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Casualty management

Printed From: Yachts and Yachting Online
Category: General
Forum Name: Race Management
Forum Discription: For race officers and competiors to discuss the topic
URL: http://www.yachtsandyachting.com/forum/forum_posts.asp?TID=8915
Printed Date: 26 Nov 20 at 10:46am
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Topic: Casualty management
Posted By: zippyRN
Subject: Casualty management
Date Posted: 12 Jan 12 at 9:34pm
In the light of  incident in Aus discussed here  http://www.yachtsandyachting.com/forum/forum_posts.asp?TID=8905&title=unfortunate-event-at-australian-youth-championship - http://www.yachtsandyachting.com/forum/forum_posts.asp?TID=8905&title=unfortunate-event-at-australian-youth-championship  maybe it's time for another 'rescue' topic 

my first question  primarily to  those who advocate single crew rescue boats or rescue crews where the 'crewman' is not dressed to enter the water   - how would you deal with this especially if it were a single hander or the crew of the casualty vessel was not 'together' enough  ( or in the case of club racing  where the crew might be a child and the helm a parent - physically capable of assisting )?

with my Health Professional Head on - my  first thought and the first thought of marshals and first aid / ambulance personnel at a motorsport even where you have a competitor knocked out  would be the possibility of spinal injury 

How many clubs  even possess Spinal immobilisation kit  never mind routinely  carry it on rescue boats  and have crews trained to use it 

- use of a long extrication board is a core part of the pool lifeguard qualification in fact Ferno make a specific   model of board for aquatic use   http://www.ferno.co.uk/product/aquaboard - http://www.ferno.co.uk/product/aquaboard

although the majority of long extrication boards are buoyant  and water proof ( being either rotomoulded or GRP ) while straps and head restraints might not be .

You can't rely on the Ambulance service being able to assist in a timely manner as  ordinary crews aren't water rescue trained - so we'd be relying on HART or the the Fire and Rescue service inland and the RNLI / Coastguard  in coastal waters 

I have visions of spending 30 or 40 minutes 'on scene'  with a hypoxic head injured patient  who is being handled poorly , and becoming more and more hypothermic because of a lack of preparation 




Replies:
Posted By: sargesail
Date Posted: 12 Jan 12 at 10:26pm
Zippy,

I'm puzzled by this.  I get the fact that they might have a spinal injury.  However surely in the majority of the conditions in which an injury would occur they would not only be at risk of drowning and hypothermia as you mention but would also have a very mobile spine due to the waves and the requirement to support them.

Next someone will be suggesting that I shouldn't lift their face from the water if they are wearing a BA not a lifejacket because thee might be spinal damage.

Surely the speeds and impacts are much less than motorsport an the risks of spinal injury much reduced.

Totally agree that rescue boats must have 2 crew.


Posted By: zippyRN
Date Posted: 12 Jan 12 at 10:41pm
Originally posted by sargesail

Zippy,

I'm puzzled by this.  I get the fact that they might have a spinal injury.  However surely in the majority of the conditions in which an injury would occur they would not only be at risk of drowning and hypothermia as you mention but would also have a very mobile spine due to the waves and the requirement to support them.


unless it was some horrid short chop an inert, 'relaxed' body  in the water wouldn't be undergoing a lot of violent movement  and is supported fairly evenly along their length by being semi immersed  ( assuming they are in BA, wetsuit / drysuit  +/- trap harness )

rather than ragging them about and them flopping all over the place as they are dragged from the water over the the side of a rescue boat and dumped in a heap on the floor ... 

