N a t i o n a l S k i P a t r o l C y c le 2008 r e f r e s hA e r O u t d o o r E m e r g e n c y C a r e C y c le A 2008 study guide ©2008 National Ski Patrol All System, rights Inc. reserved. aryeh kopa C y c le A 2008 In Retrospect
T r a c k i n g t h e e v o l u t i o n o f required to complete medical “refreshers” since 1945, when t h e o e c R e f r e s h e r Advanced First Aid was the curriculum of choice. Eventually ou’re holding the Refresher Study Guide, prepping for ski it was decided that Advanced First Aid didn’t adequately season and perhaps thinking about OEC for the first cover winter topics, which led to the 1985/86 resolution that Ytime in months. For the nearly 19,000 who complete the organization would develop its own in-house program the OEC Refresher every season, it’s hard to grasp that for called Winter Emergency Care (WEC), a development that some OEC is a 12-month-a-year operation. Yet each January would guide the OEC Refresher to where it is today. the OEC Refresher Committee convenes to begin plan- Motivated by the need to ensure that members receive ning the year’s refresher, developing delivery content and the highest level of medical training possible, longtime training materials. Instructor trainers receive this material in Refresher Committee Chair John Dobson, NSP National early summer and begin working with instructors to develop Chair John Clair and others began organizing the current lesson plans and staffing for two separate refreshers: the patrol refresher process around that time. Dr. Warren Bowman instructor refresher and the patrol refresher. Division OEC was hard at work writing the first WEC text, while Clair was supervisors work with the division and local ski areas to make busy spearheading the formation of the program as a training sure that not only does the refresher happen, but that it meets course for patrollers. In 1987/88, NSP members participated the needs of the local patrols as well as the standards of the in WEC courses for the first time, and the WEC Refresher National Ski Patrol. (now the OEC Refresher) debuted. The WEC curriculum Like the NSP, which turns 70 this year, the OEC program was based on the 1984 Department of Transportation EMT and refresher have a storied history. NSP members have been curriculum, which inspired the three-segment refresher format that’s used today. The name of the curriculum was changed to OEC in 1988. In 1993, after OEC had become the standard of training for NSP members, it was settled that a committee would be selected to develop curriculum and set standards for patrol- lers’ annual refresher recertification. Committee members were chosen for their skills as outstanding instructors, cur- riculum design specialists, writers, artistic communicators and other abilities that would parlay into a diverse, flexible program. The initial team was comprised of patrollers repre- senting divisions around the country, including Tom Pearce (Eastern), Kathy Ferrigan (Central), Rose Ann Jankowski (Far West), Charles Lentz (Southern) and Doug Kremer (Pro). The group began to meet annually at different locations, first assembling at the inaugural Powderfall in Snowbird, Utah, in ‘93. When Clair was named national chair in 1996, Dobson took over as chairman of the newly-named OEC Refresher Committee, and the group became based at NSP headquar- ters in Lakewood, Colo. The work of the committee has grown and changed tremendously over the years. Initially a great deal of effort was spent writing objectives and pulling together topics that should be included in refresher review cycles. Long-term patrollers may remember the old 30-question “test” that was once associated with refreshers. This was eventually replaced by the “You Are the Rescuer” scenario discussion format, The NSP’s Winter Emergency Care Program debuted in the late ‘80s and was the which enabled patrollers to talk about real issues and the vari- predecessor of today’s OEC program and refresher. ous ways of handling them.
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008
The committee’s focus next turned to individual patrol- ing objectives and better focus on the task at hand. It will be lers, seeking input on what they wanted from their annual prevalent over the next few years. NSP volunteers are also refresher. Heavy emphasis began to be placed on evaluations busy writing the OEC 5th edition, developing an OEC qual- and feedback from patrollers. The committee changed its ity management program, and updating the affiliate program. emphasis from an organizational focus to a responsive one, The annual refresher continues as a vital vehicle for patrol- while maintaining its goal of reviewing one-third of the OEC lers to relearn skills and be effective on the slopes. “In the NSP skills and knowledgebase each year. there are only two activities that every member must perform,” The OEC program and OEC Refresher continue to says John Dobson. “One is to register every year. The other is evolve. The “I CAN” format that’s incorporated into this year’s that you must attend a refresher. The OEC Refresher affects refresher was created to help OEC technicians identify learn- every single member of the NSP; that’s why it’s so important.”
Dr. John Dobson
A tribute from the oec committee to the m a n w h o h e l p e d s h a p e t h e R e f r e s h e r f o r m o r e t h a n a d e c a d e .
Sitting by the pool at his home in Virgin Gorda, BVI, cradling a drink, tanned, with white hair in a pony tail, Dr. John Dobson strongly resembles Sean Connery in “Medicine Man.” It’s fitting, since like many SN P members, he is a medicine man, one who carried the OEC Refresher Committee from 1996 until retiring as its chair in 2007. dobson is grinning broadly and telling a story in the smooth accent of a southern gentleman. It’s about an embarrassing moment in his ski patrol career—the afternoon of his first basic toboggan test, when the slope conditions were akin to skiing on an ice cube tray. Dobson, then 50, and on the tail-rope, fell as the sled began to pick up speed on the icy run. Forgetting to drop the rope, he careened past the sled and his partner, pulling the sled backwards down the hill, then overturning it; a wild tumble for the other candidate, sled and rider ensued. Dobson’s evaluators sug- John Dobson (left) at the 1996 refresher. Dobson retired gested he try again another day. He eventually went on finish Basic, pass as chair of the OEC Refresher Committee in 2007 after Senior, and, in 1998, was awarded National Appointment # 8618. That year 11 years. he was voted National Outstanding Alpine Patroller. recently retired, Dobson has good reason to be smiling. After stepping down as chair of the Refresher Committee, he moved from Virginia to Big Sky, Mont., and has plenty of time to ski and travel with his wife, Nici Singletary. Dobson attended the Duke University Medical School, first intending to work as a cardiologist, but switched to orthopedic surgery in 1965, a specialty in which he remained for the rest of his practice. An experience at age 7, when he rode a burro with his parents to the bottom of the Grand Canyon, launched a lifelong love of the outdoors, although it would be almost 40 years before Dobson would join the NSP in 1984 at Virginia’s Wintergreen Ski Area. He was later instrumental in the formation of the OEC Refresher, which he calls an important part of his life, and led the creation of On Scene magazine. as the years sped by, Dobson found himself spending more time as a working patroller. His energies were spent serving on the National Board and Awards Committee, directing the OEC Refresher Committee, writing portions of OEC texts and other publications, and serving as the unit rep of the Wintergreen Patrol. Like many, he is proud of the 4th edition OEC text, which has been recognized nationally as one of the best EMS texts available. His advice to new candidates? Recognize that they’re becoming a part of one the best teaching organizations in the world, and part of a family that will allow them to give, learn, grow and form friendships that they will keep for the rest of their lives. thank you, John, for your many years of service to the NSP!
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008 I Can!
hen we, as OEC technicians, set out to refresh our OEC skills, we have the text and workbook and Refresher Study “I CAN” Example WGuide (RSG) to reference, and instructors also have the Instructor’s Guide (IG). But how do OEC technicians know where they are going in the lesson(s)? This is where, much like objective assemble the O2 equipment a GPS mapping system, objectives come in. “I CAN” I can attach the O regulator Objectives give us direction, but too often messages get 2 to O2 tank. lost in convoluted phrases. What OEC technicians really want to know is what they will gain from the journey. It’s “I CAN” I can select the appropriate O here that instructors can shift their objectives in the classroom 2 setting to “I CAN” statements. Adult learners particularly delivery adjunct to meet my want to know where they are going and what they will gain patient’s needs. from their classroom experience. There’s no need to hide this message in confusing expressions. Instruction is not about recitation; rather it’s about Implementing the “I CAN” format immediately focuses producing an environment by which to integrate learning OEC technicians on the goal(s) at hand. They can see and through new pathways. Education consultant and author formulate what has to be accomplished to complete the Robert Marzano articulates: “Students learn most effectively learning objective. when they know the goals or objectives of a specific lesson Life is complicated enough. “I CAN” statements are simple or learning activity. This makes intuitive sense. If students are and straightforward. You will notice that throughout this aware of an intended outcome, they know what to focus on. refresher we have embedded the concept of “I CAN” to When setting objectives, the teacher simply gives students a drive home the positive, active-learning concept to all target for their learning. However, objectives can be written refresher participants. Together we can do this! in a number of formats and used in different ways.” selko photo
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008 What do I do Now? A Glossary for Learning
Learning is not only more fun but also more deeply engrained when it’s active. Did you know that if one sees, hears and participates in a learning activity he is 80 percent more likely to remember it? When teaching, instructors should embrace a variety of didactic learning methodologies, embed learning and bring learning to life. Following are a variety of techniques, along with “I CAN” examples, that students and instructors can employ to make learning and teaching more memorable.
