Chapter 04: First Aid and Medical Protocols
Our first-aid philosophy is dictated by the terrain we patrol and the limitations of our training and equipment. The limits of our first-aid training should always be kept in mind, as should the primary rules "DON'T BECOME A VICTIM" and "DO NO HARM." Because we patrol the backcountry, we are limited in the equipment we carry and the speed with which we can evacuate the injured. Most Nordic first-aid treatment is similar to Alpine, but transportation is decidedly different. Although some of us were trained as Alpine patrollers, we must learn to think as Nordic patrollers. Consequently, our emphasis is on stabilizing injuries, controlling shock or hypothermia, and keeping patients dry and warm until appropriate transportation can be arranged. This is why we carry or have cached such items as oxygen, ensolite pads, blankets and bivouac kits. Often the most critical decision involves the method of evacuation. Patients with minor injuries can be transported by sled; more critically injured patients should be transported by helicopter, if available, or by snowmobile.
Special first-aid procedures
As noted above, our emphasis is on keeping the patient warm and dry. All patients should be placed on ensolite pads. All patients should be covered with a blanket(s) and a tarp or space blanket. Patient temperature should be monitored continuously, through use of the hypothermia thermometer if necessary. Any person suspected of being seriously hypothermic should be evacuated immediately by helicopter. Where transport by snowmobile is advisable, a bivouac should be established to provide shelter and warm liquids unless contraindicated because of specific injuries. Snowmobile transport must be arranged by the USFS through the county sheriff, and waiting time is often considerable. Your specific location must be given, so map-reading skills are essential. You must always know where you are, and be able to give appropriate map coordinates!
Consent for treatment
Adults - If the patient refuses treatment (after persuasion and informing of worst possible consequences), ask the patient to sign the Refusal of Treatment form. If they refuse to sign, have a witness sign to form to confirm the refusal. (The witness can be another patroller or a bystander). Minors - If the injury is non-life-threatening, you must ask for guardian permission to treat. If the injury is a danger to life or limb, then treat as necessary (and guardian consent is not required). If the patient refuses treatment (after persuasion and informing of worst possible consequences), ask the patient to sign the Refusal of Treatment form. If they refuse to sign, have a witness sign to form to confirm the refusal. Unconscious (both adults and minors) - Consent is implied if the patient is unresponsive.
Decisions regarding patient transportation
As mentioned above, transportation of the injured is by sled, snowmobile or helicopter, depending upon severity of the injury. Transportation decisions also involve patient input, cost and inconvenience considerations, and availability of evacuation equipment. When a patient needs transportation, notify the Grass Valley (or Minden) dispatcher immediately of any potential need for transport, and request a helicopter in "standby" status. (The helicopter may take five minutes to takeoff and twenty minutes to arrive). After several minutes of patient evaluation, confirm with the dispatcher if helicopter or snowmobile is preferred. The helicopter can also be asked to standby over your position, without a fee until they land. Patients are usually charged for emergency transportation, a helicopter should not ordinarily be ordered for a simple fracture. However, the fact that an injured skier lacks funds or medical insurance should not dictate a slower method of transportation when an injury requires immediate advanced medical care. If asked by the patient, inform them of the cost (ranges from $7,000 to $10,000), and that most insurance plans cover the service. If they are uninsured, there are non-profits that may cover the cost. Try to convince the patient of the need for swift medical attention, and what the worst-case scenarios are without it. If the helicopter is refused, document the fact on the Incident report form, and have them sign a Release of Liability form. Patient transportation issues will be extensively discussed during training.
INFECTION CONTROL PROCEDURES
This document contains information regarding the blood-borne pathogens, which produce AIDS and Hepatitis B. All patrollers and candidates must be familiar with this material and with the patrol's infection control procedures. Avoid exposure by following proper protection protocols. If you are exposed, you should: As soon as possible, wash and remove any visible fluid Ask the ambulance or helicopter what hospital they are going to, and let them know you've been exposed. Call or go to the hospital emergency room, explain the situation, and find out if the patient has tested positive. Get tested. Document the exposure on the Incident Report form, and Daily Operations Log.
