University of Vermont AAHS
AMEA

May 1998, Vol. IX, Number 2

 Table of Contents

 Medical Personnel for Events
 Emergency Service Personnel
 Disaster Planning: Barn Safety
 The Value of Certification
 The Need for Tailored Equestrian Safety Education
 Equestrian Injuries: A Survey in British Columbia, Canada
 News Items



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MEDICAL PERSONNEL FOR EVENTS
William Lee, MD
Emergency Room Physician
 

 With the recent deaths in eventing, a discussion of onsite medical personnel at a horse event is an obvious response.  What can the medical equestrian community reasonably do?  What should we do? Are there changes in procedures which would make any difference in massive trauma cases?  The technical aspects of the sport are best left to the USCTA and the FEI.  The medical aspects are a different matter.  Key medical points should influence these decisions.

A paramedic is the best option.

   What type of medical response team should be at the event site?  In my view as a doctor of emergency medicine, a paramedic is best.  Using a volunteer physician or nurse whose specialty does not require dealing with these types of emergencies and05/23/98/or who lacks field experience can be a serious mistake.

 .  The paramedic has the skills and the equipment (intubation, intravenous infusions (IV), cervical collar, etc.) and the experience in the field to handle the trauma victim  While the emergency medical technician (EMT) may have field experience and can do basic life support, he/she cannot intubate or initiate IV's to provide continued life support.  In all accidents, airway, cervical spine management and rapid transport are the most critical.  Intubation allows controlled breathing and better air exchange. Stabilization must be completed before movement of the injured is done.

Why should a paramedic be preferred?

  Airway and cervical spine stabilization are the most immediate important issues.   Intubation is the best management of an airway. It will prevent aspiration and control breathing with a bag or oxygen if needed.  The non-reversible damage of the critical 3-4 minutes of anoxia must be prevented. Little that we can do later will repair the neurological damage of lack of oxygen to the brain. The limit of 4 minutes of anoxia mandates resuscitation and life support immediately.  The paramedic should be at the area of injury or be immediately available within these few minutes. There is a golden hour in trauma in which life or the integrity of life is determined . Using motorbikes or golf carts are options especially in getting to accidents on the cross country course. After stabilization, support must continue enroute during rapid transport to a trauma center. This may require a helicopter because the location of events may be far removed from needed medical facilities.

Communication is the key.

 Planning prior to the event will determine the selection of the location of the paramedic.  The paramedic should evaluate the area in advance to review exactly where the event is being held.  He/she should plan routes of evacuation and possible landing sites should a helicopter be required. The paramedic needs a cell phone and an onsite radio.  Radio communication should be available to the jump judges as they must be able to communicate with medical personnel.

Transportation

 An ambulance may not be the best option. Even if there is an ambulance on site transport time to the nearest trauma center may be too long.  However, the ambulance may call a helicopter if the distance is to be too great and the time prolonged.  The level of  the  health care facility designation as a basic, general level trauma, advanced or comprehensive center should be identified before the event. The paramedic will determine the  proper trauma center for the patient based on the mechanism of injury and physical assessment..

 The above scenario allows the event to continue once the victim is moved because the helicopter comes with a paramedic and a nurse. The event can continue with the
original paramedic on site.

The Cost Factor

 To address the concerns of economics, an EMT charges at $10.00 to $12.00 per hour;  the paramedic is $15.00 to $20.00 per hour; a paramedic and an EMT on motorbikes each costs $45 per hour.  A paramedic and an ambulance is $125 per hour.  These figures are the going rates in Arizona and will vary over the nation.  The choice  may be the difference between life and death.

Should a paramedic be mandatory?

 There are inherent risks in horse sports.  Helmets and vests are not going to prevent all serious injuries. Some injuries are not preventable.  Providing the highest level of on site care offers the best protection for both the competitor and the event organizer. The choice of a paramedic cannot be criticized.

Role of the American Medical Equestrian Association

   The American Medical Equestrian Association has been organized because of these exact concerns. Two excellent sources of related information are a booklet on "Planning Event Coverage" which outlines the steps that should be taken before an event.  (available at the AMEA headquarters at a cost $1.00 and the "Rider Safety Video" $17.95 plus $3.00 shipping and handling.  Orders for these materials or requests for information about the AMEA may be obtained by contacting the office at 4715 Switzer Road, Frankfort, KY 40601 or my e-mail at AmerMedEqAssn@bigfoot.com..

The need is now.

 At this moment, people are organizing horse shows, events, rallies, rides, rodeos and races.  This advisory is present to help them - in consultation with the paramedic who will work the event - make their own appropriate medical decisions.

William Lee, MD, Emergency Room Physician,
President, American Medical Equestrian Association
Desert Foothills Medical Center
PO Box 2150,  Carefree, AZ, 85377
 

COMMENTARY : MEDICIAL PERSONNEL FOR AN EVENT

Eventing is becoming more and more popular day by day.  New events are springing up every season and more and more riders are entering.  The sport is safe but has a certain degree of danger.  If more people are involved, does that mean more people could sustain injury?  Hopefully not, but preparedness is the key.

Now, more than ever there are certain questions that need to be answered concerning rider safety.  Certain groups such as the AMEA have started taking steps to answer some of these questions and establish recommendations and guidelines to insure that equestrian activities remain as safe as possible. Many popular and professional eventers are open for suggestion and in light of recent tragedies are ready to set the example for the rest of the eventing community.  Personally I believe that now is the time to refine some of our procedures and guidelines for rider safety and with a captive audience we have a good opportunity.