L i s t Provide a series of words, names or items of relevance I CAN list the signs and symptoms of shock. I CAN list them to a related topic. out loud or to myself for practice.
D e s c r i b e To create a mental picture through a detailed I CAN describe the different types of wounds so that a description. listener can visualize each type clearly.
P a r t i c i p a t e Being actively involved, taking part in, joining in, I CAN participate at the refresher with my whole self: my sharing and adding to a discussion or comments. mind, my hands and my heart. When I participate fully I am better prepared to use my emergency care skills.
P e r f o r m To carry out or execute an action, an exhibition I CAN perform the steps necessary to set up oxygen for of a skill. a patient.
P r a c t i c e To carry out, perform or apply a skill in a classroom I CAN practice applying splints at my refresher so that setting; to do repeatedly in order to learn or become proficient. I am prepared for an emergency situation.
D e m o n s t r a t e Through physical actions reveal, make obvious I CAN demonstrate how to perform a full-body survey to or exhibit a skill. Make clear by showing examples. my fellow OEC technicians. i D e n t i f y / N a m e Be able to recognize, list or I CAN name or identify the major organs of the body. classify items.
I n t e g r a t e To put together, include, incorporate and I CAN integrate the people needed to work a mass assimilate several components together. casualty incident.
D i s c u s s To discuss, consider and argue the pros and I CAN discuss “You Are the Rescuer” incidents at the cons of; to support with reasoning and evidence. refresher. These discussions provide an opportunity for active problem solving practice and gaining perspectives from fellow OEC technicians.
E x p l a i n To make clear and understandable through meaning, I can explain to new OEC technicians the proper technique to give explanation. for loading a patient into a toboggan.
C o n s i d e r To think about carefully, to examine and think I CAN step back from an incident for a brief moment to about in order to understand. consider the best care for a patient.
R e v i e w To look at, look over or re-examine. I CAN review the materials in my Refresher Study Guide before the refresher so that I am properly prepared the day of my refresher.
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008 Cycling 101
e are all familiar with the term “OEC Refresher Cycle” T h e C y c l e - s P e c i f i c t o p i c a r e a s a r e : and realize that there is a Cycle A, Cycle B and Cycle ✚ Orthopedic Trauma WC. But some have lost track of how the cycle content is ✚ Environmental & Medical Emergencies organized and related. ✚ Specific Injuries By definition, the use of the term “cycle” implies that there is a sequence of events involved in our annual refresh- Integrated Topics are applied throughout all refresher cycles ers, and, at some fundamental level, a relationship exists as appropriate to content or scenarios. between the components. Additionally, use of the designa- tions “A, B and C” implies an order in both sequence of the I n t e g r a t e d T o p i c s a r e : material and summation of parts required for completion. ✚ Body Substance Isolation Each portion of a refresher represents approximately one- ✚ Pediatric Considerations third of the Outdoor Emergency Care content. Therefore, ✚ Adaptive/Special Populations after completion of Cycles A, B and C, Outdoor Emergency ✚ Transportation and Extrication Care technicians have reviewed the entire set of critical components required for the OEC technician credential. The The material assembles into the chart on page 7 by title. A annual refresher not only represents one-third of the cur- complete table with integrated objectives is available on-line riculum, it is also comprised of content areas that are inter- at www.nsp.org under “OEC Supervisor Resource” on the related and repetitive. Each year, your refresher is comprised member side. Cycle-specific objectives are also provided in the of Annual Topics (with Focus Areas), Cycle-Specific Topics cycle-specific Instructor’s Guide each year. and Integrated Topics. There are six Annual Topics that are the same for Cycle A, Cycle B and Cycle C. This material is of such importance Cycle C Objectives and Activities that the objective of the material is repeated every year, with two of the six being featured in-depth with additional con- Cycle B Objectives and Activities tent as a Focus Area. One mechanism utilized to call atten- tion to the Focus Areas is a mini-presentation. Annual Topics (with Focus Areas designated by Cycle) are: Cycle A Objectives and Activities
a N N u a l T o p i c s a n d O b j e c t i v e s Focus Annual topic Cycle A: Shock Management Cold Injury Management Cycle A • Shock Management Cycle B: Common Outdoor Injury Management • Cold Injury Management Neurological Injury Management Cycle C: Patient Assessment & Vitals
Cycle B • Common Outdoor Injury Management Airway Management & O2 Administration • Neurological Injury Management C y c l e – s P e c i f i c T o p i c s a n d A c t i v i t i e s Orthopedic Trauma Cycle C • Patient Assessment/Vitals Environmental & Medical Emergencies • Airway Management/O2 Administration Specific Injuries Transportation and Extraction
Cycle-Specific Topics are conserved in title each year but i N t e g r a t e d T o p i c s have content that is specific to the refresher cycle. So every Body Substance Isolation year you’ll notice the same title, but different objectives and Pediatric Considerations activities. Adaptive/Special Populations
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008 Content of OEC Refresher Cycles by Title C y c l e f o c u s a n n u a l t o p i c s ( C y c l e a , B a n d C ) Cycle A • Shock Management • Cold Injury Management
Cycle B • Common Outdoor Injury Management • Neurological Injury Management
Cycle C • Patient Assessment & Vital Signs
• Airway Management & O2 Administration
C y c l e - s P e c i f i c t o p i c s T o p i c T i t l e C y c l e a C y c l e b C y c l e C
Orthopedic Trauma • Upper Extremity • Injuries to the Pelvis, • Lower Extremity Injuries, Injuries at Hip and Femur, and Injuries, General or Near Joints, Traction Splinting Management and Open Fractures Alignment of Displaced Long-Bone Fractures, Ski Boot Removal
Environmental & • Major Medical • Environmental Injuries • Common Medical Medical Emergencies Emergencies • Water Emergencies Complaints • Snowsports • Poisoning Emergencies • Trauma in Pregnancy
Specific Injuries • Burns • Review of the • Chest Injuries • Bleeding Anatomy and • Mass Casualty • Bandaging Physiology of • Face, Eye and Throat the Digestive and Genitourinary Systems • Standing Backboard • Helmet Removal
I n t e g r a t e d t o p i c s ( a pp l y a s a pp r o p r i a t e t o a l l c o n t e n t a b o v e )
1. Body Substance Isolation 2. Pediatric Considerations 3. Adaptive/Special Populations 4. Transportation and Extrication
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008
OEC Refresher Program
✚ The OEC refresher program offers OEC technicians the ✚ Allow yourself plenty of time to review the refresher opportunity to update, renew and demonstrate compe- course topics and to study the 4th edition Outdoor tency in required OEC skills and knowledge. Emergency Care references listed in this study guide ✚ The OEC technician certification is valid for three for Cycle A. years and is maintained by completing three consecu- ✚ Read the “You Are the Rescuer” section of this study tive annual refreshers. NSP members must complete guide and write down your answers to the questions each of the refreshers to maintain the OEC credential that follow each scenario. Make notes for any discussion and remain in good standing. The only NSP members points called out in questions. This year we are asking exempt from this requirement are registered candidate your instructors to write a scenario to generate discus- patrollers enrolled in an OEC course, members who sion on an incident important to your local environment complete a full OEC course after May 31 of the cur- or operation. Be sure to bring these answers, notes and rent year, and members who are registered as Medical your instructor’s scenario (if applicable) to the refresher Associates (MDs and DOs). so you can fully participate in the discussion on the ✚ A refresher does not provide a means for a person scenarios. The 2008 Refresher Study Guide and the “You with previous emergency care or medical training to Are the Rescuer” section are also available as Word and challenge the OEC course, since only one-third of the PDF documents in the “Outdoor Emergency Care” sec- curriculum is addressed. tion of the NSP website. ✚ An NSP member needing to renew active status from an ✚ Use the skill guides in Appendix B of the OEC 4th inactive registration or a missed patrolling season must edition text to review and practice the skills you will complete the refresher cycle(s) missed during the inac- be asked to demonstrate during this year’s refresher. tive period and pay dues for the missed season(s). (Speak ✚ Access www.OECzone.com to review the many online with an instructor if you have a current OEC certification resources (tools, videos and activities) available to you. and need to take a make-up refresher.) ✚ Thank you for being responsible for your own learning and ✚ Other training, such as local patrol or area needs, chairlift record keeping! Remember, you own