Next someone will be suggesting that I shouldn't lift their face from the water if they are wearing a BA not a lifejacket because thee might be spinal damage.

 the gold standard would be to roll them while trying to keep them in line 

Surely the speeds and impacts are much less than motorsport an the risks of spinal injury much reduced.

still fairly high energy - and stuff like BMX (racing rather than the stunt / freestyle stuff)) still has the same sort of marshalling and medic-ing considerations  despite lower  energies 

it's a fair old whack to knock someone out 

Totally agree that rescue boats must have 2 crew.

if you look at previous  debates   on here it's suprising  that there isn't  consensus on this or that  you need to be ready to go in the water as rescue crew  to save life or limb 


Posted By: sargesail
Date Posted: 13 Jan 12 at 8:57pm
Originally posted by zippyRN

Originally posted by sargesail

Zippy,

I'm puzzled by this.  I get the fact that they might have a spinal injury.  However surely in the majority of the conditions in which an injury would occur they would not only be at risk of drowning and hypothermia as you mention but would also have a very mobile spine due to the waves and the requirement to support them.


unless it was some horrid short chop an inert, 'relaxed' body  in the water wouldn't be undergoing a lot of violent movement  and is supported fairly evenly along their length by being semi immersed  ( assuming they are in BA, wetsuit / drysuit  +/- trap harness )

rather than ragging them about and them flopping all over the place as they are dragged from the water over the the side of a rescue boat and dumped in a heap on the floor ..

Is that you're professional opinion (I'm guessing that the RN might mean Navy)...because I am entirely unconvinced by that.  Especially as I am imagining a desperate helm/crew supporting the casualty and remaining contact with their boat - the refuge of safety.

Next someone will be suggesting that I shouldn't lift their face from the water if they are wearing a BA not a lifejacket because thee might be spinal damage.

 the gold standard would be to roll them while trying to keep them in line 

I'll buy that - but I just can't bring myself to forget that breathing comes first.  Nor do I understand why this has never been taught/considered in any of the many water based first aid courses I have attaneded.

Surely the speeds and impacts are much less than motorsport an the risks of spinal injury much reduced.

still fairly high energy - and stuff like BMX (racing rather than the stunt / freestyle stuff)) still has the same sort of marshalling and medic-ing considerations  despite lower  energies 

it's a fair old whack to knock someone out

Yes - but in 30 years in the sport I have no recollection of hearing about a single spinal injury on a dinghy.  By and large impacts are between boats and boats - on the rare occasions that they are not I can not see a correlation between a BMX racer at 30 mile an hour with plenty of air, and a dinghy at 20knots (closing speed).

So can you cite any dinghy sailing spinals?  I'm just interested because it's not a risk I have really factored in - and I'm not sure that I buy into all of your arguments but if it is then I want to ask some questions about techniques etc.

Totally agree that rescue boats must have 2 crew.

if you look at previous  debates   on here it's suprising  that there isn't  consensus on this or that  you need to be ready to go in the water as rescue crew  to save life or limb 


Posted By: zippyRN
Date Posted: 14 Jan 12 at 12:40am
Sarge  i found your last reply  hard to read 

i'm not sure of any SCIs  from Sailing but given the fact Tess Lloyd was knocked clean out and  needed Neurosurgery and is still  anaesthetisted on ICU ...  

boat to boat collisions is not necessarily the issue  ,although someone  on the wire  thrown forward  in a collision  or someone struck by a boom with the full force of a crash gybe  is getting a lot of energy exchange in a short period of time 

as for the point about an unconcious crewmember and their partner holding on to them and the boat  the unconcious person is either going to be on their back being held / towed in the classical lifeguarding  'chin tow'  or semi erect  pulled up again their crewmate  with one of their crewmates arms under their axilla 'hugging' them to keep their head out of the water ( resting on their crewmates shoulder )  and the other arm treading water or holding on to the boat .

wrong guess on the RN ... given the topic is casualty management what else might it mean ?  ( to save people from further puzzlement I'm a registered Nurse and my clinical  background is in three main areas - prehospital care, Emergency departments and Spinal injuries rehab)


Posted By: sargesail
Date Posted: 15 Jan 12 at 9:29pm
OK - I'll park my concerns.  Had you been an RN waterborne medical specialist I'd maybe have seen it differently, but without any evidence of spinal injuries and with just one case where I don't htink we we even know the mechanism of injury I'm not going to worry about equioment or training.


Posted By: jeffers
Date Posted: 16 Jan 12 at 12:38pm
The simple answer is make sure you club mandates all boats with a 'safety'role to have 2 able bodied people on board, one of whom is dressed to enter the water.
 
It is common sense if you ask me but should be written down.
 
