Extended Care Module and the

Benefits to Small Remote

PatrolsPresented by:

Rocky Findlater

Australia Ski Patrol Association

Proudly Supported By

Jacobs Ladder - Ben Lomond Tasmania

www.skipatrol.org.au

Australia Ski Patrol Association

• One of ASPA’s main roles is as a training organization

• There are three main courses made available to its Patroller members:

1. AEC (Advanced Emergency Care Course)

2. National on Snow

3. ECM (Extended Care Module)

Patrols in Australia• There are three States where skiing is

possible in Australia

• All three States have Patrols members of ASPA (Australian Ski Patrol Association)

these are:– New South Wales– Victoria– Tasmania

New South Wales

• Perisher• Thredbo• Mt. Selwyn• Charlottes Pass

NSW, Australia photo

Victoria

• Falls Creek• Lake Mountain• Mt Baw Baw• Mt Buffalo• Mt Buller• Mt Hotham• Mt St Gwinear• Mt Stirling

On Snow Exams – Falls Creek - Sept 2008

NSW & Victoria

Tasmania

• Ben Lomond• Mt. Mawson

Medical Centre• Some Patrols have

– Local Medical Centre (larger resorts)– No Medical Centre (smaller resorts)

Medical Centre• Smaller Patrols are

remote and are longer distances from a Medical Centre

(several hrs by Ambulance)

• Some Mountains have Summer Recreation

(Medical Centre are closed in Summer)

Medical Centre• Smaller Patrols are

remote and are longer distances from a Medical Centre

(several hrs by Ambulance)

• Some Mountains have Summer Recreation

(Medical Centre are closed in Summer)

On Ben Lomond

• We are a minimum of two hours (round trip) from a Medical centre by Ambulance,

Extended Care Module

• Was the Brainchild of Peter Hoyle

from Ben Lomond Patrol Tasmania

(previous Captain 1992 to 2004)

and • ASPA VP Education 2005 -

Now Retired.

Ben Lomond Patrol HQ – 2005

Peter Hoyle

Background and Intent• The ASPA ‘Advanced Emergency Care (AEC) Course’ trains Ski Patrollers to

care for people injured on the Ski Slopes.• In large resorts the patroller’s duty of care ceases when they can hand over to the

medical centre at the bottom of the slopes.• In small resorts, (both alpine and cross-country), there is often no medical centre.

Patrollers have the responsibility to care for a casualty until they can handover to Ambulance or other medical care, which may involve a wait of several hours or more.

• The ASPA project was to develop a module to provide general guidelines for Patrollers who have that ‘extended care’ responsibility.

• It is not the intent to extend the patrollers competencies to paramedic level, but it will emphasize on important aspects of patient care that are within the competencies taught in the AEC Course, as well as focus on assistance to friends and relatives, evacuation of the casualty and interaction with medical personnel.

• It is envisaged that the module will be used as a resource for training at the patrol level, with local protocols added.

• The module was in its first draft prior to 2005 season and was continued to be developed that season, with input from the Ben Lomond and Mt Mawson patrols,

• It was also hoped that Peter would go on the road in September, to Baw Baw, Mt Buffalo and as many other small patrols as possible to gain input, feedback and support .

Feedback from other Patrols• In September of 2005, Peter visited all of the patrols in Victoria & Tasmania,

and spoke with them on the concept of the ECM

• Objective to get feedback from members about their extended care issues.

Baw Baw Raul Picot, Paul Picot

St Gwinear Allan Wood, Craig Oldis, Andy Gillam, Mark Connor, John Sunderland, Dr Margaret Sunderland

Lake Mountain Andrew Paul

Mt Stirling Peter Madden, Martin Burney, Mick Stapleton

Mt Buller Sam McDougall, Ossie Ramp

My Buffalo Chris Beach

Falls Creek Glenn McIlroy, Dr Mark Zagorski

Mt Hotham Larry Doyle.

