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Falls Protocol & Recognising Concussion

This article is from the December 2020 Horse Deals magazine.

The title of this feature is somewhat off-putting and some readers may quickly turn the page. Also, it is not our intention to put people off riding horses because the activity is deemed dangerous. Life itself involves elements of danger and it is how we approach the dangerous elements of what we choose to do that make them less threatening and by definition, more enjoyable; and there are few activities more enjoyable than horse riding. So despite initial misgivings, read on as Horse Deals spoke to lifelong and international showjumping rider, Professor Brad Frankum OAM and Di Broad of R and D First Aid. Both Brad and Di understand the nature of riding injuries and give insight into how, in the event of an injury we should proceed.

Professor Brad Frankum OAM B.Med (Hons) FRACP FAMA

Ever since he qualified as a doctor, Brad has often been called upon to attend a fall or an injury at a horse show. He is not at the show in any official medical capacity, he is there to ride, but never refuses to render assistance. If there is a bad fall, it is a case of, “where’s Brad?” So one of the first questions we asked him was, what medical personnel should be in attendance at a horse show?

“The first thing to say” begins Brad, “is that you can never have the perfect response at all times. For a serious injury, we are not going to always have the level of care required; that is not possible. People need to understand that if they have a serious fall at a horse show, they may not receive a high level of medical intervention immediately. It is one of the risks we take. With showjumping, for the most part, I don’t think we can justify having a doctor on-site the whole time, whereas for eventing I think a doctor should be in attendance. The incidence of very severe injury in showjumping is quite low. It happens, but luckily, it’s very rare. The majority of injuries are minor, or fractured limbs and really a doctor is not going to be able to do a lot about the issue on-site anyway. You do, however, need very competent first aiders, experienced in the field. At times you are going to be caught out with a more severe injury to a rider, but that can and does happen at home as well.

“Head injuries are not the only serious injuries, however they are probably more likely in showjumping than the more traumatic injuries like cracked ribs, punctured lungs and ruptured livers, because the riders tend to get thrown clear, or fall on their heads from quite a height. I have been called upon to attend and assist people who have fallen at about 5% of the shows I go to. I don’t think that I was responsible for saving anyone’s life, but I have saved someone’s spine.

“There have been quite a few serious interventions and quite a few occasions where I have insisted someone go to hospital for assessment. Fortunately, I have never had to perform CPR at a horse show, but I have at an athletics competition. People must understand too, that I am going to err on the side of caution and conservatism, because I am in the field without any equipment and obviously, I don’t want to miss a nasty injury. I am pretty confident about saying something is a minor injury and not to worry about it. But it is not just the competition arena where accidents can happen. The practice arena and indeed anywhere where horses and people mingle. Around horses, you must remember that anything can happen. At jump club, I remember a groom was kicked in the head and was lying on the ground, with a huge hematoma forming and not knowing if she had been unconscious or not. I insisted on an ambulance being called. It turned out that she was OK, but it could have been serious and not insisting on that line of action would have been negligent, to my way of thinking.

“There is a lot of emphasis on concussion when we are talking about the consequence of falls, but I don’t like using the term concussion in assessing head injuries, because you can have a serious head injury without actually having concussion. Concussion refers to a deceleration injury of the brain. This occurs when you hit your head on one side and your brain gets shoved over and bangs against your skull on the other side, and then back again, a bit like a jelly in a bowl. Whiplash and Shaken Baby Syndrome can also cause concussion-like symptoms.

What to look for when assessing head injuries

“The best way to judge a head injury is to observe it happening. I really do like the concept of the medical attendees as much as possible observing the competition. If you see the injury, you can assess the level of impact and the mechanism of injury and the likelihood of severity.

Did they lose consciousness for any period of time? Lost consciousness always signifies significant trauma to the head and always requires a visit to hospital for assessment.
Visible signs of injury to the face or skull. E.g. Haematoma, bruise on the face etc.
Loss of orientation or memory. An immediate headache is not such a reliable sign; it hurts when you hit your head. However, a persistent headache is to be taken very seriously, or worsening headache, or persistent nausea for more than a short period of time, as it is a potential sign of raised intracranial pressure and should be further assessed.
Any abnormal neurological sign is very serious. E.g. Weakness on one side of the body, changes in the pupils of the eyes, visual changes like blurred vision.