We have the rule at Hunts and we are a small inland club where the shore is never much more than 30 secnds way by powerboat at full throttle.


-------------
Paul
----------------------
D-Zero GBR 74


Posted By: radixon
Date Posted: 16 Jan 12 at 8:30pm
The RYA Safety boat course or first aid course do not deal with spinal boards. I dont think it is something that should worry us. Hyperthermia and drowning are more of an issue with sailing than having a back injury.




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Posted By: zippyRN
Date Posted: 16 Jan 12 at 10:46pm
Hypothermia is a significant consideration,  but cold shock is more likely to kill you 

and why might people sailing drown ?  because of head and neck injuries   from the boom striking them  or being struck by another boat ... 

 the " it'll never happen " has happened  with the unfortunate incident in Aus , will it take a fatality for attitudes to change ?





Posted By: zippyRN
Date Posted: 16 Jan 12 at 11:42pm
For those asking aobut injury prevalence etc  - a  very quick and dirty literature review throws up a variety of discussion in professional literature as well as general news items and specific information from sailing clubs 

http://www.ncbi.nlm.nih.gov/pubmed/10859791 - http://www.ncbi.nlm.nih.gov/pubmed/10859791

http://www.ncbi.nlm.nih.gov/pubmed/19203134 - http://www.ncbi.nlm.nih.gov/pubmed/19203134

http://www.msscentershop.info/content/40/7/587.full.pdf - http://www.msscentershop.info/content/40/7/587.full.pdf

http://www.working-well.org/articles/pdf/Sailing.pdf - http://www.working-well.org/articles/pdf/Sailing.pdf

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/01/08/sailing-injuries-common-survey-finds - http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/01/08/sailing-injuries-common-survey-finds

http://www.broads-authority.gov.uk/broads/live/authority/meetings/broads-authority/2011/05-13/%5breport%5d%20Annual%20Safety%20Audit%202010%20ba130511.pdf - http://www.broads-authority.gov.uk/broads/live/authority/meetings/broads-authority/2011/05-13/[report]%20Annual%20Safety%20Audit%202010%20ba130511.pdf

http://www.rbyc.org.au/news.asp - http://www.rbyc.org.au/news.asp

part of the problem is drilling down through all the over use vs acute trauma and the fact that 'sailing' as a whole  can  cover a variety of disciplines - including  windsurfing and kiteboarding at times as well as dinghy / keelboat/ yacht


Posted By: jeffers
Date Posted: 17 Jan 12 at 7:26am
The problem is that unless you have a trained paramedic in each 'safety' boat you are never going to be able to cover all possibilities.
 
Spine and neck injuries are a possibilites but give that (most) dinghy crashes are low speed and most people crewing safety boats at sailing clubs are volunteers you have to give them an overview of the most likely situations which are drowning and hypothermia.
 
At the end of the day you and only do what you can do at any given incident. Regretably sometimes this may not be enough (this from a former first aider who had someone die on them from a heart attack). The main priority is to get the casualty out of the water and administer first aid and get them ashore as quickly and safely as possible. At that point the professionals can take over.
 
No doubt there can be lessons learnt from this incident not least of which is observation is key when sailing on a crowded race course and being aware of potential incidents (and giving additonal requirements to hail may help).
 
At large events such as this one then it may be practical to have at leat 1 safety boat crewed with a paramedic, at grass roots level this is just not possible.


-------------
Paul
----------------------
D-Zero GBR 74


Posted By: zippyRN
Date Posted: 17 Jan 12 at 2:11pm
Originally posted by jeffers

The problem is that unless you have a trained paramedic in each 'safety' boat you are never going to be able to cover all possibilities.

that's odd given pool lifeguards with the NPLQ and  St John Ambulance 'Advanced First Aiders ( under the 2011/12  skill sets)' are taught  casualty handling  for the patient with a suspected  spinal injury  based on mechanism of injury .

ditto for none Paramedic ambulance staff including  the voluntary sector crews  as well as technicans and assistant grades in the NHS, Some of whom will be using the JRCALC selective immobilisation guidelines as well.

have we got any RNLI personnel or Mountain rescue types who could let us know what is taught at a basic level and for designated casualty care pers ?