Ben Lomond John Marshall, Phil Harris, Rocky Findlater,

Dr Alex Thompson

Mt Mawson Andrew Davey, Liz Caldwell

Mt Selwyn Peter Mowbray

Benefits Issues and feedback:• Medications

– Doctors bag medications• Responsibility of supplying doctor• Security, kept in a safe, key access limited, Patrol director or Mt

Manager• Some patrols will not have medications because of security

concerns.• Must be kept in date • Records must be kept

– Patrollers should only have access to those medications for which they are certified

– There should be a minimum requirement for the facilities needed in a ‘Remote Area’ first aid room

– Panadol should not be offered by Patrollers, but:-• If a patient asks for it, it should be readily available• Nothing by mouth

• Duty of Care & Insurance– Doctors who assist in the ski patrol should be sure that they are

covered by their professional indemnity for ‘good Samaritan’ voluntary work

– Standard advice sheets to give patients who are not ambulance cases

– waiver forms to be signed– when does our duty of care end?

• Care Room Issues– Toileting

• Output should be measured, test strips used– Clean up and disposal of blood waste is important– Peer Support and debrief strategies should be in place– Abusive, uncooperative patient

Benefits Issues and feedback:

• Training– ASPA should offer extended competencies, eg:-

• O2 Nebuliser, Angenine, Sucking, Epipen, Gadel Airways, O2 Bagging

– Knowledge of specialized dressings, eg for abrasions, burns together with maintaining an A septic field is important

– ASPA AEC course concerns• Length of attendance at the full course, 3 weekends are difficult• Can more competencies be tested at the patrol level by ASPA

accredited assessors?• Can the short course concept be extended?• Can more of the course and testing be on-line?• Agreement that the prac component should be maintained • Pre course workbooks are good.• More 4 day courses?

Benefits Issues and feedback:

• Ambulance – Payment and patient refusal– Advice on likely destination (which Medical Centre ?)– When is an ambulance necessary?– Briefing Ambulance Staff and handover

• Documentation - needs more information – Form for doctors to use, their personal qualifications, history etc– Every intervention should be recorded– Abdominal girth to be recorded for internal injuries– Oximeter readings. – Changes in pupil size.– Frequency of observations guide is needed– Duplicate documents for both hand on and patrol records.

Benefits Issues and feedback:

• Other issues– Patients need to be advised when surgery might be likely and

anesthetics may be required.– Who do you let go? What do you say or advise to the walk out

patient who seems to have got better?– Involving family and friends in what is going on, give them

something to do, how do they feel? Don’t cause unnecessary concerns or worry.

– Planning the evacuation from the hill as well as from the mountain

– Methods of evacuation • Own transport car or Bus• Ambulance• Helicopter

– Returning gear and finding and advising other group members

Benefits Issues and feedback:

Managing Long Term Care

• Planning the care from the time first Patroller arrives on scene

• What are likely scenarios ?

improve

or

deteriorate

• How to keep Casualty calm and confident in our management & their outcome

– What is going through their mind

• How does the family or team members with them feel? Keep them informed. How can they help or be involved?

• What evacuation plan?

Thank you:Peter (Rocky) Findlater

TreasurerAustralian Ski Patrol Association

Captain - Ben Lomond Patrol

PO Box 616FORTH Tas 7310treasurer@skipatrol.org.auPh (home) (03) 64282221Mob (priv) 0418128827Skype Name: Rocky Findlater