Dr. Lee's recommendations of having paramedics on site at an event with the proper communications and coordination with event officials sets the stage for another level of care.  Should an ambulance be on site?  Some could perceive the answer to this question as a "no brainer", but there are considerations.

The first consideration is a time factor.  When a critical injury occurs time is of the essence.  Trauma victims should be treated and transported to an appropriate facility as soon as possible.  The "golden hour" which is the first hour after a major injury occurs is the time frame that is most critical.  The chances of survival are less as precious minutes tick by.  If an ambulance is on site, once access to the victim is gained transport can be immediate.  There is no guess work or wait on the part of the paramedics on duty at the event.  Some events may be a short distance away from the local emergency medical services and an ambulance can arrive shortly after the victim is being treated by on site personnel.  Pre-planning is the key and some persons may not realize that they do not have an ambulance as close to their event as they think.  Do your homework!  When a critical injury occurs, then is not the time to find out that the local ambulance is 20 miles away!

Another factor is cost.  Some privately owned ambulance services may charge as much as 300 dollars or more just to stand by.  Then if someone is transported or treated another charge is added.  Municipal or volunteer services are usually more apt to stand by for just a donation to their service or no charge at all.  This is an ideal situation.  Unfortunately, due to the remoteness of some events a private ambulance service is the only option.  Event organizers are trying to keep the costs of entries down and these charges could cause entry fees to rise and make it difficult for some persons to afford.

The final factor to consider is the availability of helicopter transport services.  With paramedics on site and a helicopter service locally available an ambulance on site might not be necessary.  The paramedics could begin the treatment, the helicopter could arrive and possibly land in closer proximity to the victim resulting in a more rapid transport of the patient to the trauma center.  Weather, terrain and power lines are important considerations when using helicopters and again pre planning could help in considering this possibility.  A cost is not incurred unless the service is used and if a minor injury occurs an ambulance could be called.

The ideal set up would be paramedics on site with communications, ambulance and a helicopter on stand by if needed.  However, at certain times this is not practical and not necessary.  Pre planning of an event should involve local emergency medical services personnel and persons with experience in eventing
medicine. Guidelines established by the AMEA, USCTA and other sources should be followed.

We do not need to take the attitude that medical services create a negative image of the sport.  The attitude to take is that we have a fun, safe sport, but if something goes wrong we are prepared.  If a critical injury occurs and treatment or transport of the victim is delayed what kind of image are we creating?  Our hearts and prayers go out to the victims of recent eventing tragedies and I hope that our efforts  inspire the sport to improve standards.

Rusty Lowe, EMT-P
2855 Five Oaks Lane
Birmingham, AL 35243

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EMERGENCY SERVICE PERSONNEL

 Each state has its requirements for licensing emergency service personnel.  These can be found in EMERGENCY MEDICAL SERVICES,  "State & Province Survey" December 1997 p 194-208 or by contacting the AMEA, Michael Nolan, Executive Secretary, 4715 Switzer Road, Frankfort, KY 40601.

The following is a general outline of the levels of certification and required training for those levels.

First Responder:  (ambulance attendant) requires 60 hours of training.
 Entrance requirement are a high school diploma, general education development (GED) or successful completion of entrance examination assessing basic reading comprehension skill at a minimum of the 10th grade level.
 Upon completion the First Responder will possess the skills necessary to access the needs of both the medical and trauma patient, provide for airway management, bleeding and hemorrhage control, shock assessment and management and cardiopulmonary resuscitation.  The course also provides an orientation to trauma, medical emergencies, emergency childbirth, psychiatric, pediatric and environmental emergencies, communication and patient care documentation.  In addition the student is introduced to fracture management and spinal immobilization.

EMT  Basic (BLS):  requires 165 to 185 hours class work which includes 10 hours clinical (Emergency Room) and pass state examination.

 The course teaches skills for assessing patients, handling patients by utilizing Basic Life Support equipment, performing CPR, using semi-automatic defibrillators, controlling hemorrhage, providing non-invasive shock treatment, fracture and spinal immobilization, managing environmental emergencies, emergency childbirth, and properly documenting patient care.

EMT D:  requires basic EMT plus 20 hours and pass state examination.  The final skills exam must incorporate evaluation of the placement of a blind insertion airway device (BIAD), administration of epinephrine 1:1000 for a systemic allergic reaction, and automated defibrillation.

 Entrance recommendation of one year prehospital EMS experience.

EMT Intermediate: requires 144 additional hours including 24 at hospital emergency  room, 24 hours on the emergency vehicle and pass state examination. All patient assessments and a minimum of 5 intravenous administrations must be performed on  live persons.

 The class room instruction is based upon the premise that the student has a minimum of one year's experience as a basic EMT in the field.  The Intermediate student is given instruction in all areas of basic EMT as refresher information and then focuses on advanced medical and trauma patient assessment.  Emphasis is placed upon advanced treatment for shock, trauma and early advanced cardiac care and interfacing with BLS and ALS providers as a team.  The intermediate EMT is given training in intravenous fluid therapy, advanced airway management and expanded cardiac rhythm recognition and defib management.

