By Jonas Karlsson, MD
Few things in the natural world awe and inspire as much as waterfalls. Western North Carolina is fortunate to have more than 250 waterfalls in the region, with hundreds of thousands of people visiting their splendor and magnificence every year. Unfortunately, waterfalls bring danger along with their beauty, and each year many people are injured, some fatally, due to waterfall-related trauma.
The majority of the regional waterfalls are in various public lands, namely Pisgah National Forest, Nantahala National Forest and the Great Smoky Mountains National Park, covering more than 1.2 million acres. Waterfall injuries represents a major cause of death in the Great Smoky Mountains National Park, and the report by the National Park Service from 2015 cites an average of nine serious injuries annually related to falls from waterfalls.
Mission Hospital is the only designated trauma center in western North Carolina. As such, any significantly injured patient will be brought to Mission Hospital for care. In 2016 and 2017, 22 percent of the patients seen at Mission Hospital for waterfall-related injuries met criteria for major trauma. Many victims have multiple injuries, depending on the height of the fall.
Common injuries are extremity and pelvic fractures, spinal column fractures with spinal cord injury, traumatic brain injury and rib fractures. To complicate matters, rescue personnel are often significantly delayed in reaching victims because of the remote location of many of these waterfalls – sometimes the delay is several hours.
Secondary injuries such as hypothermia and ongoing blood loss are not uncommon. Of the patients who arrived at Mission Hospital, 87 percent survived their injuries, while 13 percent did not.
The great tragedy is that these injuries are nearly completely preventable by following these widely available safety recommendations:
- Obey posted warning signs and stay on designated trails.
- Do not climb on rocks near the waterfall. These rocks are extremely slippery from water and algae.
- Unless an established trail exists, do not attempt to climb to the top of a waterfall, the surrounding areas are often unstable due to natural erosion, as well as slippery.
- Do not jump or dive into rivers or streams, including pools near waterfalls. Underwater hazards such as boulders, logs or branches may be present.
- Do not swim in water upstream of a waterfall or attempt to cross a stream near the top of a waterfall. The swift current can easily overpower even in shallow waters.
- Closely supervise children at all times.
Additional information is available at these sites:
- U.S. Forest Service waterfall safety checklist 
- Great Smoky Mountains National Park water safety guidelines 
Jonas Karlsson, MD, FACS, is a trauma surgeon at Mission Hospital Trauma Services.