidents occurring in the raft or what happens to a guest when ejected from the raft into the water.
Limitations
It is important to note that this study does not include injury sustained by river guides nor does it include fatalities. This study was also limited by the information provided in each of the injury reports reviewed. The review of injury reports suggested that the definition of a “reportable injury” may be inconsistently interpreted, and clarification of reporting requirements may be needed to ensure consistent reporting. Many Injury Report Forms had information that was incomplete, illegible, missing, or marked “other.” This absence of information creates a void in the reporting system by failing to communicate a true picture of the frequency and severity of injuries being sustained by guests.
Conclusions
The total number of injury reports reviewed compared with the estimated total number of visitors on the 2 rivers during the time period indicates that the probability of any reportable injury is very low when compared with the total rate of participation. Nevertheless, commercial whitewater rafting, like other activities conducted in backcountry environments, presents unique challenges for injury control and prevention for outfitters and risk managers. Decreasing the incidence of injuries is an important goal of risk management. When viewed over time, injury patterns and their likelihood of occurrence can indicate where attention is needed to reverse an unwanted trend, to educate staff, to strategize preventive measures, to gauge the success of measures that have been implemented, and to share experiences by recounting significant events.
Future research should focus on the efficacy of guide education, implementing an experimental research design to determine the effectiveness of introducing new or modified safety equipment for customers, and incorporating behavioral observations to determine how injuries occur in the raft, in the water, or in transition (from raft to water). By knowing what injuries are common, the likelihood of their occurrence, and the settings in which they happen, outfitters can initiate practices to reduce injury rates.