EMT Paramedic (ALS):  requires additional 430 hours classroom, 120 hours hospital emergency room, 180 hours on emergency vehicle and pass state examination.

The EMT paramedic has reached the highest level of pre-hospital certification.  The paramedic has all basic and advanced skills including advanced patient medical and trauma assessment, advanced airway management including endotracheal intubation, chest decompression, endotracheal tube (ETT), esophogeal obturator airway (EOA), advanced shock management including intravenous initiation and maintenance, intraosseous infusion and phlebotomy.  Additional skills include calculation and use of emergency medication, administration of aerosol, IM,. SUBQ, oral, sublingual and intravenous medications; basic EKG recognition and appropriate interventions, use of semi-automatic and manual defibrillator, use of external pacemaker and advanced documentation of care.

Editorial Note: Information from New York State Critical Care program and North Carolina Community College EMT Curriculum outline.

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DISASTER PLANNING:  BARN SAFETY

BEFORE:

 Plan, Plan, Plan.  You never can stop planning ahead for an unknown disaster.  Have a plan in place before the disaster.  The plan can start with a safety inspection of your farm premises. The inspection should include:

Electrical systems:

 Are the service boxes in a dry, dust free location and mounted on fire resistant   materials?
 Are the electrical fixtures free of dust, dirt, cob webs, chaff, hay or    combustible materials?

Heating and cooling systems:

 Are they  designed for barns and stables?
 Are they installed properly?

Fuel Storage:

 Are the storage tanks located away from buildings at least 40 feet?
 Are the tanks properly grounded?
 Are there fire extinguishers near tanks?
 Are the tanks protected from collision by vehicular traffic?
 Are there clean up protocols for spills?
 Are your barns and buildings free of weeks, grass and debris?
 
Are your barns and buildings free of weeds, grass and debris?

Is the hay cured prior to being stored?
Are the roofs, walls and windows weather tight?
Are many fire extinguishers located in every building?
  *Are they annually charged?
  *Is there 10 pounds ABC or better?
  *Are they protected from freezing?
Is there a phone in all barns with important numbers (fire, police, key    personnel)?
Are there no smoking signs are is the rule enforced?
Are horses valued over $100,000 stabled in separate barns?

Paddock and pastures:

Are they free of harmful objects?
Are there no broken planks, exposed nails, sharp or broken gates?
Are the horse rotated to break the life cycle of parasites?

Stables:

Are the aisles at least 12 feet wide?
Are the aisles free of harmful objects?
Are the stalls latched?
Are the stalls designed to prevent contact with neighboring horses?
Are electrical fixtures (fans, etc.) wiring inaccessible to horses and properly   protected?
Are the grain and feed rooms locked and containers covered?

This is not a complete list.  It is a start on your way to a safer environment for your horses.

BEFORE A DISASTER:

Survey your property for the best location for animal confinement. WRITE IT DOWN.
Alternate water and power sources should be identified.  WRITE IT DOWN.
Cell phone, portable radios, flashlights, extra batteries, portable generators are all good sources to have on hand.
Evacuation plans to relocate (route to fairgrounds, other farms, race tracks, humane societies).WRITE IT DOWN.
A list of all resources - feed, supplies, vets, EMTs, truckers. Include all emergency telephone numbers (police, fire, hospital (vet and human, EMT, poison control). WRITE IT DOWN. Make many copies:  this information should be available at various locations on the farm.
Have a current list of the horses on the farm or in the stable.
 *What paddock and stall they are in?
 *Who are the owners or contact persons and what are their telephone numbers?
 * A written procedure on what is to be said to owners/agents in a disaster?
 * Make a script and follow it.
 * Records of feeding, vaccinations, Coggins, amount of hay and feed and what   kind given to each animal should be available.  WRITE IT DOWN.
Have a procedure on what animals will be saved in an evacuation and what animals will  be put out to safety.
Have a job description on who does what.
Have a phone tree of all key personnel and make sure they know how to use it.
Have a drill every quarter in the barn regarding a disaster.
 * Who does what? Who calls who? DON'T PANIC.
Have emergency kits available in farm trucks and tack rooms.  Emergency kits should have the necessary supplies to treat almost any kind of minor injury or assist in stopping a major injury from getting worse.  You should have halter shanks, dressings, bandages, medicines, water buckets, flash lights, radios, etc.

WATER/FEED

Make sure you have enough water/feed for 72 hours.  Secure it before the disaster occurs.  Most horses drink 5 gallons per 1,000 pound weight and 20 pounds of hay.
Make sure all horses are identified with halters or neck straps and spray point names on horses left outside to weather the storm.
If you evacuate and mark horses make sure you have enough feed and hay for 48 hours.  Call prior to movement to other farms to make sure the site is still available.  Bring the emergency kit with you.
If you leave horses behind make sure they have water and hay for 48 to 72 hours.  Leave them in an area that you have determined appropriate for the disaster situation.
Make a list of the animals that you evacuate and where they go. Be sure they are identified.
Reinforce the emergency training drills you have done at the farm prior to the disaster.
Plan, Plan, Plan.  WRITE IT DOWN.