the card. evacuation, CPR, AED and other on-the-hill training, is usually provided by your local patrol or area represen- B e S u r e t o B r i n g tative. These are not part of the OEC refresher course ✚ The 2008 Refresher Study Guide with your “You Are the requirements. The NSP is not responsible for the content, Rescuer” answers and discussion notes. instruction or scheduling of local patrol training. Each ✚ Your current OEC, CPR and NSP member cards. patroller should consult with his or her patrol represen- (You can get a duplicate OEC or NSP card by sending tative, area or resort for schedules, topics to be covered a check or money order for $5 [payable to NSP] to: and other requirements. National Ski Patrol, 133 South Van Gordon St., Suite 100, Lakewood, CO 80228. Allow 3 to 4 weeks for a T T e n d i n g a R e f r e s h e r delivery.) ✚ Check with your patrol, region or affiliate group to find ✚ A fully stocked aid belt, vest or pack as well as any addi- out when and where your refresher course will be held. tional items required at the refresher you’ll be attending. If you have a conflict, contact the OEC region adminis- Dress appropriately to participate in both indoor and trator or check the course calendar on the NSP website outdoor refresher activities. (www.nsp.org) under “NSP Education programs.” ✚ Please notify your patrol representative or affiliate group I m p o r t a n t o e c R e c o r d K e e p i n g leader in advance if you cannot attend your patrol or ✚ If you attend another patrol’s refresher, remember affiliate’s refresher. Prearrange attendance at another to provide your patrol representative with the OEC refresher with the instructor of record or patrol repre- Refresher Completion Acknowledgement form in this sentative for the host area. If you do attend a refresher study guide (page 24). Also make sure that the instructor with another patrol, be sure the Refresher Completion of record has all the necessary information to verify your Acknowledgement form (located on page 24) is completion of the refresher on a supplemental roster for completed and returned to your patrol director. the national office (see page 24). Necessary information
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008
includes your NSP membership or OEC technician ID number, your name as it appears in national registration Want to Know More? records, current address and patrol/group affiliation. ✚ The instructor of record of the refresher that you Have you ever encountered a concept in the OEC text that attend must sign and date your OEC card, then return just didn’t make sense? Or have you had a hard time remem- it to you. bering and visualizing all of the anatomical structures lying ✚ Be sure to complete the 2008 Cycle A Feedback form beneath the chest and abdominal wall? We are now fortunate on page 25 of this study guide. to have many resources at our fingertips to help us toward ✚ Not receiving OEC material from the NSP? Contact understanding and remembering the basis for the care we Carol Hudson at member services: [email protected] provide to our guests. or 303.988.1111 x 2637. cycle A Refresher resources are as close as your PC or textbook! All of the following are readily available for you to C P R Policy (for A c t i v e n s P M e m b e r s O n l y ) use as a tool for review or to provide a new perspective that ✚ You must hold a current professional rescuer-level CPR may bring it all in focus. certification from the American Heart Association, • See the Chapter Sweep at the end of each chapter in the American Red Cross, National Safety Council or OEC text. It includes a vocabulary review, a chapter sum- American Health and Safety Institute. (The certifying mary, a scenario to consider and questions to prompt further body need not issue a new card unless the card expires thought, as well as Points to Ponder, which tap your exten- before the start of the upcoming ski season.) sive experience as a ski patroller and challenge you to think ✚ You must demonstrate your CPR skills each season, beyond the obvious. regardless of the certifying agency’s requirements or the • See www.oeczone.com: Topical quizzes, anatomy and expiration date on the card. vocabulary challenges, activities, links to in depth EMS and medical education sites. W h a t ’s growing in Y o u r A i d B e l t ? • See www.nsp.org: Instructor Resources page for download- Have you checked the status of your emergency care supplies able PowerPoint presentations that will guide your review lately? As the new season approaches, take this opportunity to of nearly every topic in the OEC text. perform these four important tasks with regard to your first • See http://info.med.yale.edu/library/education/powerpoint. aid belt, vest or pack: clean out, update and donate. html: For help in bringing more visuals to your learning 1. Clean out the contents and organize the new and process. Also the Yale University Medical School PowerPoint old items. resource site includes free access to links for medical 2. Remove and replace latex gloves with non-allergenic images, x-rays, etc. at http://picture.med.yale.edu/ nitrile or vinyl ones. Remember that loose latex gloves imagesearch.html. will have cross-contaminated (with allergenic latex • Borrow an OEC Instructor Manual and review the pertinent proteins) any items in your pack that they came in chapter material. Frequently, supplemental instructor mate- contact with. rial is provided that is not included in the OEC text. The 3. Toss out yellowed, mildewed or aging bandages, outline format also facilitates a quick review process. cravats, etc. 4. Donate your older (non latex) items for use at the refreshers or OEC training classes.
You don’t have to start every season with completely new materials, but you should remove any soiled, aged and out- dated items. Ask yourself, “Would I want this article used on me or my family members?” You don’t want to get to your first incident of the season without gloves or with gloves that “blow-out” as you try to put them on. Items that aren’t up to standard might be suitable for practice/classroom settings, so evaluate possible donations before you throw them out. Now ask your fellow OEC providers, “What’s in your aid belt?”
R e f r e s h e r S t u dy g u i d e National ski patrol 2008 C y c le A 2008 “I CAN” Refresher Objectives
Annual Topics Cycle-Specific Topics
P a t i e n t A s s e s s m e n t a n d V i t a l S i g n s O r t h o p e d i c T r a u m a ( i n - d e pt h t o p i c ) ✚ I can manage both open and closed upper extremity ✚ I can perform a focused history and physical exam injuries that are at or near a joint such as: shoulder on a responsive medical patient. girdle; elbow; wrist and forearm; hand; humerus. ✚ I can perform a rapid body survey. ✚ I can obtain vital signs rapidly and accurately. E n v i r o n m e n t a l a n d M e d i c a l E m e r g e n c i e s ✚ I can perform a full assessment, identify and treat the A i r w a y M a n a g e m e n t a n d O x y g e n patient suffering from: heart attack; stroke; diabetes; a D m i n i s t r a t i o n ( i n - d e pt h t o p i c ) seizures; substance abuse. ✚ I can properly assemble, set up and administer oxygen ✚ I can list signs and symptoms and specify the manage- with all delivery devices including: airway adjuncts ment of injuries associated with activities offered at my (BVM, oral and nasal pharyngeal airways, pocket masks); ski area such as: tubing; snowmobiling; other activities. suctioning; assisted ventilations. ✚ I can dissemble the tank after use. s P e c i f i c I n j u r i e s ✚ I can demonstrate the emergency care for thermal burns. S h o c k M a n a g e m e n t ✚ I can demonstrate several techniques to control bleeding ✚ I can describe the anatomy and physiology of the and manage soft tissue injuries. circulatory system. ✚ I can demonstrate general bandaging techniques on the ✚ I can recognize and describe the different kinds of shock head, torso and extremities. and their contributing factors. ✚ I can demonstrate ways to prevent and manage shock i n T e g r a T E D T O P i c s
(administer O2, prevent heat loss, position and secure ✚ I can protect myself and my patient by initiating scene patient, and provide rapid transport). safety and using BSI precautions. ✚ I can consider the appropriate care of pediatric patients, C o l d I n j u r y M a n a g e m e n t whether actual or implied. ✚ I can describe the body’s heat production mechanisms. ✚ I can modify my communication, assessment and care to ✚ I can list the causes, signs and symptoms for hypothermia serve the needs of adaptive and special patients. and frostbite. ✚ I can safely and correctly demonstrate “jams and pretzels” ✚ I can demonstrate how to manage patients with hypo- extrication techniques for the three anatomical positions thermia and frostbite. (prone, supine and side-lying) and in doing so use: long axis drag; log roll; toboggan loading. C o m m o n O u td o o r I n j u r y M a n a g e m e n t ✚ I can assess and manage knee injuries and tibia and fibula fractures. Not Using the OEC 4th N eurological I n j u r y M a n a g e m e n t ✚ I can assess the need for placing a patient on a backboard. Edition? Why Not? ✚ I can properly place, position and secure a patient on a How could we justify not using the updated techniques backboard. proven to improve the outcome of our patients? Did you know that new textbook editions have been released about every five years? This is about $10 a year—probably less than you spend on gloves.