Patrol Specific Outdoor Emergency Care (OEC) Protocols
Upon successful completion of the Outdoor Emergency Care (OEC) Course, patrol members are certified as OEC Technicians by the National Ski Patrol. The following information serves as a supplement to the training and instruction received by the OEC Technician during the OEC Course. It includes patrol-specific protocol regarding the treatment of patients, which may differ from the protocol as taught in OEC. It also serves to clarify other items not fully covered in the Course. For further information, please contact the TBSP OEC Advisor.
Infection Control Procedures & Body Substance Isolation (BSI).
- Patrollers, as OEC Technicians providing emergency care for patients, are at risk of exposure to blood and other bodily fluids. Such fluids, in particular blood, may potentially contain pathogens and viruses such as Human Immunodeficiency Virus (HIV, the virus that causes AIDS), or Hepatitis B (HBV or HEP-B). Therefore patrollers must always be diligent in protecting themselves from potential exposure.
- To protect against exposure to a patient's body fluids or substances that may contain viruses, patrollers must follow BSI precautions at all times when assessing and treating patients. At a minimum these precautions shall include the wearing of latex or nitrile gloves; it may also require for the wearing of safety glasses, and protective mask or face shield. When safety glasses are not available, the patroller's sunglasses or goggles may have to suffice as a substitute.
- Used, disposable protective materials such as gloves, dressings, and bandages shall be placed and sealed in a plastic bag. The materials shall be passed on to a member of the advanced life support (ALS) crew upon pickup of the injured or ill patient, for subsequent proper disposal at the hospital or other advanced care facility.
- At a minimum, non-disposable and potentially contaminated equipment not delivered with the patient to the ALS team shall be decontaminated in the backcountry with dressings treated with alcohol or other antiseptic, then covered with plastic for transportation back to the TBSP Operations Center or Equipment Shed. Upon arrival at the TBSP Operations Center, affected areas of the equipment shall be sprayed with a dilute solution of chlorine bleach and left to stand in the open air for at least one hour. As needed, it may be given a final cleaning with soap and water. Allow to air dry. Leave a conspicuous tag attached to the equipment for the TBSP Equipment Manager or Operations Officer, noting how and where it was contaminated, and how it had been decontaminated.
- Potentially contaminated blankets, or patroller uniforms or clothing may be machine-washed at the Chalet. Patroller sunglasses or goggles may be decontaminated with antiseptic wipes or with bleach solution.
- Patrollers shall carry an ample supply of antiseptic hand wipes or hand sanitizer, and shall use these materials before and after treating a patient in the field.
- Snow or soil contaminated by a patient's blood or other body fluids or substances shall be buried in soil or in the snow and not left at the snow or ground surface.
- If a patroller may have been exposed to a patient's body substances, the patroller shall thoroughly clean the affected area, and if possible accompany the patient to the emergency room and let the hospital staff know you are an emergency responder exposed to the patients' bodily fluids. They can recommend post-exposure prophylaxis, especially after the patient's blood is tested. Also contact the Patrol Leader and Mountain Manager, and contact the patroller's doctor or caregiver as soon as possible for further direction. Treatment for such exposure may also be covered by the US Forest Service under the volunteer agreement that TBSP operates with them. Contact the TBSP OEC Administration Officer for more information.
- Though at present no vaccines exist for some viruses such as HIV, there is a vaccine available for Hepatitis B (HBV).
- As first responders that may come into close contact with bloodborne pathogens, all patrollers are strongly encouraged to consult their own doctor for more information about HBV vaccination. Patrollers should understand the contraindications for this vaccination.
- For more information on HBV and the vaccination, see the attached Hepatitis B Fact Sheet from the Center for Disease Control (CDC):
- For further information on this and other bloodborne pathogens, contact your doctor. Also visit the Center for Disease Control (CDC) online, at: http://www.cdc.gov/ncidod/dhqp/bp.html
Spine Immobilization (Backboarding).
- Injuries or conditions requiring patient stabilization and immobilization to a long spine board (backboard) include:
- Head, neck or back injuries
- Unresponsiveness (unless it was caused solely by a witnessed medical condition/emergency)
- Mid-shaft femur fracture
- Proximal femur fracture ("hip fracture")
- Pelvic fracture
- Hip dislocation
- Backboarding is contraindicated if maintaining the patient's airway or the patient's ability to breathe is compromised by strapping to the backboard and/or across the patient's severely injured chest. Maintaining breathing and the ABC's takes priority over treatment of spinal injuries.