DURING A DISASTER

Be calm, don't panic - remember the emergency drill procedures
Get information from the Emergency Broadcast System. Know the station.  Use a battery operated radio if the power is off.
If you evacuate and take horses, take all important records, feeds, etc. Call prior to shipping to make sure emergency location is still available.
If you leave horses behind make sure they are turned out in a pre-selected area that would be appropriate for the disaster situation.
Leave enough hay and water for 48-72 hours.  Power may be lost: a large water tub would be a better choice vs. automatic water.
Identify all horses with halters and possible splint boots or bandages with information on the horse inside.

DO NOT PANIC

Horses will be aware of the disaster by the way you act and the environment they will be  in.
Call all owners/agents regarding the disaster.  Keep them updated if possible.  Use a  script or prepared statement when you call.

AFTER A DISASTER

Call all owners/agents regarding the disaster, even if there is no damage to your property.
Check fencing, pastures and gates for sharp objects.
Check power lines.
Be aware of wild animals and snakes.  They could be a danger to you and the horses.
If horses are lost, contact local farms, veterinarians, humane societies.  Listen to the  Emergency Broadcast system for people that are accepting lost animals.
Be careful in approaching animals that have gone through a disaster.  They may be  frightened and unruly.
Check with your veterinarian and the Department of Agriculture for information about  possible disease outbreaks.
Examine all horses after a disaster.
Check all feed.
Inventory all horses.

TO SUMMARIZE:

It is very important to plan and have written procedures in place before the disaster: phone numbers, cellular phones, flashlights, generators, emergency kits.

Have drills every quarter to sharpen the employees' and owners skills.

Joe Carr
American Bankers Insurance Group
PO Box 4238, Lexington, KY, 40544

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THE VALUE OF CERTIFICATION

 Why is certification important to the riding instructor and to the horse industry?

 The experiences required for certification are more beneficial to the instructor than the certificate itself.  The process of certification reflects the guided examination and evaluation of the teaching abilities of the candidate.

 Certification demonstrates to the public, to the employer, and to one's peers, the value that a riding instructor places on the profession.  Most candidates pursue certification for job requirements, insurance coverage or to aid in their personal growth in the riding and teaching industry.

 Courts of law tend to view credentials and seals of approval as evidence of the professionals' attempt to keep abreast of current information and practice and to be aware of the "state of the art."  Certification has become important to our society for several reasons. When businesses of consumers select a product or service they need a starting point.  In other words, how does this product or service compare?  How does this riding instructor measure up to the standards set by the British or the French?  This need as well as the desire of professionals to regulate themselves, "police their own ranks" as it were, has given rise to the establishment of "seals of approval" or certification. Certification represents personal pride professional effort and an expenditure of time and money ...just like acquiring a college degree in a shorter term.

 In insurance and litigation issues, more courts not only look favorably on "certificates of achievement" but are apt to consider the certified instructor in a more favorable light than that of the un-schooled, but perhaps, equally talented person.  The unavailability of liability insurance for many stables has heightened the need for certification.  Indeed, there are many insurance companies who will only issue coverage to "certified" instructors. Litigation in case of an accident is sometimes avoided or arbitrated based on the documentation of an instructor's education.  Attorney's realize that certification in most cases is granted only after the successful completion of a variety of experiential and cognitive learning activities.

 In 1980-81 study conducted by Hawkins and Associates of Washington, DC, Project Evaluators, hired to evaluate the impact of the American Camping Association Camp Directory Institute experience, documents the belief of employers and participants that the Camp Director Institute has had a beneficial impact on the professional performance of the camp director (CCD) who participated.  A 1980 consumer survey prepared for American Camping Association by Hawkins and Associates documented that parents of campers desired more camp directors complete certification.

 There are, of course, strengths and weaknesses on both sides.  Foes of certification are concerned that the issuance of a certificate indicates that the holder has merely fulfilled the necessary requirement for safety and excellence in teaching.  It may well be that in the certification process, those requirements were met but there is no assurance that he or she in daily practice is a safe and effective instructor.  It is argued that the possession of a certificate does not constitute a necessary condition for being a safe and effective instructor.  Examples are given of riding instructors who have taught successfully for many years with excellent safety records who hold no certification at all.  In the attempt to equate "certification" with excellence and the converse relationship of "excellent with certification" that causes the foes of certification concern.  The strength of the argument for certification lies in the premise that safety and excellence in teaching others can be taught.  With this thought it is reasonable to assume that it is better to have instructors who have been certified as knowing safe practices than to have instructors whose knowledge of safe teaching techniques is not known.

 The protection of equestrians from poorly trained instructors could be the focus of all instructors.  The value of certification to the instructor is a better edge in the job market, liability insurance availability, and a heightened concern for his/her students safety.  To the employer certification demonstrates that the instructor has met the basic competencies required for certification.  The certified riding instructor may do a better job of teaching having made a major professional achievement that took time, money, and expertise.

Betty Bennett-Talbot
517 Bear Road, Lake Placid, FL 33852.

Editors note:  Betty Bennett-Talbot with her late husband founded the Horsemanship Safety Association in 1967.  The AMEA joined others in January 1998 to elect Betty Bennett-Talbot to the Lifetime Achievement Award given by the North American Horsemen's Association.
 