R e f r e s h e r S t u dy g u i d e 10 National ski patrol 2008 C y c le A 2008 Cycle A Topics and Resources T o p i c C h a pt e r (OEC 4th edition) S k i l l G u i d e s (Appendix B, OEC 4th edition) Annual Topics Assessment (In-depth topic) Chapters 7 and 30 • Perform focused history and physical exam on responsive medical patient (pg. 844) • Perform rapid body survey (pg. 845) • Practice obtaining vital signs (pg. 836)
Airway Management and Chapter 6 • Administration of oxygen (pg. 839) Oxygen Administration • Oropharyngeal and nasopharyngeal (In-depth topic) airways (pg. 837) • Suctioning of the oral cavity (pg. 838) • Use of pocket mask for artificial ventilation (pg. 840) • Use of bag-valve mask for artificial ventilation (pg. 841)
Shock Management Chapter 9
Cold Injury Management Chapters 2 and 15
Common Outdoor Injury Management Chapters 14, 24 and 25
Neurological Injury Management Chapter 26
Cycle-Specific Topics Orthopedic Chapters 24 and 25 • Assess and immobilize shoulder, upper arm, (Upper extremity injuries, injuries elbow, forearm, wrist and hand injuries at or near joints, open fractures) • Manage injury at or near joint (pg. 848) • Manage open fracture (pg. 849)
Environmental and Medical Emergencies Chapters 13 and 14 • Signs and symptoms, causes and emergency (Major medical emergencies and care for major medical emergencies snowsports emergencies)
Specific Injuries Chapters 8 and 19 (Burns, bleeding and bandaging)
Integrated Topics Body Substance Isolation Chapter 2 Pediatric Considerations Chapter 30 Adaptive/Special Populations Chapter 31 Transport and Extrication Chapter 3 and 27 • Jams and pretzels (pg. 855)
R e f r e s h e r S t u dy g u i d e 11 National ski patrol 2008 C y c le A 2008 You Are the Rescuer Discussion Resources
our scenarios have been selected for the “You Are the They are based on actual incidents. Using the matrix below, Rescuer” (YATR) exercise, one of which is an invita- formulate your opinions on the leading questions. Potential Ftion for you alone, or with the help of an instructor, to discussion points have been suggested for each question, but write your own. Regardless of where the incident actually these should not be considered comprehensive. occurred—on a ski slope, in a river or on a hiking trail—the Remember there are many correct answers. “Solving assessment and basic emergency care remain essentially the the problem” is not the objective; exploring all possibilities same. Each OEC technician should have read every scenario through discussion is. Always consider how these scenarios and formulated an opinion as to his or her proposed actions. could differ at your particular location and be ready to discuss Carefully read the scenarios on the following pages. the possibilities at your refresher course.
L e a d i n g q u e s t i o n s Discussion p o i n t s As you approach this patient, Describe and discuss what you would do to: what are your priorities? • Ensure scene safety • Manage the scene • Assess the patient
What possible problems do you Identify potential problems and the signs and symptoms of each. think the patient may have?
What resources might you need For example: to manage this patient/situation? • Equipment • Human resources • Resources needed at base
What emergency care does this Describe and discuss: patient require? • Immediate emergency care needs • Needs during transport • In the patrol room • Important considerations
What problem(s) might you encounter For example: as you manage the scene? • Complications with patient • Crowd control • Challenging terrain
What are your transport considerations? For example: • From the accident scene to the base facilities • ALS/BLS? • Air ambulance?
How would your emergency care of this patient differ had it occurred in a different season or while doing a different activity?
R e f r e s h e r S t u dy g u i d e 12 National ski patrol 2008 C y c le A 2008 Scenario 1 Bryan jimi frances RAY
t’s a warm morning, and you and your sailing mate are N o t e s sitting in the cockpit of your sailboat at anchor in a small, Iunpopulated harbor. You notice a pair of divers approach in their small boat and anchor nearby. They have their dive gear ready to go, and in no time, with their regulators in their mouths, plunge into the water. Minutes later you notice one of the divers frantically waving and yelling. Upon closer look you see the female diver has the male by the collar of his jacket, and you notice something on his head. You and your companion grab the first aid kit on board, jump into your dingy and head over. As you get closer, you see that the male diver is bleeding profusely from a large scalp wound, yet he is responsive and thrashing in the water. Upon reaching the divers you find the woman frustrated, as she is unable to lift him into the boat. Thankfully she has inflated both her jacket and that of her dive partner, so he is buoyant. Since your arrival the male has started to calm down, though he is still unable to hoist himself into the boat. You radio the Coast Guard for assistance, but they are a mini- mum of 45 minutes away. The woman tells you they had turned on their tanks before leaving shore during a buddy check, but had turned them off for the ride over. It wasn’t until they were descend- ing that they realized they had forgotten to turn their tanks back on. Her partner had descended quite quickly, and shot for the surface when he realized his mistake. Failing to look up, he crashed head-first into the propeller shaft of the boat’s motor. Rescue Tip: Immersion hypothermia develops rapidly because The male starts to shiver. Though the water is calm, the of the ability of cold water to conduct heat away from the body shoreline is rugged and rocky, so the injured man cannot be about 25 times more rapidly than cold air. transported to shore. You are concerned for spinal consider- —OEC 4th edition, page 471 ations but have nothing that can be used as a backboard.
R e f r e s h e r S t u dy g u i d e 13 National ski patrol 2008 C y c le A 2008 Scenario 2 ala b ari taylor K greg
t’s an overcast day with temperatures hovering around 20ºF N o t e s and a cold northern wind at 15 mph. You receive a report Iof a downed skier at the top of an intermediate run. You’re told that the skier is a 55-year-old male paraplegic in a sitski who is complaining of intense pain in his left shoulder. On approach to the scene you notice a strongly carved track leading past a small group of bushes. The track seem- ingly ends there, followed by a large, obvious sitzmark in the snow. On arrival at the scene, you find a skier strapped into a sitski lying on his left side. The skier is in obvious pain, but acknowledges your arrival and asks for help. You note that the skier appears to be short of breath, and that his left arm is severely abducted, with a broken outrigger still attached around his forearm. Your scene size-up concludes that the scene is safe, and you have a single patient. You mark the scene and immedi- ately assess the patient’s breathing. At this time, the skier asks you to loosen the strap around his chest, as it is too tight in his present position. On loosening the strap, the skier affirms that he can now breathe more easily. As you continue your assess- ment, he tells you that he caught his outrigger in the brush as he made a turn. His arm, affixed to the outrigger, was pulled away from his body and behind him. He lost control of the equipment as his ski lost its edge. He heard and felt a “pop” as his arm was pulled away from his body, and then heard a second “pop” as he slid to a stop. His arm, still strapped into his outrigger, was trapped over his head. Your focused history and physical exam reveals deformity of the left shoulder. The skier tells you that he dislocated his right Rescue Tip: Some patients with dislocated shoulders occasion- shoulder in a biking accident the previous summer, and that it ally report numbness in the hand or skin over the deltoid muscle felt a lot like this. Vitals are within an expected range, but there is because of nerve or circulation compromise. a significant strength deficit in his left hand. Since loosening the —OEC 4th edition, page 617 strap around his chest, his respirations are now robust.
R e f r e s h e r S t u dy g u i d e 14 National ski patrol 2008 C y c le A 2008 Scenario 3
an approximately 45-year-old male alone in the chair and slumped over the safety bar. He has no detectable breath and no palpable pulse. There are no other patrollers immediately available, and none can reach the scene by skiing from the top of another lift. The lift operator states that he completed the pre-season Outdoor First Care course taught by the patrol, and about a dozen other untrained guests are nearby.