Australia Ski Patrol Association

Proudly Supported By

Sandy Findlater with Ben Lomond Gnome

www.skipatrol.org.au

Discussion paper - October 2005•• INTRODUCTION• ASPA Emergency Care Course trains Ski Patrollers to care for people injured on the Ski Slopes. In large resorts the patroller’s duty of care ceases when he can hand over to the medical centre at the bottom of the slopes. However in small resorts, both alpine and cross-country, there is often no medical centre. Consequently, patrollers often have the responsibility to care for a casualty until they can handover to Ambulance or other medical care. This may involve a wait of several hours or more.• This module is intended to provide general guidelines for Patrollers who have that extended care responsibility. Operational protocols and details of equipment will vary between patrols.• The module does not extend the patrollers competencies to paramedic level, but it does emphasize important aspects of casualty care that are within the competencies taught in the Emergency Care Course, as well as focusing on reassurance of the casualty, family and friends, evacuation and interaction with medical personnel.• CONTENT• Action to be taken when the casualty is brought into the First Aid room• Introduction to the Ski patrol • Explain to the casualty where he is • Introduce yourself and others who will be carers • Obtain permission to care for the casualty• Vital signs• Check DRABC• Observe BP, Pulse, Conscious state, Skin condition, Temperature • Determine frequency of Observations• Recording• Enter personal details, details of accident previous observations on the required Report Form.• Accurately record all observations and actions taken.• Secondary Survey• Locate and check the presented injury• Conduct standard Secondary survey with an intensity according to the casualty’s state of consciousness, the history of the accident and the extent of the survey that was done on the slopes. If the casualty’s condition deteriorates, secondary survey may need to be reassessed.• Splints, bandages and RICE• Check splints and bandages for effectiveness and comfort.• Continue RICE regime for Sprains and Contusions• Comfort and warmth• Close doors, turn up heaters, restrict movement of people through doors• Blankets, pillow, hotwater bottles• Remove boots if possible• Warm drink unless contraindicated.• Check on the need for toileting• Do not remove wet clothes until the person is warmed up• Do not sit a cold person close to a radiant heater, Do not rewarm too quickly• Do not allow alcohol to be given• Do not locate O2 near a heater• Do not give food or extensive drinks if the casualty may need surgery.• Pain relief• Check for contraindications• Be aware that the wait may be beyond the effectiveness of Penthrane/Entonox if too much is given too soon. Casualty can be educated in economic self administration.• Stabilize the injury, create a comfortable, warm and calm atmosphere• Establish the need by observing the casualty and asking “ how much is your pain on a scale of 10”• O2 therapy helps to relieve pain • Seek assistance from a Doctor or Paramedic for further pain relief if necessary.• Reassurance of the Casualty• A calm, friendly and competent atmosphere must be created to alleviate the psychological shock of injury. Often when a person has calmed down, the signs and symptoms will be less severe.• The patroller can help by attending to these matters which will probably occur.• Establish first name relationship, ask how you can help• Turn off noisy radios• Restrict non essential people, establish privacy, keep doors shut• Try to have a friend or relation in the room, especially a parent for a child. • Explain to the casualty and the friend what you are doing to help• Try to establish normal conversation, ask about interests, experiences and other thing you think they might want to talk about.• Be sympathetic about the injury, maybe it happened to you once!• Explain what you are doing with equipment, ask “Is that helping” “Does it make you feel better”• Improvement in condition may mean that some therapies, such as O2 or core warmer can be discontinued, which will give encouragement to the casualty.• Help to solve the ‘domestic’ problems of friends, children, transport, property, food, rental return, phone calls.• Answer the “what will happen to me” question as accurately as you can.• Be truthful about the casualty’s injuries. Say that you cannot be sure of the extent of injuries because only doctors with X rays can tell you that. If you do have further knowledge of the type of injury be careful that you do not alarm the casualty. Do not offer a diagnosis.• Casualties’ questions may go beyond your expertise or experience. Advise the casualty when this is the case. Do not pretend to be a medical expert!• Advise the casualty if a medical checkup will be necessary.• Discuss with the casualty the arrangements that can be made to get to medical aid and get explicit permission for them . Be able to advise re ambulance costs, and the likely hospital destination.• It is very important when a collar or a backboard has been applied that the patroller should explain that protocols require us to treat the worst case scenario, as a precaution pending further medical examination.• Reassuring friends and relatives.• Explain what is happening and what you a doing, consider a child of an injured parent.• Ensure parental consent for the care given to an injured child• Allow 1 or 2 supporters to be present and to help give support and comfort.• Give friends a chance to help, with returning rental equipment, fetching clothing for the casualty and accounting for his property.• During a long wait, consider the friends, there may be no reason why they should not go back skiing for a while• Allow friends to base themselves in the patrol waiting room, if there is room.• Help the friends to organize their transport. Tell them where the casualty is going, the route to the hospital etc.• If a triage situation develops explain to your casualty and friends why you must give someone else your attention for some time, don’t let them feel abandoned.• Privacy and legal issues• Patrollers should endeavour not to be alone with a casualty of the opposite gender.• Ensure consent as often as possible.• Use curtains, blankets to ensure dignity.• For toileting, try to arrange same gender assistance if possible.• Keep a partner, friend or family member nearby if possible.• Avoid discussion of the casualties in their hearing, unless they are specifically included in the discussion.• If another casualty has to be brought into the room, try to preserve calm and privacy as much as possible. If a triage situation develops, explain to your casualty why you must give someone else your attention for some time, don’t let them feel abandoned.• Try to have more than one Patroller present when giving important information to the casualty or relatives. It maybe necessary to make a record of what has been said.• Evacuation and Transport.• Ambulance• The patroller must make the decision regarding an ambulance call. It should be done as soon as possible to allow for travel time. Cost should not be a consideration.• Order the ambulance for:-

