Accident Scene Management

One of the primary legal objectives which NSP has been attempting to improve this past year is re-emphasizing the need to legally manage an accident scene. NSP wants to remind patrollers that they not only have an obligation to medically manage an accident, but also to legally manage an accident scene. These efforts have caused a re-emphasis on basic risk management techniques. These techniques include properly documenting an accident and  recognizing when to supplement normal accident forms with additional and more detailed information. These legal management skills include, for example,

(1) the patroller in charge becoming aware of when an accident scene’s problems have escalated to where he or she needs to call another patroller just to have another witness at the scene,

(2) training patrollers how to deal with the potentially serious situation when an injured skier refuses first aid care,

(3) the need to preserve evidence, especially evidence which could protect the patroller.

The objective is to increase the patroller’s understanding that he or she needs to master the skills of caring for the injured skier while also taking care of the legal aspects of every accident scene. Increasing the education of patrollers, throughout the country, on legal principles has already succeeded in reducing the legal risk of patrolling and continuing to support the historic fact that patrollers are hardly ever sued. Continuing this legal and risk management training remains an objective of NSP legal. 

Antiseptics

Antiseptics that are meant to kill organisms in a wound will also kill healthy tissue. Therefore hydrogen peroxide, iodine, Betadine, and alcohol will all inhibit wound healing and are contra-indicated in the management of wounds by OEC technicians. These agents will have a deleterious effect from the point of initial injury to the time that the wound is healed.

Contrary to another post on this topic, soap is also contra-indicated in the managment of wounds by the OEC technician.

The management of wounds should be determined by local circumstances and under the direction of local medical advisors. For those OEC technicians that work in environmeents with long transport times prior to the patient getting to definitive care it may be appropriate to clean out the wound prior to bandaging, while those OEC technicians that work in environements with short transport times it may not be needed to clean out a wound prior to bandaging. For those OEC technicians that may need to clean out a wound prior to bandaging the recommended agents to clean the wound are only sterile normal saline (0.9% NaCl), sterile water, or clean water.

Rember that after the wound is cleaned it should be covered with a sterile dressing.

Also remember that the most effective method to control bleeding is direct pressure.

Happy refresher season.

Michael G Millin, MD, MPH, FACEP
NSP National Medical Advisor

Hands only CPR for ski patrollers - NO

Thank you for this question. This is actually an interesting question that is filled with controversy and quite a bit of active research.

The short answer to your question is that the current recommendation is that CPR preformed by a trained healthcare provider (including OEC technicians) should include both chest compressions and rescue breaths in a ratio of 30 compressions to 2 breaths.

The long answer is a bit more complex, so please bear with me. For many years it has been believed that the keys to survival from sudden cardiac arrest are chest compressions and defibrillation. The primary initial rhythm in sudden cardiac arrest is typically ventricular fibrillation, which is best treated with electrical defibrillation. The purpose of chest compressions is to circulate blood to the cardiac muscle. Despite years of community programs to get bystanders to perform chest compressions, there are still low percentages of sudden cardiac arrest patients that get bystander CPR. It is believed that one reason for low bystander CPR is fear of doing mouth-to-mouth rescue breathing. Therefore, researchers have examined the question of survivability if CPR is performed by the lay public with only chest compressions. These studies have clearly shown that when performed by the lay public compression only CPR is just as effective as standard CPR with compressions and rescue breathing. It is this research that has evolved to the most recent recommendation by the American Heart Association (AHA).

It is important to understand that the above mentioned research has all been examining CPR in the hands of the lay public. At this point in time, the medical literature is not able to answer the question of standard CPR vs. compression only CPR when performed by a skilled healthcare worker. This is why the recommendation for trained healthcare providers is to continue with standard CPR.

If you are ever truly faced with doing CPR in your capacity as an OEC technician you will notice that CPR is hard work. You will break ribs on your patient, and after 2 minutes of pushing hard, pushing fast you will be exhausted. While I have seen the value of chest compressions in my own clinical practice, this is supported in the literature as well. The most notable recent study was published by Wik, et al. that demonstrated for those patients with a down time greater than 5 minutes, chest compressions before defibrillation were more successful that just defibrillation.

The bottom line is that the current literature supports compression only CPR when performed by the lay public and standard CPR when performed by a skilled healthcare worker. When performing CPR, Push hard and push fast for 30 compressions then perform 2 rescue breaths. Do five cycles and then using an AED, defibrillate if indicated. After defibrillation immediately Push hard, push fast. Do not check for a pulse. Frequently rotate the rescuer doing the chest compressions to minimize fatigue and degradation of the quality of the compressions.

Finally, the coordination of doing CPR and getting the patient out of the environment can be quite complex. Exactly how you do this is up to your area. You should look to your local medical advisors, patrol leadership, and area management for direction. The fact is that you may have to stop chest compressions in order to get the patient off the side of a mountain. This is not ideal, but it is reality. If you do have to stop chest compressions, your area should develop a protocol that utilizes resources to as much as possible minimize the time that the patient is without CPR. The reason that this should be an issue of local direction is that the best way to minimize time without CPR will be dependent on the local resources and the topography of the area. I will say that at my local hill we have developed a protocol whereby two patrollers take the patient down in a toboggan. Other patrollers are then strategically placed at about 30 second intervals to perform CPR along the route to the base of the mountain. While we have not had an actual case yet with this new protocol, we have practiced it many times and it seems to work well. Regardless, every area is different so every area should develop a system before the event that works for the local area. The key is to have a protocol in place that works before the actual event. In addition, I can’t stress enough that regardless of the details of your area’s protocol, it should not put OEC technicians at harm. Your plan should not put OEC technicians (or the public for that matter) at harm for the purpose of trying to save the life of a dead person that has a low chance of survival.

Just so that we are clear one more time: 30 compressions with 2 breaths – Push Hard, Push Fast.

Michael G Millin, MD, MPH, FACEP
NSP National Medical Advisor