N o t e s ari taylor K
t’s 20:15 on a clear, breezy night with a temperature of 10ºF when you are called by the top lift operator, who is report- Iing an unresponsive skier in the chairlift at the off-ramp. You race from the patrol facility to the off-ramp and find Scenario 4
n the past, you’ve been presented with several scenarios for and apply them to your scenario. Think about the major top- discussion. You were provided the details of an actual inci- ics of scene safety, assessment, emergency care (equipment Ident and asked to respond to discussion points with fellow and helpers), extrication and transportation. Be realistic here rescuers. This year, to challenge you in a slightly different way, and have some fun with it—you never know when it might we are asking you to write your own scenario. actually happen. Here’s how: Think of a specific location at your home Feel free to share and discuss this scenario with your fel- area where an accident could happen. Keeping in mind the low rescuers. Also, ask your instructors if they might stage cycle-specific topics for this year’s refresher, imagine a worst- this incident at a future training session or on-the-hill clinic. case scenario—literally. What type of incident could happen As an alternative, if you would prefer to write up an actual at this location? Would it be a great challenge to you as the incident for your refresher course that occurred at your area, first person on scene? which falls into the topic areas being covered at this years’ Take into consideration the gender, age and physical con- content, feel free to do so. Try to choose one that was chal- dition of your patient or patients. What would the weather be lenging for you. like? Would the accident be due to a collision, a fall, a medical condition? How much help would you have available? What N o t e s type of equipment would be available or needed? How soon would help arrive? If you would like, draw a stick figure sketch of what the scene would look like upon your arrival (similar to the pho- tos provided in the YATR scenarios). Describe the condition of your patient and what you would expect to find in your assessment. Then note how the patient’s condition would change if help was unavailable. Refer to the points for discussion in the other scenarios
R e f r e s h e r S t u dy g u i d e 15 National ski patrol 2008 C y c le A 2008 Refreshments
he following are additional study pages offered as food for Without an adequate amount of functional insulin, glucose thought. Although you’re not required to write down the builds up in the blood and never enters the cells where it is T emergency action you’d take, as with the “You Are the utilized. The cells essentially starve and suffer cellular injury Rescuer” scenarios, this material is included to refresh your or death. Each event of elevated blood glucose level (blood memory and stimulate your interest in other Cycle A subjects. sugar level) is a likely indication of cellular starvation that ultimately results in organ damage, such as blindness, heart disease, kidney failure and nerve disorders. Complications of Diabetes Mellitus: DM are the leading cause of adult blindness and chronic renal failure in the United States. The Silent Killer The normal blood glucose level is around 80 to 120 Diabetes mellitus (DM) is a disease of the endocrine system mg/dL. In the body’s attempt to lower the build-up of glu- with broad-reaching negative effects on many of the body’s cose in the blood (hyperglycemia ) at levels in excess of organ systems. Though, as OEC technicians, we infrequently 200 mg/dL, the kidneys begin to excrete water, glucose and confront diabetic emergencies, we all recognize the potential all other water-soluble substances found in blood via urine. for encountering this truly urgent and life-threatening medi- Until control is achieved through the supply of an adequate cal emergency. According to the Centers for Disease Control amount of functional insulin and/or decreased dietary intake and Prevention (CDC) in 2005, 7 percent of the U.S. popu- of carbohydrates, the body will: continue to produce frequent lation, or 20.8 million adults and children, have DM and are and plentiful urine (Polyuria); experience insatiable thirst and frequently within our realm of care. frequent drinking of liquids (Polydipsia); and sense excessive Type 1 DM is thought to be caused predominantly by hunger due to cellular starvation (Polyphagia). These are the a destructive autoimmune response against the islet cells of “3 Ps” of uncontrolled DM. the pancreas. Onset typically occurs before age 30, and some In uncontrolled DM, the body begins to metabolize fat as degree of genetic predisposition is reported to be associated an alternative energy source. Among other substances, ketones with certain Human Lymphocyte Antigen types. Patients with and fatty acids can accumulate at dangerous levels. They are type 1 DM produce very little, if any, insulin (a hormone) and byproducts of fat metabolism that are very difficult to excrete. become insulin-dependent for life. Type 2 DM causative fac- A build-up of fat metabolites results in acidosis or, in DM, tors are more lifestyle dependent and manifest with inadequate diabetic ketoacidosis. Hallmarks of diabetic ketoacidosis are a secretion of insulin, peripheral insulin resistance, and/or sweet, fruity breath odor (similar to Juicy Fruit gum), warm increased liver release of glucose in the blood. Onset generally and dry skin, vomiting, abdominal pain, normal or rapid and occurs after age 30, but recent studies indicate a significant full pulse, and deep and rapid breaths. If not treated with increase of type 2 DM among U.S. children that is attributed to childhood obesity. Risk factors for type 2 DM are obesity, inactivity, high triglycerides (>130 mg/dL), a high ratio of triglycerides to high density lipoprotein, and positive family history. Type 2 DM generally responds to diet, exercise and oral medication to stimulate islet cell production of insulin. Many patients with type 2 DM are able to stop all medication after strictly adhering to a regimen of diet, exercise and weight oche loss. Others are unable to control type 2 DM solely with oral R medication and require supplemental insulin.
All cells need glucose to function properly, and some cells courtesy of will not function without normal levels of glucose. Without a constant source of glucose, or with very low levels, brain cells rapidly suffer permanent damage. Insulin is the “cellular key” to facilitate the entry and utilization of glucose in the cell. In type I diabetes, most patients do not produce insulin at all; they have insulin- Insulin released into the blood is removed by the liver within dependent diabetes mellitus. To control blood glucose, daily injections of supple- 15 minutes, so a constant steady supply of insulin is necessary. mental, synthetic insulin are needed to control blood glucose.
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unconsciousness and death are rapid, occurring over a period of minutes to hours; onset is rapid and minutes truly make a difference in the outcome. The emergency care for hyperglycemia or hypoglyce- mia is to follow the standard approach to initial assessment by checking the patient’s level of consciousness, verify an open airway and adequate breathing, and, as needed, establish an airway, provide oxygen or assisted breathing, and moni- tor. Perform a focused history, physical exam and obtain a oche
R SAMPLE history from the patient, family member or bystander to learn whether the patient: ✚ Has overeaten recently but has not had the usual courtesy of intake of medication, or has been ill or had alcohol (hyperglycemia); ✚ Has not eaten regularly but has the usual intake
Glucose is the major source of energy for the body, and all cells need it to function of medication (hypoglycemia); properly. A constant supply of glucose is as important as oxygen to the brain. ✚ Has been ill (hypoglycemia); Insulin is needed to allow glucose to enter individual body cells to fuel their ✚ Has been exercising more than usual (hypoglycemia); functioning. Shown here: A compact blood glucose meter with integrated test ✚ Has taken too much insulin (hypoglycemia). strip drum and lancet device for documentation of blood glucose levels.
Look for an emergency medical identification symbol on a intravenous fluids and insulin, the acidosis progresses and results bracelet, necklace or wallet card. Do not discount the pos- in cell damage, unconsciousness (diabetic coma) and death. sibility of other illness or injury in conjunction with or When DM is diagnosed early and is well controlled, mimicking a diabetic emergency. Most often the diabetic patients live relatively normal lives and can minimize organ patient can tell exactly what is happening and can be assisted damage over a long period of time. Careful control is in accessing their own glucometer (a pocket-sized device that achieved through adherence to a customized diet and intake measures glucose levels in blood from a finger stick), their of supplemental insulin or intake of oral medication to stimu- own medications, or glucose. If the patient is conscious and is late insulin production by the pancreatic islet cells. able to swallow, but is unable to provide direction to resolve A number of events may upset the careful balance their condition and a glucometer is not available, administer achieved by a well controlled diabetic and result in a diabetic glucose in liquid or gel form (if approved by the mountain emergency, requiring rapid response by the OEC technician. management, and if authorized for use by First Responders A diabetic who has taken too little medication, has overeaten in your state) regardless of whether you suspect hypergly- significantly, is stressed by an infection, illness, over-exertion, cemia or hypoglycemia . If the patient is hyperglycemic the fatigue or alcohol may suffer an elevated blood glucose or additional glucose will not do significant harm over the short hyperglycemia and exhibit the signs and symptoms of keto- term. If instead the patient is hypoglycemic, the administra- acidosis noted above. The progression toward ketoacidosis and tion of glucose may be life-saving. Do not administer glucose diabetic coma occurs over a period of hours or days; it does in solid form, such as candy, which can easily be aspirated if not occur rapidly. the patient exhibits a decreased level of consciousness. Since Conversely, the carefully balanced diabetic may have had little absorption of glucose occurs through the mucous mem- too little dietary intake for the amount of medication taken, branes of the mouth, but instead must be swallowed to be had physical activity of an unusual length, intensity or in effective, DO NOT administer glucose in ANY oral form to the cold environment, been ill, vomiting or unable to eat, or an unconscious patient and thereby risk aspiration. Monitor have taken too much insulin. All of these events may result the patient carefully and arrange for rapid transport. If the in too low of a circulating blood glucose level (less than 80 patient is conscious, offer them a glass of orange juice with mg/dL) or hypoglycemia . Typical signs and symptoms of several well-stirred teaspoons of sugar. hypoglycemia are pale and clammy skin, diaphoresis, dizzi- Glucose gel in a tube is commercially available under ness, headache, hunger, normal to rapid respirations, rapid various brand names. DO NOT administer glucose gel to and weak pulse, anxiety, lethargy, confusion, hypoglycemic any unconscious patient. A conscious patient who is hypo- seizures, unconsciousness and death. The progression toward glycemic or a conscious patient whose blood glucose level
R e f r e s h e r S t u dy g u i d e 17 National ski patrol 2008 C y c le A 2008 is undetermined, yet is exhibiting signs and symptoms of a misbalanced glucose level, should rapidly receive glucose gel or Wounds and Wound Care liquid (if approved by the mountain management, and if autho- Open wounds are a common injury that are encountered by rized for use by First Responders in your state). Minutes count! OEC technicians and are often the most obvious sign that 1. Examine the tube for a broken seal or cracks and a patient has been traumatized. While most wounds are not confirm the tube has not expired. life-threatening, they can signal more serious underlying con- 2. Put on gloves. Grasp a tongue depressor and squeeze the cerns. While the basics of wound identification and care are entire contents of tube onto the distal third of the stick. universal, the focus of care can vary for front-line emergency 3. Ask the patient to open his or her mouth. medical care providers with quick access to definitive medical 4. Place the tongue depressor and gel in the pocket care, and those providers who may be providing care within between the cheek and lower gums. a wilderness setting where access to definitive care can be at 5. Remove the tongue depressor if the patient becomes least 24 hours away. A basic understanding of the physiol- unconscious or has a seizure, or once the gel has ogy of wounds and wound care is a must for all Outdoor dissolved. Emergency Care technicians, as is the ability to determine the type of care needed for a specific wound. For the sake of Prevention or careful control of DM is the key to a long and this article, OEC technicians who provide care when medi- healthy life. According to the CDC, almost 7 million people cal follow up is readily available will be referred to as “quick have DM but don’t know it yet. In 2007, $174 billion was care” providers; those who may be responsible for providing spent either directly or indirectly for the care of DM, a 32 patient care for 24 hours or more due to extrication difficul- percent increase since 2002. One in every five U.S. health ties (i.e., mountaineering or river guides) will be referred to care dollars is spent caring for someone with DM. Type 2 as “extended-care” providers. DM may be preventable through about age 60 by adhering Wounds can be categorized into two main types: open or to a low fat diet, engaging in aerobic exercise and receiving closed. Open wounds include abrasions, avulsions, lacerations, regular check-ups. punctures and penetrations, and amputations. Closed wounds R e s o u r c e s include contusions, hematomas, or any injury that occurs ✚ Bowman, Warren D., MD FACP, and Johe, David, MD, beneath the skin or mucous membrane but leaves the overly- Outdoor Emergency Care, 4th ed., 2003. ing surface (skin) intact. Stretch and crushing injuries may be ✚ Mistovich, Joseph J. and Karren, Keith J., Prehospital either open or closed. Emergency Care, 8th ed., 2008. The objective of wound care for both quick and extended- ✚ Beers, Mark H., Porter, Robert S., and Jones, Thomas V., care providers is the same, although some components of care The Merck Manual, 18th ed., 2008. are different for the extended-care provider. ✚ American Diabetes Association, www.diabetes.org. Wound management can basically be summarized into the following steps. 1. Body substance isolation (BSI) 2. Control bleeding 3. Protect from further damage 4. Prevent further contamination* 5. Decrease the risk of infection* 6. Promote healing 7. Reduce the need for evacuation* * Indicates variation in care for quick and extended-care providers.