• Potentially Life threatening situations • Injuries with deteriorating vital signs• Neck, Spinal, Concussion, and Femur fracture• Arterial bleeding, serious chest injuries, • Any compromised conscious state• When painkillers have been given. (Except paracetemol which the casualty may have taken)• Serious Medical emergencies • Persons with no other means of transport

• Private transport• Injuries that are stable and will remain so without pain relief or O2• Casualty can be made comfortable in a car and a seatbelt can be worn.• No previous loss of consciousness• No Penthrane or Entonox has been given.• No painkillers have been administered by a Doctor.• The driver can be judged competent and confident.• The car owner’s explicit permission has been obtained if the driver is not the owner.• Third party insurance only covers non paying passengers.• Examples:- simple upper limb fractures, knee ligament, lower limb fractures with air splint, other minor injuries• Give Clear instructions for return of equipment to the Ski Patrol• Serious time critical injuries, such as an Elbow fracture/dislocation with a compromised circulation, may need to be taken directly to surgery without waiting for an ambulance. Details of such arrangements for such situations will be resort specific, the following points are general guidelines:-• The Hospital should be advised of the incoming emergency• A patroller should accompany the casualty if penthrane/entonox or O2 is administered.• Possibly arrange to meet the ambulance on the way.• Helicopters

• Resorts should have protocols in place for emergency Helicopter evacuation• Decision to call a helicopter rests with Ambulance service and/or Police• Helio response times vary between resorts, in some tey are quicker than road ambulance, others are slower.• Never rely on a helicopter coming, have an alternative plan!

• Interaction with Paramedics and Doctors• In small resorts that do not have medical personnel on duty, doctors or paramedics can often be found on recreation. They are almost always willing to help with a serious case in Ski Patrol, provided that they are supplied with the necessary information, equipment and medications, and that their time is not taken up unnecessarily. It is helpful if the Patrol has a register that lists the area of expertise of Medicos who are willing to assist.• A Patroller caring for a casualty who needs help that is beyond the scope of ASPA Emergency Care Course protocols, should seek the assistance of a Doctor or Paramedic. In doing this he should:-• Privately explain the situation and show the Doctor the Report Form with the Observations record.• Introduce the Doctor to the Casualty and allow him time to conduct his own examination /consultation.• Be able to provide requested equipment and medication• Obtain the Doctor’s signature on the Report sheet which has recorded his acceptance of responsibility for the action taken.• Obtain doctors signature on a register for any medications given.• In the First Aid room the patroller should be able to provide to a Doctor with:-• Sterilised Surgical equipment• Suturing equipment• IV equipment• Syringes• Pain relief and medications• Situations that would warrant seeking medical assistance:-• Deteriorating Vital signs• Serious cases of shock, hypothermia, head injury, chest Injury, complicated fractures, heart attack, medical emergencies• Dislocations• Lacerations requiring suture.• PRESENTATION OF THE MODULE• Combination of :-• Lecture by a doctor “ What I would want if you called me into your First Aid room”• Scenario sheets that require priorities to be determined• Video clips as part of a Power Point presentation• Information sheets about equipment medications and pain relief in the first aid room• Practice in record taking on report sheets• Reassurance skills seminar• Practice competencies and equipment eg Blood Pressure and Pulse, Core Warmer, O2 Therapy, Asthma Spacer, Air Viva, De Fib• Local information about Ambulance, Hospital and Medical Services• Inventory of a remote area first aid room• A Septic procedures protocols• Specialized dressing information.• VP Ed Com Peter Hoyle hoyle@vision.net.au 0363911149(H)• 0438911149(mob)