OUTDOOR EMERGENCY CARE 5TH EDITION
Chapter 21
Scenario #21-01 Degree of Difficulty = 6
INJURY / ENVIRONMENT / PERSONNELHead injury (3)
Probable internal/pelvic injuries (3) / Racecourse (0) / Trained rescuers (0)
GENERAL SCENARIO DESCRIPTION: Giant slalom racer catches a gate at a high rate of speed. S/He spins and swirls in cloud of snow, hitting his/her head twice on the hard pack, and collides with a horizontal/rigid pipe.
INFORMATION GIVEN TO TRAINEE: You have been assigned to the racecourse for the day. You are located halfway down the course. There is another rescuer located at the start of the course with a fully equipped toboggan.
PATIENT SUMMARY: Skier is responsive only to painful stimuli. Assessment reveals pupils are unequal and sluggishly responsive. S/He is groaning with pain. S/He is not moving as s/he lies over the pipe. S/He will need full attention and extrication before the race can resume.
VITAL SIGNS
Time in minutes / Pulse and respirationsInitial
5 minutes
10 minutes / P = 108; R = 29
P = 116; R = 30
P = 124; R = 30
SCENARIO OBJECTIVES
Decision Making
Secure scene safety including stopping the race; patient assessment; correctly identify all injuries; recognize as “load and go” situation due to existence of life-threatening multiple trauma; prioritize rapid extrication, transport, and transfer to ALS (Advanced Life Support); request toboggan with trauma pack and additional personnel; activate ALS with request for air evacuation; notify management.
Problem Management
Standard Precautions; OEC skills; spinal immobilization; fracture management of the pelvic area with possible internal injuries; administration of O2 as soon as available; lift techniques; transportation and transfer plan.
Leadership
Direct others; coordinate rapid extrication and transfer to EMS; notify management and request their assistance; address race officials who are interested in restarting the race; direct additional rescuers to get statements of witnesses.
Scenario #21-01
INFORMATION FOR SCENARIO PLANNING AND OEC INSTRUCTORS
This is a life-threatening injury with a focus on rapid extrication and transfer to ALS, based on the MOI which indicates the possibility of multiple, significant trauma to head and lower abdomen/pelvic area. Scene safety, crowd management, and race officials need to be addressed. However, the primary focus will remain rapid extrication, ALS, and oxygen ASAP.
Location/terrain: GS racecourse
Moulage: Bruising and crepitus over pelvis; unequal pupils (described); clear fluid from the left ear
Weather: Must be the same as the day of scenario use
SPECIFIC INSTRUCTIONS FOR INJURED PATIENT
Position: Patient is lying over a horizontal metal pipe and is not able to move.
Answers to SAMPLE
Signs and symptoms: responsive only to pain, unequal pupils, clear fluid from left ear, crepitus over pelvic area
Allergies: none
Medications: none
Past history: none
Last meal: breakfast
Events leading: this is the second run on this course
Behaviors: Patient has clear fluid draining from his left ear, and pupils are unequal. Patient responds only to deep pain.
SPECIFIC COMMENTS FOR EVALUATORS
The trainee needs to recognize that this is a “load and go” situation. The trainee should request additional rescuers and toboggan with full trauma pack. Trainee should request ALS based on MOI. It is a difficult extrication and probably should move the patient directly on the backboard. Trainee also needs to address the crowds and the race official. The trainee also recognizes that management needs to be notified per local protocol.
OUTDOOR EMERGENCY CARE 5TH EDITION
Chapter 21
Scenario #21-02 Degree of Difficulty = 6
INJURY / ENVIRONMENT / PERSONNELPossible neck or spine injury (3)
Knee sprain (2) / Deep powder on steep terrain under the lift (1) / Single patient (0)
Trained rescuer (0)
GENERAL SCENARIO DESCRIPTION
A 15-year-old skier falls 20 feet out of the chair into deep powder. Friends reported this to the lift operator at the top.
INFORMATION GIVEN TO TRAINEE
You are called to respond to an accident of a teenager falling out of the chair at Tower 2. Equipment and available personnel to be sent upon request.
PATIENT SUMMARY
Patient is semi-lying down in a large depression in the snow. Patient complains of pain in the right knee. Patient is alert and responsive to your questions when you arrive. S/He does not complain of any neck or back pain, and wants to return to skiing.
VITAL SIGNS
Time in minutes / Pulse and respirationsThroughout / As found plus 12 pulse, and plus 4 respirations
SCENARIO OBJECTIVES
Decision Making
Secure scene; stop lift until assessment is performed to verify severity of injury. Patient assessment: correctly identify all injuries found and reported, but also consider possible injuries due to MOI. Assessment should include how s/he landed and rule out the presence of any neurological deficits from the fall. Inform patient of dangers of this large of a fall and possible injuries to the spine and back. Determine where parents are; inform him/her of the impact of being a minor and the ability to give informed consent and implied consent. Call for spinal immobilization. Notify management. Have base attempt to find parents.