In order to provide the best care possible for wounds, OEC technicians must have a basic understanding of the anatomy and physiology of the areas injured. A review of Outdoor Emergency Care, Chapter 19 (Soft Tissue Injuries) can provide a great deal of insight and understanding into wound care. Basically the skin is divided into two primary layers. These are the tough, outer layer(s), the epidermis, and the underly- ing inner layers, the dermis. selko photo
R e f r e s h e r S t u dy g u i d e 18 National ski patrol 2008 C y c le A 2008
should never sever a partial amputation. If an amputation is complete, the part should be wrapped in sterile gauze, moist- ened with sterile saline (if available), placed in a Ziploc® bag and kept cool (one part ice to four parts water) and sent to the medical facility with the patient. Do not place the ampu- tated part directly on ice. Penetration involves damage from a sharp, pointed object, which can do massive underlying damage. In addition, puncture wounds run a high risk of infection due to the fact that they do not self-cleanse well and can entrap pathogens beneath the skin. Another type of soft tissue injury is a crushing injury, which can cause significant tissue necrosis, impaired healing and an increased risk of infection. Along with this, a condition known as crush syndrome can occur. This happens when (for example) a limb is crushed for a lengthy period of time (sev- eral minutes to hours). When the entrapped limb is released, the build-up of toxins within the affected area is absorbed into the bloodstream, causing toxic shock. Thus, patients who are removed from this type of lengthy entrapment should be in the care of advanced level medical providers (i.e., on-scene paramedics, trauma physicians). bb Stretching injuries often involve underlying tissues and cause nerve damage. Bleeding from these injuries can be Brian w. ro Wounds can be categorized into two main types: open or closed. Open wounds include fairly severe and is evidenced though massive ecchymosis abrasions, avulsions, lacerations, punctures and penetrations, and amputations. (bruising). The basics of wound care for all providers include the The epidermis is the water-tight covering and “first line following. of defense” for the body. It contains the pigments that provide 1. Body substance isolation skin color and consists of cells that are constantly sloughed off 2. Controlling bleeding (through direct pressure, elevation, and replaced. The dermis contains the structures that affect dressing and splinting or pressure point pressure skin function and appearance including the hair follicles, if needed) sweat and sebaceous glands. Body orifices (nose, mouth, anus 3. Dressing the wound appropriately and vagina) are covered internally with mucous membranes 4. Splinting the wound (if large or severe) to minimize and not skin. further tissue damage Disruption to the integrity of the skin can occur for 5. Follow-up with appropriate medical care varying reasons, including blunt and penetrating trauma. In 6. For large or severe wounds or those with potential an abrasion, the outer layer is rubbed off by friction. While underlying trauma (i.e., chest or abdominal wounds, in itself usually non-life threatening unless it covers a large severe burns) shock intervention is essential (02, splinting percentage of the body (20 percent or more), it is extremely and bandaging as appropriate, minimize heat loss, painful and opens the skin to infectious matter. Lacerations rapid extrication) are smooth (often referred to as incisions) or jagged cuts caused by sharp objects or, at times, blunt force that can cause Beyond superficial cleaning, sterile or clean dressing, and the skin to “split.” These injuries vary in depth and severity. maintaining BSI (to protect both the rescuer and their Avulsions occur when the varying tissue layers separate but patients), quick-care providers generally do not provide are not severed from the surrounding skin. In an amputation further wound care. Improper cleaning or debridement of a there is complete severance of the part, which could include wound can exacerbate injury, increase tissue damage, and thus layers of skin, a digit, nose, lips, external genitalia or limbs. is not recommended for this level of care. The use of caustic Partial amputations are amputations that are nearly complete disinfectants (i.e., alcohol, betadine, hydrogen peroxide) kills yet connected by a piece of tissue. Since it may be possible normal skin cells at the same time they kill bacteria, and to re-attach severed parts, rapid treatment and extrication to scrubbing with abrasives (i.e., rough gauze) can increase tissue definitive medical (surgical) care is warranted. Field providers damage. However, those OEC technicians who find them-
R e f r e s h e r S t u dy g u i d e 19 National ski patrol 2008 C y c le A 2008 Controlling Bleeding from a Soft-Tissue Injury 1 2
Apply direct pressure with a sterile bandage. Maintain pressure with a roller bandage.