 COMMENT on THE VALUE OF CERTIFICATION

 Enhanced safety awareness, continuing education, credibility, confidence and peace of mind of a client are just a few of the benefits that a certified instructor brings to a horse program.  Who becomes certified?  Certified instructors consist of professional individuals who have dedicated additional time and finance to enhance their knowledge and committed to further educating themselves in each of their chosen fields.  These people may be riding instructors, program directors, trainers and even people in competition.  Safety is an issue that effects everyone regardless of discipline or specialty.  There are organizations through the US, Canada, Australia and England that work toward the common goal of instructor certification.  One of these is CHA, a US based international organization that certified hundreds of instructors each year.  The goal of CHA and other like organizations is safety in all aspects of the equine environment.

L. J. Skiver
Executive Director, CHA-The Association for Horsemanship Safety & Education
5318 Old Bullard Road, Tyler, TX 75703

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NEED FOR TAILORED EQUESTRIAN SAFETY EDUCATION

 As primary health care professionals, we look to prevent injury.  As horse people, we understand the risks inherent in horse activities.  We can better develop injury prevention programs with an understanding of people's perceptions on risk and health protective behavior.  As part of our effort to understand equestrians' perceptions of risk to horseback riding injury and engagement in health protective behaviors, preliminary results of a survey are summarized here.

 A respondent profile is emerging from a sample of 43 equestrians in the Chicago area.  The typical respondent is female (81%) and 39 (SD 2.2) years old.  She owns her horse or pony (93%) and rode more than 7 times in the past 12 months (95.3).  Her most frequent style of riding is English (86%).  She is likely to engage in certain types of health protective behaviors; use of helmets (67.4%), lessons (83.7%), and riding boots (95.3%).  She in unlikely to use safety stirrups (83.7%).

 Several statistically significant correlations (p < .05) show moderate relationships (r range = .31-.47).  Positive relationships exist among style of riding (English), helmet use (r = .4, p<.01) and lesson use (r =
.3, p < .05).  Strong positive relationships exist among variables measuring perceived likelihood of injury, perceived likelihood of head injury (r =.5, p <.0001) and the combined susceptibility variable (r =.8, p
<.0001).  Helmet use correlates positively with only one perception variable: personal perceived susceptibility to head injury (r = .4, p<.01).

 So, it appears from this small study that if health professionals work to increase equestrians' personal perceived susceptibility to injury and perceived likelihood of injury these same equestrians may increase their engagement in health protective behaviors.  The physician and nurse practitioner could tailor anticipatory guidance to equestrian perceptions of susceptibility to injury and concomitant use of health protective behaviors.  This safety teaching could result in decreased emergency room visits secondary to horseback riding injury.

 Physicians and nurse practitioners in the emergency room could use the "teachable moment" that usually follows an injury to reinforce primary care teaching.  Development of written material such as handouts and fact sheets could provide additional reinforcement of risk reduction and injury prevention teaching.

The 1,958,500 horse owners and the 4,335,000 family members and horse industry volunteers in the United States (Barents Group LLC, 1996) stand to benefit from this study.  Advanced practice nurses, physicians and public health professionals need to work together to provide safety education tailored to equestrians' perceptions on susceptibility to horseback riding injury and adoption of health protective behaviors.
 
Rosemarie Stefaniw Gottlieb,  MS, RN, CFNP, MPH  (Masters Project)
3847  N. Sacramento Avenue, Chicago, IL 60618

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EQUESTRIAN INJURIES:  A SURVEY IN BRITISH COLUMBIA, CANADA

Introduction:  The recent tragic accident involving "Superman", actor Christopher Reeve, who sustained a neck injury rendering him permanently quadriplegic,  has brought the attention of the world onto the potential severity of riding accidents. It is timely to review recent literature and statistics on this popular sport.  Although it is estimated that there are 30 million riders in the USA,  no corresponding data is available for Canada.  A survey in 1994 by the Ministry of Agriculture put the number of horses in
British Columbia, Canada, at 75,000 with 33,000 riders [10].  Unfortunately many non-competitive horses and riders were missed.   Knowledge of equestrian activity and the specific injuries sustained by riders may be necessary to  treat these athletes adequately.

Case 1:  A professional exercise rider from the race track who gallops twenty young horses per day from a thoroughbred horse farm and inspite of wearing the mandatory safety helmet and body protection, sustained a head injury and loss of consciousness for 15 minutes.  She was transported to a local hospital where an X-ray revealed no fracture and she was apparently told to return to work.  Luckily, the trainer would not allow her to re-mount without a doctor's note.  The woman obtained a note from a local Walk-In Clinic the next day.  Again, fortunately,  one of the horse owners was a retired  neurologist who refused to let the woman ride.  Ultimately, the woman was informed that she would not be able to ride again until all evidence of dizziness was gone and the soft tissue injuries to her cervical spine were healed.  She was also forbidden to work around horses to prevent possible re-injury.  She was off work for 4 weeks and only allowed a gradual return to work.

Case 2:  An inexperienced woman who purchased a stallion was kicked in the left knee as she attempted to lead him.  She was taken to a local hospital where an x-ray revealed a possible avulsion fracture in the knee.  She was given a few analgesics and sent home with no further arrangements for treatment.  An office visit revealed an effusion and severe internal derangement of the knee.  Referral to an orthopaedic
surgeon was made and a Jones splint and crutches provided, as well as adequate analgesia. MRI revealed an anterior cruciate tear, as well as tear of the medial meniscus.

These cases dramatically illustrate how physicians may underestimate risk to the rider on a 500 kg animal who can travel 65 km/h and raises the rider 3 m above the ground. The force of the kick of a highly athletic animal equipped with metal shoes is not trivial  These animals are also quick to change direction without warning and this involves  an enormous amount of centrifugal force on the rider who must maintain absolute balance.