“It’s these cases it does require a certain expertise to do a neurological examination to assess whether someone has focal neurological issues.

“I am not a specialist in trauma or orthopaedic injuries, that is not my speciality, but I have been around for a long time in horse sport so know how easily brain injuries can occur. It is important to have experienced medical aid at horse shows and they need to be skilled at airway management. Horse shows should remember that the medical attendees are more important than the hospitality tent.

“I never get on a horse without a helmet these days. People should always wear a helmet, and they should not ride when there is no one else around. The brain is so delicate, and even an innocuous fall can cause serious injury.”

R and D First Aid

We observed Rick and Di Broad in attendance at a Willinga Park showjumping event and were impressed with both their attitude and their action. They were camped ringside with their quadbike kitted out with all the gear they thought needed for the occasion. “We like to see how the fall happened, so we can assess the possible severity of injury,” says Di. “For instance, if they fall on their shoulder, we are likely to be dealing with a broken collar bone or shoulder. We live at Tumut and both Rick and I have had 25 years experience in the SES, alpine rescue and road crashes. We have all our first aid qualifications and are actually first aid trainers. A few of the local drafts said they were having trouble getting first aiders, we helped out and it has snowballed from there. So we started the business, organised insurance and went about getting all the qualifications to meet the requirements of the ABCRA (Australian Bushman’s Campdraft and Rodeo Association) and different associations like that. We are horse people and have five horses of our own and breed a few and compete and I think that gives us insight as to how the horse works and the nature of some common injuries.

“We ask to be put ringside; ideally somewhere where we can see the practice ring as well. It is good to be right there, as sometimes when someone falls off, people rush in to help and they move the rider, or they pick them up perhaps and sometimes that can do a lot of damage. Fallen riders shouldn’t be moved until they are properly assessed. Of course, if they are in immediate danger, you must get them out of there. We are interested in the high level of showjumping, but wherever we are, showjumping, campdrafts and stockman’s challenges, we are there to do a job, so we make ourselves interested in what is going on. There are certainly more falls associated with showjumping than campdrafting.

“The head injuries get a lot of publicity and we check every rider for concussion regardless of what we think the injury may be. We do the concussion check which involves a list of questions we ask the patient and a physical check for any knocks to the head. You can often tell by looking at them; do they have any bleeding from the nose or ears, do they have any ringing in their ears, are they nauseous, are they feeling faint? We have a list of about 25 questions and observations that we go through. If they seem OK at the time we give them a list of red flags to watch for later. Two to three hours later and up to 48 hours later, they may suffer from delayed concussion. Even if they are OK when they leave us, we tell them to watch for the seven red flags illustrated above.

“Symptoms can vary greatly. We make it clear to the patient and their connections that if any of the red flags appear, they must seek further medical help.

“Arms, legs and shoulders seem to be the main jumping injuries and with showjumping too, you have to contend with the actual jumps themselves; falling on the rails, hitting the wings. We are not paramedics, however we have done further study when we started up our business. We have done Advanced Resuscitation incorporating the use of oxygen and the defibrillator and we are also qualified to give the Green Whistle (Penthrox) via the inhaler, which is beneficial in pain relief whilst waiting for the ambulance to arrive and helps prevent the patient from going in to shock.

“A lot of what we do is just common sense like advising riders to always wear a helmet. You only have one head and it is a good thing for the kids to see the senior riders wearing a helmet. We have all the gear on the quad bike as well as lollipops. Sometimes kids have fallen off and are not hurt, but frightened and upset and it is amazing how often the lollipop stops the tears. A lot of accidents too, don’t happen in the competition arena. There are kicking, crushing and head knock injuries wherever there are horses. Also, we cannot carry all the equipment for everything and sometimes we have to improvise.”

As you can imagine, with 25 years of experience in serious and minor first aid and the horse world, Di and Rick are in great demand.

Article: Anna Sharply

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