3 4 4th ed. OEC If bleeding continues, apply a second dressing and roller bandage over Splint the extremity. the first, and apply pressure to the corresponding arterial pressure point. selves providing longer term care (extended-care providers) flushes small particulate matter from the wound. Depending may need to take further steps to minimize the chance of on wound size, up to 1L of irrigant may be required for this infection for their patient. type of mechanical cleaning. Because irrigation can cause the First and foremost, a dirty wound should never be closed. solution to spray back, it is imperative that BSI, including face Closing the overlying skin provides a perfect environment for protection (i.e., mask, shield, glasses) be used. bacterial growth. Whenever possible, sterile dressings should While follow-up with definitive medical care is good be used for direct wound contact and be covered with clean advice to give any patient cared for by an OEC technician, an roller gauze. Soaking a wound does not adequately clean it, so, extended-care provider should be able to differentiate those unlike the quick-care provider, extended-care providers may wounds that require rapid transportation from those that can find themselves needing to clean a wound more thoroughly. wait. Among those wounds that might require rapid trans- Although sterile saline (available where contact lens solu- portation are scalp wounds with significant bleeding, certain tions are sold) is the preferred solution for cleaning an open chest and abdominal wounds, or significant hand lacerations, wound, clean water (from municipal tap or water bottle) may including de-glovings. The most common cause of hand inju- be the only substance available and is an acceptable alternative. ries in wilderness settings are those caused by crushing, falls, Irrigating the wound with a moderate force of the solution sharp object lacerations (knives, hatchets) and rope injuries. (7-8 psi) significantly reduces wound bacterial counts while it Another type of serious injury is a ring avulsion. This can
R e f r e s h e r S t u dy g u i d e 20 National ski patrol 2008 C y c le A 2008 occur, for example, when a climber falls and the ring on a sified as minor, moderate or critical. The assessment is made finger catches on a crack in the rock, causing the overlying based on the depth, extent and location of the injury. skin to be forcibly removed or avulsed. This, and penetrating ✚ Minor: Partial thickness involving less than 10 percent (i.e., knife) wounds, can damage digital nerves. In short, if of total body surface area the CMS assessment shows a hand wound with any evidence ✚ Moderate: Partial thickness involving 10-20 percent of of neurovascular functional compromise, then the situation total body surface area mandates evacuation for definitive care. Open wounds of ✚ Critical: Full or partial thickness covering 20 percent this nature should be cleansed and bandaged in a position or more of total body surface area and/or involving of function (fingers in slight flexion at the interphalangeal the hands, face, feet, airway and genitals. It is critical to joints and in 90o of flexion at the metacarpophalangeal joints remember that facial burns can involve the upper airway, which maintained by placing bulky gauze in the patients palm and can subsequently swell shut. separating the fingers slightly with gauze). Separating dig- its that have open wounds is important so the tendency to If the patient is less than 5 years of age or over 55, the burn adhere to one another is minimized. A sling and swathe or classification should be upgraded one level. similar immobilization device should be utilized. Closed injuries are characterized by contusions (bruising Truncal or chest wounds: Regardless of the cause (blunt usually caused by blunt force), ecchymosis (a blue or reddish or penetrating trauma), OEC technicians should always discoloration caused by bleeding under the skin), or a hema- maintain a high index of suspicion for internal injury. When toma (pooling of blood under the skin). In severe cases, and a hard blow is dealt to the chest or abdomen the patient in certain areas of the body, up to 1 liter of blood can pool, often exhales rapidly and violently. During exhalation the causing a massive hematoma. Thus OEC technicians should diaphragm lifts up, exposing the upper quadrant abdominal provide early shock intervention (02, splinting and bandaging organs to possible damage. Thus, a patient suffering from a as appropriate, minimize heat loss, rapid extrication). chest wound could also have a lacerated liver or ruptured In summary, the basics of wound care are: follow BSI pre- spleen. Rapid extrication on a backboard with knees bent cautions; stop bleeding; bandage and splint appropriately; and (unless a spine injury is suspected or if required for patient extricate the patient to definitive medical care. The difference comfort) and high flow oxygen are recommended. between short-term care providers and the long-term care With open or closed chest wounds, OEC technicians providers is the need to assess whether or not rapid extrica- must keep a close eye on the patient’s airway, including lung tion (from a wilderness setting) is required, and to minimize sounds. The key question to ask is, “Is air moving WELL?” Air infection by irrigating and cleansing a wound. Solid up-front or blood collecting in the pleural space is known as a pneu- intervention, combined with good bandaging and splinting, mothorax or hemothorax, respectively. A hemopneumotho- can foster rapid healing and minimize disability. rax is blood and air in the pleural space. Uncontrolled, these can lead to lung collapse and death. The use of an occlusive R e s o u r c e s dressing, administration of high-flow oxygen, and rapid extri- ✚ Auerbach, Paul S., MD, MS, FACEP, Wilderness Medicine, cation are imperative. 3rd ed., 2005. Burns: A burn is basically defined as the body receiving ✚ Bowman, Warren D., MD FACP, and Johe, David, MD, more energy than it can absorb without injury. Burns are clas- Outdoor Emergency Care, 4th ed., 2003.
Defusing the Situation
icture the scene: It’s a clear day and six inches of fresh his nose. He is screaming and pointing at another person, who is powder cover the mountain. You’re standing by the lift sitting on the snow, rubbing the side of his head. In response, the Pwatching happy, smiling skiers. Suddenly, your radio crack- seated person makes an obscene gesture at the agitated man. les. You are summoned to respond to an accident in a lower Managing a potentially hostile scene can be extremely dif- bowl. As you ski to the scene, you see a small group of people ficult and poses numerous challenges to patrollers. Knowing off to one side…and hear yelling. Clicking out of your bindings, how to de-escalate this situation requires quick thinking, a you survey the situation: One person has blood streaming from calm demeanor, and an eye for detail.
R e f r e s h e r S t u dy g u i d e 21 National ski patrol 2008 C y c le A 2008
The causes of aggressive or violent behavior are myriad and may be a reactive response (i.e., outburst of anger or It Can Happen To You…. violence due to an emotional factor), organic or structural in nature (i.e., hypoxia, hypoglycemia, head injury, stroke), or Each of these events occurred during the 2007/08 due to external factors (i.e., alcohol, drugs, carbon monoxide). ski season. Reactive responses are the most common cause of aggressive • A patroller is faced with a violent confrontation behavior, followed by external factors. Alcohol use is a com- between two dozen teenagers on the slopes. mon denominator in incidents involving violence. • A resort guest brandishes a knife during an The signs of overt or impending agitation can be obvious altercation with another guest. or subtle. Obvious signs include shouting, cursing, obscene • Shots are fired at a resort mechanic who witnessed gestures, pointing, punching the air, hitting inanimate objects, a vehicle break-in. kicking, throwing things and charging. Subtle signs of anger • A patroller is physically assaulted by a guest often precede a violent outburst and can be identified by while riding the lift. the person’s body language. These signs may be verbal or non-verbal in nature. The most common verbal signs are raising the volume, pitch or tone of one’s voice. Especially not physically intervene, as merely touching or physically ominous is when the tone suddenly increases or decreases by restraining an unconsenting party without permission is a full octave. Non-verbal indicators include: furrowing of the considered battery. If more than one patroller is present, each eyebrows; intent staring; clenching and unclenching the jaw, should escort one side of the dispute at least 30 feet from the temple muscles, or fists; or grinding the teeth. Beware the other. Ideally, combatants should be out of direct eyesight of “target glance,” in which a person casts more than one furtive one another. On an open slope, this can be accomplished by look at a specific person, object or body part within a short moving the parties and positioning them so they are facing time span. This unconscious sign frequently indicates where away from each other. This strategy is especially effective in the person will soon strike. Also pay attention to body stance, that it allows you to retain line of site contact with your fel- as a person who nonchalantly turns their profile or shoulder low patroller and both combatants. towards their opponent, a condition known as “blading,” is Once removed from the conflict maintain a normal, yet sending a signal that they are preparing to fight. friendly, speaking level, and the person often will respond Management of the violent scene begins with a careful in kind. This is important, as you do not want the person assessment of potential hazards and removing obvious threats. to project their anger onto you. Keep your hands in front The key to a successful outcome is to separate the combatants of you and in plain view. In most circumstances your hands and to employ de-escalation strategies as quickly as possible. A should be empty. Tilt your head slightly forward towards the silver tongue and a calm demeanor are powerful tools and are person and maintain eye contact while you are speaking to often all that is necessary to mitigate future problems. Begin by them. Demonstrate concern for the person’s well-being and introducing yourself and stating the purpose of your presence acknowledge their emotions by stating, “I can see you’re (i.e., “Hi, my name is…..and I’m here to help.”). Your mere upset. Tell me what happened.” As you collect information, presence can often sufficiently quell tempers long enough remain neutral and non-judgmental. Employ active listening for you to ascertain the nature of the dispute. Sometimes it skills to facilitate mutual understanding. Use phrases such as, cannot. In this event, maintain a safe distance between you “If I understand you correctly, you’re saying….” If necessary, and the hostile party(s) until you are able to establish a rap- employ distraction techniques such as, “Look directly at my port. Contact management or security for assistance, and do forehead while I examine your eyes”, “Are you hurt any- where? Show me where…” or, “Do you mind if I examine you to see if you have been hurt?” Humor, when used appro- De-Escalation Strategies priately, can also effectively reduce stress and anger levels. Aggressive or violent behavior is not an uncommon • Scene safety occurrence on the slopes. Although violence presents patrol- • Introduce self lers with unique challenges, the situation can be managed • Separate combatants (distance, line of site) successfully by carefully observing the patient for subtle clues • Remain impartial, non-judgmental of growing agitation and by employing strategies designed to • Level tone of voice defuse the situation. • Distraction techniques
R e f r e s h e r S t u dy g u i d e 22 National ski patrol 2008 C y c le A 2008 OEC Refresher Committee Mission Statement
he mission of the OEC Refresher Committee is to provide assistance to all Outdoor Emergency Care technicians so that they may effectively review Outdoor Emergency Care content and skills each year and render competent emergency care T to the public they serve. Take a moment and let us know how we can make your refresher course better.