It is difficult to obtain statistics on local riding demographics and accident information.  The National Electronic Injury Surveillance System (NEISS) horse related injury figures were published in the American Medical Equestrian Association (AMEA) newsletter of August, 1997.  The NEISS reports 60,316 injuries in 1996.  The overall injury rate has decreased in the past 6 years from 74,349.  Injuries occurring to the head account for 17.9% of the injuries in 1996.  Female gender accounts for 54.7%  of the injuries and 51% of the injured are over 25 years old  The present study was undertaken to determine some local information on horse-related injuries.

Methods:  A  questionnaire was composed and circulated at a popular demonstration of  horse training techniques and to my equestrian patients.   The rider was asked to specify age, gender, activities with the horse, type of saddle,  years of riding experience and the amount of time spent with the horse per month (this included activities mounted and on the ground).  The riders were asked to recall the location of their accident, the severity of injury, the area injured,  type of injury and the cause. They were also asked if they were mounted and whether they used a helmet.

Results:  339 participants at the demonstration returned 37 questionnaires.  22 of 30 equestrian patient questionnaires were returned.  These 59 questionnaires were analyzed.  The people who answered the questionnaire were mostly female  (86%) over the age of 31 years (84%) who spent greater than 30 hours per month with their horse (70%) and had been riding more than 10 years (53%).  Of 59 replies, there were 68 injuries. There was a fairly equal distribution of riders using a saddle with a horn (usually Western) and those without a horn (usually English) 45% but many participants use both at different times.  The data shows that these 59 people used their horse in 147 activities, indicating that many horses perform several duties but most were involved in pleasure riding (31%).  A helmet was worn by 52% of the riders.

There were 18 (31%) who had sustained no injuries in the previous year. This included 80% of the men in the study.  All the uninjured riders had more than 5 years experience and  worked with horses over 40 hours per month.  The uninjured ranged from 31 - 50 years of age.  Fifty percent wore a helmet.  They mainly used saddles with horns (56%) or both (17%) types of saddle. The injured riders were most often mounted (66%) in an arena (37.5%) or on the ground in the barn (27.5%).  Those who were mounted mostly used their horse for pleasure (30%), and trail riding (21%).  The most frequent site of injury was the head (31%) and lower limb (31%).   The injuries were mostly mild (62%), involved bruising (33%), or a strain (28%).  Only 5% were considered serious.

 The moderate and severe injuries involved experienced riders (67% >10 years) spending 30 hours per month with a horse (75%).  Helmets were worn by 58%. The mechanism of injury was distributed mainly between bucks (18%), kicks (16%) and stepped on (16%).

Discussion:  Although the numbers involved in this analysis are small, they agree with the findings of several larger studies1,2 and the NEISS data, in that females predominate and most injuries are mild [11].    The small number of men in the study probably reflects a reluctance to fill in the forms.  Falls while mounted and kicks to handlers on the ground were the main mechanisms of injury [1]. Most horses are used for pleasure riding, but this study indicates that most injuries occur in an arena, where schooling the horse usually occurs.  The second most common location was in the barn, where a horse is in a confined area, sometimes receiving unpleasant treatment, and the person on the ground is at risk.  The rider least likely to be injured used a Western saddle but this is impractical for jumping due to the horn in front. The sample presented is a much older and more experienced group than many other studies [1,2,3 ] but still we see a large number of accidents including multiple injuries or repeat injuries.  This data supports the hypothesis of other authors that experience alone does not prevent injury 2.  The present study had no comparison for skill level. This study differs from some studies which only examine lethal injury [1,8,13].

Whether the helmet was approved, in place or correctly fitted at the time of the impact is unknown. Recommendations for contraindications to riding include previous cervical spine fracture, absence of odontoid,  temporary paralysis, head injury with permanent impairment and narrow spinal canal.  Relative contraindications include repeat concussion, brachial injury, lumbar injury, disc herniation and repeat soft tissue injury to neck and back [12, 4].  This sort of guideline would be beneficial to circulate to prospective horse riders through groups such as the Horse Councils, Pony Club and 4H clubs.  This information should be made available to physicians and riders, much as information on contraindications to Self-Contained Underwater Breathing Apparatus (SCUBA) is provided by the Professional Association of Diving  Instructors (PADI).  The Canadian Equestrian Federation (CEF) has established Instructor levels and could provide this information through these instructors.

 Physicians must be aware that horse riding is considered a moderate to high impact sport 4 and head injury guidelines for return to activity should be followed14.  These activities include handling the horse on the ground. Education of parents of young riders, equestrians and physicians needs to be undertaken.

A copy of a brochure attributed to Macaulay [9] recently circulated in the AMEA newsletter which addressed prevention of equestrian injuries.  This information  included selection of an appropriate horse, supervision and education of the novice rider, use of approved  helmets,  reliable riding equipment, horse handling and safety at organized meetings and competitions.    Unfortunately some studies show that safety instruction did not decrease the incidence of injury [5].  A large prospective study needs to be done to address this issue.

Riding will never be without risk but properly fitted approved helmets may
prevent lethal injuries [2,3,4].