- An adjustable cervical collar is to be sized and installed as soon as possible.
- Backboard straps shall be hook-and-loop (Velcro) "Spider" straps. If Spider straps are not available, 1" minimum width nylon webbing from a patroller's sled hauling kit may be used, criss-crossed across the patient's body starting from the shoulders down.
- Head is to be stabilized using a blanket roll. Blanket may be rolled long and placed in a horseshoe shape from top of shoulder to top of head to top of opposite shoulder, or a dual-rolled blanket slid under the patient's head with each roll against each ear. Blankets may be doubled to provide required volume for proper stabilization.
- Cervical spine is stabilized manually throughout the backboard process until the patient's head is taped to the backboard and all backboard straps are tight. Two to three passes of tape in an "X" over the forehead is required. No tape is to be placed over or under the patient's chin.
- Padding should be placed under the patient's knees before strapping. A long rolled blanket provides modest padding while gently flattening the lumbar spine. Padding under the knees is required for a pelvic fracture.
- Prior to strapping, additional blankets shall be applied to fill "voids" around the legs or hips due to other injuries such as hip dislocations or femur fractures.
- Diaper or foot hitches using cravats shall be used as needed to supplement the backboard straps for patients on steeper inclines or when injuries near the hip prevent the hip straps to be pulled snugly.
- Arrange the suctioning device and oxygen on the patient's left side if possible. Patroller monitoring the airway should be ready to suction from that side. If patient vomits, patient should be rolled to the left.
Mid-Shaft Femur Fracture (Kendrick Traction Device)
- Patients with a fractured femur mid-shaft shall be splinted with a Kendrick Traction Device (KTD). Open fractures are to be bandaged prior to splinting.
- Prior to arrival of the splint, manual traction shall be applied distal to the injury. To maintain the rescuer's hands free, a manual traction "hitch" should be fashioned using cord or webbing, attached to the patient's ankle on the injured side, and wrapped around the rescuer's back. Manual traction may be maintained by leaning against the hitch, with the rescuer's foot pressed flat against the patient's foot on the uninjured side. Manual traction shall be maintained constantly until traction is pulled with the KTD.
- The RED Velcro strap shall be placed directly over the midshaft and injury.
- Feet shall be tied with a figure-of-eight to prevent rotation of the injured leg.
- Boots shall generally be left on the patient's injured leg, provided adequate assessment of the distal pulse, sensation, and motion can be made.
- Boot buckles and/or laces shall be loosened on the injured side to allow for swelling and for patient comfort.
Splinting of Lower Leg Injuries
- In lieu of a quick splint, patroller may fashion a proper splint by using the patient's ski poles, ensolite pad, cravats, and if needed, additional padding.
- As with all splints, the injury site shall not be completely covered by the splint to allow for regular, subsequent injury assessment while waiting for or during transportation.
Reductions & Compromised Distal CMS
- If the patient's injury (dislocation or fracture) exhibits compromised distal CMS before splinting, and transport to an advanced care facility is greater than one hour, at least one attempt to realign the injury to improve distal CMS is required.
- Shoulder dislocations or AC (acromioclavicular) separations may require careful reduction in the field if transport to an advanced care facility is greater than one hour. Assist patient in reduction of the dislocation.
- Reductions of lower extremity joints shall not be attempted.
- Oropharyngeal or oral airways shall be properly sized and installed with all unresponsive patients without a gag reflex.
- Nasopharyngeal or nasal airways should be installed with responsive patients with a compromised airway.
Hypothermia in the backcountry is a significant danger. TBSP provides specific guidelines for the gentle handling of hypothermic patients during prehospital care and transport.
TBSP's medical protocols cover several other potential backcountry scenarios, including lower leg splinting and femur traction devices in the absence of designated medical devices. TBSP training covers the following improvised devices:
Makeshift traction devices
Using a ski pole to pull traction.
Using a combination of ski poles, cravats and ensolite closed cell foam pads to provide joint immobilization.
Not permitted: Spinal immobilization
Use of makeshift devices for spinal immobilization (backboards) is not permitted. Tahoe Backcountry Ski Patrol Manual