Spine and neck injuries are a possibilites but give that (most) dinghy crashes are low speed and most people crewing safety boats at sailing clubs are volunteers you have to give them an overview of the most likely situations which are drowning and hypothermia.

Volunteer  does not  have to mean incompetent or undertrained , would you be quite so forgiving of volunteer Race Officer who couldn't  do a general recall ? 

 
At the end of the day you and only do what you can do at any given incident. Regretably sometimes this may not be enough (this from a former first aider who had someone die on them from a heart attack). The main priority is to get the casualty out of the water and administer first aid and get them ashore as quickly and safely as possible. At that point the professionals can take over.
 
No doubt there can be lessons learnt from this incident not least of which is observation is key when sailing on a crowded race course and being aware of potential incidents (and giving additonal requirements to hail may help).
 
At large events such as this one then it may be practical to have at leat 1 safety boat crewed with a paramedic, at grass roots level this is just not possible.

You don't need a Paramedic to be able to provide adequate casualty care ...

also  a safety boat is a poor platform to perform  actual 'Paramedic' ( or other Healthcare professional only ) interventions  vs life saving first aid intereventions and  safely packaging someone for transfer to shore/ a larger  boat / rescue helicopter where  you can provide advanced life support care.




Posted By: ASok
Date Posted: 17 Jan 12 at 2:16pm
Originally posted by zippyRN

For those asking aobut injury prevalence etc  - a  very quick and dirty literature review throws up a variety of discussion in professional literature as well as general news items and specific information from sailing clubs 

http://www.ncbi.nlm.nih.gov/pubmed/10859791 - http://www.ncbi.nlm.nih.gov/pubmed/10859791

http://www.ncbi.nlm.nih.gov/pubmed/19203134 - http://www.ncbi.nlm.nih.gov/pubmed/19203134

http://www.msscentershop.info/content/40/7/587.full.pdf - http://www.msscentershop.info/content/40/7/587.full.pdf

http://www.working-well.org/articles/pdf/Sailing.pdf - http://www.working-well.org/articles/pdf/Sailing.pdf

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/01/08/sailing-injuries-common-survey-finds - http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/01/08/sailing-injuries-common-survey-finds

http://www.broads-authority.gov.uk/broads/live/authority/meetings/broads-authority/2011/05-13/%5breport%5d%20Annual%20Safety%20Audit%202010%20ba130511.pdf - http://www.broads-authority.gov.uk/broads/live/authority/meetings/broads-authority/2011/05-13/[report]%20Annual%20Safety%20Audit%202010%20ba130511.pdf

http://www.rbyc.org.au/news.asp - http://www.rbyc.org.au/news.asp

part of the problem is drilling down through all the over use vs acute trauma and the fact that 'sailing' as a whole  can  cover a variety of disciplines - including  windsurfing and kiteboarding at times as well as dinghy / keelboat/ yacht
 
I'm not sure why you have posted any of these references. I know this is a 'quick and dirty' review, but I don't believe they show any credible evidence of risk to spines in this sport. The reports reference that head injuries account for between 22-35% depending on the reference used and those references do not take into account degrees of injury. The statistics could include everything from a little bump to a great whack, mid-gybe.
 
I have faith that the RYA has people well versed in researching this topic. If it was a significant issue then the RYA as a governing body would be reviewing training and issuing new guidance. As people have noted above, they haven't.
 
The main issue here is ensuring that clubs put two in the safety boats. Thats a basic step and hard enough to achieve for some, without adding additional responsibility to the mix.


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Posted By: jeffers
Date Posted: 17 Jan 12 at 2:43pm
Originally posted by zippyRN

that's odd given pool lifeguards with the NPLQ and  St John Ambulance 'Advanced First Aiders ( under the 2011/12  skill sets)' are taught  casualty handling  for the patient with a suspected  spinal injury  based on mechanism of injury .
 
The difference is Pool Lifeguards are paid and employed specifically to be responsbile for safety. MOST sailing clubs are run by VOLUNTEEERS who give up their free time.
 