Problem Management
Standard Precautions; OEC skills: Fracture management: knee; spinal immobilization per local protocol especially since the patient is a minor and needs treatment for knee injury anyway; release of liability by parents for a minor. Notify management due to chair involvement. Call for ALS. If appropriate and available arrange for helicopter transportation to a trauma center.
Leadership
Develop and execute a plan of action. Demonstrate thorough understanding of legal issues related to minor giving consent and how this impacts his/her decisions; direct others with clear instructions and with confidence; communicate with clarity and firmness with patient; direct additional rescuers to obtain statements from any witnesses; thorough documentation. Assist with any documentation necessary for accident involving a lift.
Scenario 21-02
INFORMATION FOR SCENARIO PLANNING AND OEC INSTRUCTORS
This scenario addresses the need for a thorough assessment based on the MOI to determine the need for spinal immobilization. The trainee should demonstrate understanding that a fall more than 2½ to 3 times one’s height presents the danger of spinal trauma. (This is mitigated in this scenario by the soft landing in the snow, and assessment demonstrates no signs of head or spinal trauma.) Trainee should be able to communicate a rationale for the decision to use spinal immobilization based on assessment and legal issues of patient being a minor. Trainee should also demonstrate how s/he would address the fact that the patient is a minor.
Location/terrain: Difficult to moderate terrain with deep powder under a lift. This terrain is in a closed area and a short distance from the loading ramp.
Moulage: None
Weather: Must be the same as the day of scenario use
SPECIFIC INSTRUCTIONS FOR INJURED PATIENT
Position: Patient is partially lying down under the lift.
Answers to SAMPLE
Signs and symptoms: knee pain
Allergies: none
Medications: none
Past history: has had previous knee surgery
Last meal: has not eaten all day
Events leading: has been skiing very hard for two hours
Behaviors: Patient is oriented and alert. Patient complains of pain in the right knee. Patient reports no tenderness upon palpation of spine. Patient reports no neurological impairment in his lower extremities. S/He feels that he can return to skiing.
SPECIFIC COMMENTS FOR EVALUATORS
The trainee should be evaluated on the knowledge of MOI issues, reasons for concern about possible hidden spinal problems, and legal issues related to a 15-year-old falling from a chair. Trainee should demonstrate knowledge of management issues and local protocols. Trainee should develop a plan for extrication and transport to aid room for further assessment and consultation with parents.
OUTDOOR EMERGENCY CARE 5TH EDITION
Chapter 21
Scenario #21-03 Degree of Difficulty = 7
INJURY / ENVIRONMENT / PERSONNELBilateral broken ankles (4)
Back injury (3) / Outside maintenance building/garage / Single patient (0)
Trained rescuers (0)
GENERAL SCENARIO DESCRIPTION
A maintenance man is finishing up some painting while perched on a garage roof. He is on the peak of the garage roof, working on the adjoining building. You hear a ladder fall to the ground and notice the maintenance man is rolling around on the driveway in severe pain.
INFORMATION GIVEN TO TRAINEE
You are at your ski area helping prepare your aid room for the upcoming season. You noticed a maintenance employee on the garage roof completing a painting job. You heard the employee scream, and heard the ladder fall. You call out to see if all is ok; when you don't get a response you rush over to assess the situation.
PATIENT SUMMARY
The patient slipped while standing at the peak of the garage roof, rolled down the roof, hit the ladder, and fell onto the driveway. He landed on both feet, causing great pain in his feet and back. Patient did not strike his head. Patient is rolling around on the driveway in a great deal of pain (occasional groans, grunts, or gasps). He is able to verbalize clearly when asked questions.