References:

1.      Aronson H. Tough SC - Horse-related Fatalities in the Province of Alberta, 1975 -  1990 Am J of Forensic Med & Path 14(1): 28 -30 Mar 1993
2.      Bixby-Hammett, D.M. - Accidents in Equestrian Sports AFP 1987;36(3):209 - 214
3.      Bixby-Hammett, D.M. - Pediatric Equestrian Injuries Pediatrics 1992        89(6):1173-1176
4.      Bixby-Hammett, D.M., Brooks, W.H. - Neurologic Injuries in Equestrian Sports   Sports Neurology, Aspen Publications 1989 pp 229-234
5.      Christey, G L., Nelson,D E., Rivara, F P., Smith, S M., and Condie, C - Horseback     Injuries Among Children and Young Adults J Fam Pract 1994;39:148-152
6.      Hobbs, GD., Yealy, D M. and Rivas, J - Equestrian Injuries: a Five Year Review  J           Emerg Med 1994;12(2) 143-145
7.      Hughes, K. M, Falcone, R E., Price, J, Witkoff, M - Equestrian-Related Trauma   Amer J of Emerg. Med 1995;13(4)485-487
8.      Ingemarson,H,Grevsten, S, and Thoren,L - Lethal Horse-riding Injuries - Journal of   Trauma 1989;29(1)25-30
9.      Macauley,C- Preventing Equestrian Injuries AMEA News 1997;8(2) 11
10.     Ministry of Agriculture of British Columbia 1994
11.     NEISS 1997 Horse Related Injuries AMEA News August 1997;8(2)1-3
12.     Nelson, D E., Bixby-Hammett, D - Equestrian Injuries in Children and Young  Adults AJDC 1992;146  611-614
13.     Pounder, D J. - The grave yawns for the horseman Equestrian deaths in  South  Australia 1973-1983  Med J Aust 1984; 141: 632-635
14.     Quality Standards Subcommittee Practice Parameter:  The Management of    Concussion in Sports (summary statement) Neurology 1997;48:581-585
15.     Stewart, G. - Bullriding Related Brain and Spinal Cord Injuries, as presented  at  AMEA annual meeting October 1997

Dr. Janet M. Sorli.
1675 - 128  Street, Surrey, B.C., Canada

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NEWS ITEMS
AMEA ANNUAL MEETING NOVEMBER 6-7, 1998

 Danny Emerson will be the keynote speaker at the AMEA Annual Meeting November 6-7 in Durham, NC, at the Radisson Governor's Inn.  The planned program begins Friday afternoon and will cover Coaching/Teaching Equestrians.  The second session will address the Physical Aspects of Riding.  In the evening the participants will be attending the Duke Children's Classic Horse Show.

 The third session Saturday morning will be on Therapeutic Riding Modalities followed by Equestrian Injuries.  There will be a 12 noon luncheon.  At 1:15 the topic will be Preparing for an Equestrian Event.

 Mark your calendar today to attend this excellent program and the AMEA annual business meeting.
 

AYER -HAMMETT AWARD

During the 1997 AMEA annual meeting, the board approved the creation of an award to honor an individual who has advanced the cause of rider safety.  The award, to be named the Ayer-Hammett Award, will be bestowed by the AMEA board when it receives a nomination which it believes merits
the honor.  Therefore, the Award may not be presented every year.  Included with the Award will be an opportunity to address those in attendance at the annual meeting

The board has selected an individual to receive the Award at the 1998 meeting.  Any AMEA member who wishes to nominate someone to receive the Award in 1999 should submit a letter to the AMEA Frankfort office with information on that individual, and the reasons why he or she should be recognized.

The Award was named in honor of two individuals who have contributed greatly to the horse industry: the late Neil Ayer and Dr. Doris Hammett. Neil Ayer was instrumental in the growth of the United States Combined Training Association and was a strong advocate for safety.  Posthumously, the Neil Ayer Foundation has funded work in equestrian safety including the AMEA Equestrian Safety Video.  Doris Bixby-Hammett is well known to all AMEA members as a founder, for the tremendous job she did as Executive Secretary.  She presently is serving as the Editor of the AMEA News.  Dr. Hammett has worked tirelessly for more than twenty years on a multitude of safety issues, particularly the development of helmet standards and testing.

Michael Nolan
Executive Secretary, AMEA
 
 

EQUESTRIAN SAFETY

 EQUESTRIAN SAFETY:  A guide to Promotion of Helmet Use for Riding Clubs and Communities, is prepared for those interested in safe riding and how barriers to protective equestrian helmet use might be overcome.  The samples in the guide can be reprinted for educational purposes without permission but the authors ask that the following guidelines are followed:  there is no charge for the materials and the materials should not be altered in any way.  There are eleven pages of information that can be copied.

  The guide was originally developed by the Harborview Injury Prevention and Research Center. It was revised and updated by the Children's Safety Network Rural Injury Prevention Resource Center, National Farm Medicine Center, 1000 North Oak Avenue, Marshfield, WI 54449. The material was developed as a tool for local clubs and other organizationsThis publication can be obtained for $1.00 plus shipping and handling $1.00 from Bulletin Office, Washington State University, PO Box 645912, Pullman, WA 99164-5912

For technical assistance in implementing equestrian safety programs for youth contact Chris Hanna, MPH, in Marshfield, WI at email: <hannac@mfldclin.edu>.