2 0 0 8 o e c R e f r e s h e r Cathy Setzer Eastern Division Pacific Northwest Division C o m m i tt e e Boyce Park Patrol Bill Devarney Carol Fountain Greg Bala 36 Northgait Drive 120 Lincoln St 906 McKinley St. Kelly Canyon Ski Patrol Slippery Rock, PA 16057 Northboro, MA 01532-1741 Boise, ID 83712 2857 W. Meadow Lark Lane (724) 458-5451 (508) 335-9354 (208) 345-6934 Idaho Falls, ID 83402-5301 [email protected] [email protected] [email protected] (208) 522-2710 [email protected] P e e r R eview Panel European Division Professional Division John Dobson Micaela Saeftel Carol Hudson Jennifer Bryan Past OEC Refresher Karlstrasse #5 133 S. Van Gordon St. Ste. 100 Sky Tavern Ski Patrol Committee Chair Heidelberg, AE 69117 Lakewood, CO 80228 173 Nottingham Court Ed McNamara Germany (720) 963-2637 Reno, NV 89511 OEC Program Director (011) 496-214381341 [email protected] (775) 849-3370 Denis Meade [email protected] [email protected] NSP Education Director Rocky Mountain Division Michael Millin Far West Division Ann Gassman Bob Morris NSP National Medical Advisor Keith Tatsukawa 1038 Ptarmigan Run Schweitzer Mountain Pro Patrol Bruce Ries 587 N. Ventu Park Road, #E-8 Loveland, CO 80538 325231 Hwy 2 Past NSP Legal Counsel Newbury Park, CA 91320 (970) 667-8814 Newport, WA 99156 (310) 980-7716 [email protected] (509) 991-6051 D i v i s i o n o e c [email protected] [email protected] S u p e r v i s o r s Southern Division Alaska Division Intermountain Division Leslie Carter Nancy Pitstick Paul Brooks Carrie Vondrus PO Box 180 Brighton Patrol PO Box 111252 1784 N. 650 E. North Garden, VA 22959-0180 P.O. Box 71548 Anchorage, AK 99511-1252 Ogden, UT 84414 (434) 295-4463 Salt Lake City, UT 84171 (907) 346-2938 (801) 737-2829 [email protected] (801) 943-7609 [email protected] [email protected] [email protected] o e c e D u c a t i o n s T a f f Central Division Northern Division Ed McNamara Thomas Rabaglia Deb Endly Bill Cathey OEC Program Director Devils Head and Cascade Patrols 2300 Overlook Dr. 408 Tyler Way Michael Millin W. 10990 Lakeview Drive Bloomington, MN 55431 Lolo, MT 59847-8729 NSP National Medical Director Lodi, WI 53555 (952) 884-8126 (406) 273-3602 Denis Meade (608) 592-7397 [email protected] [email protected] NSP Education Director [email protected] Carol Hudson NSP Education Assistant Brigitte Schran-Brown Summit at Snoqualmie Central Patrol 21704 141st Avenue S.W. Vashon Island, WA 98070 www.OECzone.com (206) 463-3447 [email protected] R e f r e s h e r S t u dy g u i d e 23 National ski patrol 2008 C y c le A 2008 o e c r e f r e s h e r 2008 Cycle A OEC Refresher Completion Acknowledgement (Designed for use by visiting OEC technicians.) Have this form signed by the instructor of record at the refresher and return it to your NSP patrol representative, patrol director or group leader to verify that you have attended and successfully completed all requirements for the 2008 refresher. Please print.
OEC Technician Name
NSP ID #
Ski Patrol/Affiliate Group Registered With
Refresher Location and Date
Name of OEC Instructor of Record
Signature of OEC Instructor of Record
C y c le A 2008
o e c r e f r e s h e r 2008 Cycle A OEC Refresher Supplemental Roster Information (Designed for use by visiting OEC technicians.) After completing the refresher, fill out this form and submit it to the instructor of record. This will help the instructor document your completion of this year’s OEC refresher requirements for the national office. Please print.
OEC Technician Name
NSP ID #
Address
City State Zip
E-mail Address
Ski Patrol/Affiliate Group Registered With
Refresher Location and Date
OEC Instructor of Record
R e f r e s h e r S t u dy g u i d e 24 National ski patrol 2008 C y c le A 2008
o e c r e f r e s h e r Feedback for the Refresher Committee Those who created and presented your refresher want to hear from you. Please fill out and return these forms before you leave today. The page 25 portion will concentrate on course materials, while the page 27 portion provides feedback directly to your refresher. Please print legibly.
Name (optional): Number of years patrolling:
Your Patrol/Affiliate Group: Division:
Circle the following categories that best represent you: OEC EMT Paramedic Nurse MD
R e f r e s h e r s T u d y G u i d e : r e f r e s h ing your skills: Helped me prepare ______Yes ______No Do you feel your skills were adequately refreshed? Enhanced my understanding ______Yes ______No Shock management ______Yes ______No Contained pertinent information ______Yes ______No Cold injury management ______Yes ______No OEC 4th edition references useful ______Yes ______No Common outdoor injury management ______Yes ______No My patrol used the Sample Refresher ______Yes ______No Neurological injury management ______Yes ______No Patient assessment and vitals ______Yes ______No
Comments: Airway management and O2 ______Yes ______No Upper extremity injuries ______Yes ______No Injuries at or near joints ______Yes ______No Open fractures ______Yes ______No Major medical emergencies ______Yes ______No Snowsports emergencies ______Yes ______No Describe or identify the most helpful, innovative or relevant Burns ______Yes ______No presentation at this refresher. Bleeding ______Yes ______No Bandaging ______Yes ______No Body substance isolation ______Yes ______No Pediatric considerations ______Yes ______No Adaptive/special populations ______Yes ______No Transportation and extrication ______Yes ______No If you’re not using the Refresher Study Guide or the OEC 4th edition to prepare for the refresher, why not? Specifically, how could these skills have been better refreshed?
R e f r e s h e r S t u dy g u i d e 25 National ski patrol 2008 C y c le A 2008
o e c r e f r e s h e r Fun & Games
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A c r o s s D o w n 1 to give explanation and make clear through understanding 2 to repeatedly do to learn or become proficient 6 to put together several components 3 to be able to recognize and identify items 8 to create a mental picture through a detailed description 4 to execute an action or exhibit a skill 9 to make obvious by showing examples 5 to provide a series of words, names or items 10 to examine and think about carefully to understand 7 to look over or study again 8 to talk about or consider and support with
reasoning and evidence
iscuss D 8. iew v e R 7. ist L 5. Perform 4. Name 3. Practice 2. : n ow D sider n o C 10. strate n emo D 9. escribe D 8. tegrate In 6. n lai p x E 1. cross: A
R e f r e s h e r S t u dy g u i d e 26 National ski patrol 2008 C y c le A 2008
o e c r e f r e s h e r Feedback for Your Specific Refresher r e f r e s h ing your skills: E q u i p m e n t : Do you feel your skills were adequately refreshed?______Yes ______No Was adequate equipment available, in good repair and functioning? R e f r e s h e r O r g a n i z a t i o n : O2 equipment and adjuncts ______Yes ______No Was the OEC refresher well organized ______Yes ______No Intubation manikin and airways ______Yes ______No Efficient refresher flow ______Yes ______No Lower extremity splint(s) ______Yes ______No Started and finished on schedule ______Yes ______No
Adequate facility ______Yes ______No What additional equipment was needed or should be Materials presented well ______Yes ______No repaired/replaced?
How could the refresher have been improved?
P r e s e n t a t i o n s : Evaluation Sheets and You Were the presentation tools effectively utilized? Each and every year the Refresher Committee reads all of the (i.e., posters, videos, PowerPoint) evaluation sheets that are sent to the national office. With this feedback, improvements are made to the content or structure to Up-to-date and accurate ______Yes ______No meet your needs. However, the committee continues to receive Enhanced my learning ______Yes ______No a volume of feedback that cannot be acted on—the type of Positive addition to presentation ______Yes ______No feedback that can only be implemented at the local level. To this end, we’ve deployed a new evaluation sheet that’s split Well implemented by instructor ______Yes ______No into two parts—the page 25 form is sent to the national office with the completion forms for use by the Refresher Committee. What other tools could have been used better? The page 27 form is retained at the local level to better serve your needs.
R e f r e s h e r S t u dy g u i d e 27 National ski patrol 2008 C y c le A 2008
Driver’s Ed for Toboggan Handlers.
Outdoor Emergency Transportation: Principles of Toboggan Handling Getting a toboggan from point A to point B safely and quickly is no easy task, but it’s one of the most important things you do as a Getting a toboggan from point A to point B safely and quickly is no easy task, but it’s one of the most important things you do as a patroller. Whether you patrol on alpine skis, telemark skis, a snowboard, or cross-country gear, the new OET manual contains a wealth patroller. Whether you patrol on alpine skis, telemark skis, a snowboard, or cross-country gear, the new OET manual contains a wealth of knowledge about various types of toboggans and the key skills for conveying transportation equipment down an icy slope or across of knowledge about various types of toboggans and the key skills for conveying transportation equipment down an icy slope or across a remote backcountry trail. Designed for toboggan operators as well as instructors, this comprehensive resource is the a remote backcountry trail. Designed for toboggan operators as well as instructors, this comprehensive resource is the essential guide to toboggan operations in the outdoor environment. So study up, check out the training exercises in essential guide to toboggan operations in the outdoor environment. So study up, check out the training exercises in the manual, and be sure to get plenty of mileage under your belt. After all, your passengers’ safety is in your hands. the manual, and be sure to get plenty of mileage under your belt. After all, your passengers’ safety is in your hands. item #500 www.nsp.org item #500 www.nsp.org R e f r e s h e r S t u dy g u i d e 28 National ski patrol 2008