VITAL SIGNS
Time in minutes / Pulse and respirationsInitial
5 min
10 min
15 min / P + 20 R = 24
P + 20 R = 24
Decrease to actual if appropriate splinting or other care/comfort measures are administered (i.e., high-flow O2
Actual (as above)
SCENARIO OBJECTIVES
Decision making
Scene safety. Patient Assessment, correctly identify patient’s injuries, prioritize back injury over ankle injuries. Request spinal immobilization equipment, oxygen, two quick/hill splints, blankets, EMS transport. Notify management of employee injury
Problem management
Standard Precautions, OEC skills: spinal immobilization, general management of a fracture at a joint, oxygen administration. Obtain permission to assist. Appropriate assessment. Fracture management: Applies splints and backboards appropriately. Checks CMS before and after splinting/backboarding. Implements risk management/employee protocols as per area protocols. Transportation decision
Leadership
Directs others appropriately and with confidence, continued communications with patient, and team members, ensure correct OEC skills of helpers where appropriate. Risk management/employee injury protocols as per local protocol. Verbalizes appropriate transportation decision
Scenario #21-03
INFORMATION FOR SCENARIO PLANNING AND OEC INSTRUCTORS
Location/terrain: Outside maintenance building/garage on concrete or blacktop driveway
Equipment: Backboard, cervical collar, quick splints, blankets, oxygen per area protocol, gurney or wheeled stretcher
Moulage: Bruising about the ankles
Weather: Must be the same as the day of scenario use
SPECIFIC INSTRUCTIONS FOR INJURED PATIENT
Position: Lying mostly on back, writhing in pain
Answers to SAMPLE
Signs and symptoms: lower back pain, pain in both ankles
Allergies: none
Medication: none
Past history: none
Last meal: report actual
Events leading: painting roof peak, slipped and fell off roof
Behaviors: You are in a great deal of pain in your lower back and both ankles. You are writhing about in pain, but comply if asked to lay still. You calm down when reassured, and treatment is initiated and carried out.
SPECIFIC COMMENTS FOR EVALUATORS
Trainee should prioritize back injury over ankle injuries. Additional backboard help should be available upon request.
OUTDOOR EMERGENCY CARE 5TH EDITION
Chapter 21
Scenario # 21-04 Degree of Difficulty = 3
INJURY / ENVIRONMENT / PERSONNELContusion of head (1)
Lower arm fracture (2)
Medical condition (0) / More difficult slope in proximity to a snow gun (0) / Single patient (0)
Trained patrollers (0)
GENERAL SCENARIO DESCRIPTION
A mid-40s-aged skier was skiing fast on a moderate pitch, caught an edge and fell forward into the base of an unpadded snow gun.
INFORMATION GIVEN TO TRAINEE
Dispatch: Received a call to respond to an injured skier on a more difficult slope.
Equipment and available personnel to be sent upon request.
PATIENT SUMMARY
The patient has a contusion at the hairline due to collision with a snow gun, and an angulated lower arm fracture with good distal neurovascular response; patient reveals that s/he has chronic hepatitis.
VITAL SIGNS
Time in minutes / Pulse and respirationsInitial
5 minutes
10 minutes
15 minutes / p = 16, r + 6
p = 20, r + 6
p = 24, r + 8
p + 24, r + 8
to as found by trainee
SCENARIO OBJECTIVES
Assessment
Verify scene safety
Obtain permission to assist
Primary assessment reveals contusion on head, lower arm fracture, and history of Hepatitis B
Request needed equipment and personnel
Secondary assessment, no other injuries found
Rote Skills
Standard Precautions
Management of head/spine – spinal immobilization
Fracture management – lower arm. Correctly splint arm
CMS before and after splinting
Oxygen administration per area protocol
Lifting Techniques; loading/position in toboggan
Problem Management
Patient stabilization
Treat for shock as appropriate
Verbalize appropriate transportation plan - EMS notification (based on local protocol)
Notify management for collision incident
Scenario #21-04
INFORMATION FOR SCENARIO PLANNING AND OEC INSTRUCTORS
Location/terrain: On or at the bottom of a moderate-pitch slope by an unpadded snow gun, or other similar man-made object that would be the source of the head contusion.
Equipment: Toboggan with standard area equipment
(Spine-boarding equipment if not included in the standard toboggan, following local protocols)
Moulage: Contusion at the hairline. Slightly angulated mid-shaft lower arm fracture. Medical Alert tag for Hepatitis B.
Weather: Must be the same as the day of scenario use
SPECIFIC INSTRUCTIONS FOR INJURED PATIENT
Position: You are sitting, leaning against the snow gun, alternately cradling your injured forearm and holding your forehead.
Answers to SAMPLE
Signs and symptoms: lower arm pain and deformity, contusion at the hairline
Allergies: none
Medications: none
Past history: you had hepatitis B three years ago after a blood transfusion, and now you have chronic hepatitis
Last meal: report actual
Events leading: you were headed downhill very fast, caught an edge and fell. In attempting to break your fall you put your arm out and fell on it, and then you ran into the snow gun, hitting your head.
Behaviors: You are alternately placing your hand on your head, and cradling your broken arm. You are in some pain from both injuries. You admit that you were stunned on the impact with the snow gun, but know you did not lose consciousness, is responsive,and remains fully oriented. You have a headache from the impact, but deny having any neck pain or back pain.