Doris Bixby Hammett, MD
 

RIDING AT A PUBLIC STABLE

1.  Child mounted without protective helmet, in sandals with foot in the leather stirrup strap with the stirrup hanging below the foot.
2.  Child mounted without protective helmet, in a shoe without a heel with the foot in the leather stirrup strap with the stirrup upside down below the foot.
3.  Mounted adult in shorts without headgear, infant in shorts without headgear riding double in front of the adult, child holding reins of the horse.

 These pictures showing riders at great risk were seen and photographed at a popular public stable.  We are frequently confronted by dangerous situations with riders.  The challenge to those concerned with safety is what can be done about what we see.  If the situation allows, we can speak to the rider involved.
Alernatives include:
1.  Talk to the stable's manager:  often those working at a stable are without knowledge about safety.  The routine answer is:  "We NEVER have had an accident, so what we are doing must be right." Sometimes riders, parents, and even instructors are unaware of the risks - perhaps they have never had the difference between a riding hat and a truly protective helmet explained to them.

2.  Work through the stable's insurers.  This assumes that the stable is covered by insurance.  Insurance companies are increasingly aware of safety, and before insuring a stable may ask about safety measures.  The Ark Insurance Agency, Linda Leistman, North American Horseman Association, feels that stables with poor safety operations are decreasing.

3.  Work though the local horse community leaders:  speak to the local extension agent, contact the local riding clubs, local horse shows and events and the local horse community  This will be a teaching/learning situation for many horse organizations.  Be prepared with information: use information from 4-H, Safe Kids (see article in this NEWS), "Every Time ...Every Ride..." video and the booklet of "saved " stories (Washington State 4-H Foundation, 7612 Pioneer Way, Puyallup, WA 98371), AMEA Safety Video (Contact William Lee, MD, Desert Foothills Medical Center, PO Box 2150, Carefree, AZ 85262) and the AMEA brochures (office address in masthead AMEA NEWS.)

 If you have suggestions or have had successes in your community, please take a moment to write about them for  the AMEA NEWS.

 Doris Bixby Hammett, MD
 Editor
 
 

 EQUINE-RELATED NEUROSURGICAL TRAUMA:
A PROSPECTIVE SERIES OF 30 PATIENTS

 Thirty million Americans rider horses: 50,000 are treated in emergency rooms annually. Equestrian activities are uniquely dangerous because the participant is unrestrained, often helmetless, and riding large, unpredictable animals capable of 30 mph speeds and kicking with up to 1 ton of force. Neurologic injuries in equestrians constitute the majority of severe injuries and fatalities.  We prospectively studied all patients admitted to the University of Kentucky Medical Center with equine-related neurosurgical trauma from July 1992 to January 1996.

 Eighteen of 30 patients were male. Age ranged from 3 to 64 years.  Five patients died (17%) and two suffered permanent paralysis.  There were 24 head injuries (80%) and 9 spinal injuries (30%).  The majority of injuries (60%) were caused by ejection or fall from the horse.  Twelve patients (40%) were kicked by a horse, and four patients sustained crush injuries.  Six patients underwent craniotomy, three had operative spinal stabilization, and five required ventriculostomy.  Eleven patients (37%) were professional riders.  Twenty-four patients (80%) were not wearing helmets, including all fatalities and craniotomy patients.

 Our data show that equine-related neurosurgical injuries can be severe and fatal because of the significant size, force, and unpredictability of these animals as well as the lack of proper headgear.  We recommend that helmets be worn at all times around horses because a significant number of our patients (33%) were injured as bystanders. Risk of serious injury appears to be a function of cumulative exposure to horses, not level of expertise.  Experience is not protective;  helmets are.

Timothy C. Kriss, MD and Vesna Martich Kriss, MD
The Journal of Trauman Injury, Infection and Critical Care, Vol. 43. No 1, Pages 97-99.
 

HEAD, FACE, AND NECK TRAUMA
FROM LARGE ANIMAL INJURY IN NEW MEXICO

Background: Head, face, and neck injuries (HFNI) occur during animal-related trauma.  We compared patients with HFNI and without HFNI after animal-related injuries to determine the significance of these injuries.

Method:  Retrospective review of admissions for animal injuries between January, 1990, and December 31, 1995, by age, gender, mechanism, animal, Glasgow Coma Scale (GCS) score, Injury Severity Score (ISS), Abbreviated Injury Severity score for head and neck (AIS Head/Neck), AIS score  for face (AIS Face), intensive care unit stay, hospitalization length, morbidity, and mortality.

Results:  There were 153 admissions: 61 HFNI and 92 no HFNI.  Significant difference occurred in gender, animal, activity, GCS, and ISS.  HFNI were from horses in 87% and occurred during recreation in 89%;  39% of patients with HFNI were 18 years or younger.

Conclusions:  HFNI occur in females and young people and produce lower GCS score, higher ISS, higher AIS HEAD/Neck, higher AIS Face, and higher mortality.  Most occur during recreational horseback riding.  Protective headgear should be mandated.

R. Thomas Temes, MD, John H. White, MD, Loren H. Ketai, MD, Joan L. Deis, MSN, Stuart B. Pett, Jr. MD, Turner M., Osler, MD, and Jorge A. Wernly, MD.
The Journal of Trauma,  Injury and Critical Care.  Vol 43 No. 3, pages 492-495.
 
 
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