Also MOST sailing clubs would fold should there suddenly become a requirement for safety boat crews to hold an advanced first aid certificate (which I seem to recall is a 5 day+ course) partly on cost and partly because I don;t know many people who would want to do that.
 
It is all about getting the casualty to safety so the professionals can do their job, this incluides getting them out of the water. I would not like to see a spinal board being used in rough conditions. Even at my local club (which is inland) the safety boats rock about quite a lot.
 
Given the option of pulling someone out of that water and saving their life from certain death over leaving them in the water to die because they 'might' have a spinal injury which 'might' be aggravated by my actions I know which option I would take every time.
 
Perhaps if you have serious concerns you should speak to the RYA, I know they have a lot of advice and a good legal team who will be able to assist if required.


-------------
Paul
----------------------
D-Zero GBR 74


Posted By: zippyRN
Date Posted: 17 Jan 12 at 3:14pm
Originally posted by jeffers

Originally posted by zippyRN

that's odd given pool lifeguards with the NPLQ and  St John Ambulance 'Advanced First Aiders ( under the 2011/12  skill sets)' are taught  casualty handling  for the patient with a suspected  spinal injury  based on mechanism of injury .
 
The difference is Pool Lifeguards are paid and employed specifically to be responsbile for safety. MOST sailing clubs are run by VOLUNTEEERS who give up their free time.


SOME  pool lifeguards are paid staff , i also note you have conveniently skirted the issues of the other  volunteers mentioned in my previous posts 

 
Also MOST sailing clubs would fold should there suddenly become a requirement for safety boat crews to hold an advanced first aid certificate (which I seem to recall is a 5 day+ course) partly on cost and partly because I don;t know many people who would want to do that.

would they ?  the same  arguments against developing standards have been trotted out elsewhere , including the excuses that  because a service is provided by volunteers  it shouldn't have to meet any kinds of standard 

It is all about getting the casualty to safety so the professionals can do their job, this incluides getting them out of the water. I would not like to see a spinal board being used in rough conditions. Even at my local club (which is inland) the safety boats rock about quite a lot.

I'd much rather see someone safely packaged on an extrication board than dragged into the bottom of a safety boat in an uncoordinated fashion 

 
Given the option of pulling someone out of that water and saving their life from certain death over leaving them in the water to die because they 'might' have a spinal injury which 'might' be aggravated by my actions I know which option I would take every time.

ah  the excuse of lay person necessity  rather than of having pride in delivering service 

do not think being a volunteer or an organisation being a not for profit  will prevent  individuals or the organisation being prosecuted. 

Interestingly the landmark case in this respect involves a rescue boat ... operated by St John rather than a sailing club


 


Posted By: jeffers
Date Posted: 18 Jan 12 at 7:23am

zippyRN, you and I are clearly not going to agree on this. Our sport is self regulalted and, on the whole, well managed with very few serious incidents.

To expect what you are expecting of people who give up their free time to participate and help run the sport is unreasonable and would sound the death knell for many clubs in the UK.
 
That is my opinion and my final wording on the matter.


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Paul
----------------------
D-Zero GBR 74


Posted By: sargesail
Date Posted: 18 Jan 12 at 8:11am
Over zealous application of a specialist area, undestandly due to exposure to the consequence of spinal injuries.

Lifeguards need training.  People break their necks and backs diving into pools every year.  

In thirty years of sailing I have not heard of a single spinal injury, there is no evidence in them in the water related accident stuff, and I have not even seen anything in the reporting of the  incident that sparked this thread to link it.

More pertinent:  I have twice been involved in CPR in a rescue situation.  Once I gave it in the water.  I'm not sure it was needed, and I'm not sure it was effective: it's near impossible in even the most benign conditions.  But the guy coughed up the water and was OK.  In the second case it was a hard stint in the rescue boat.  No way it could have been done in the water.  It's all about the priorities.

In my professional life I deal with risk management.  It's about probability against consequence then mitigation.  No matter what the serious of the consequence if the probability is nil or next to it then there is no need to treat the risk.

But I have seen senior practitioners pick up on threads like this and take actions which diverted resources and actually increased risk to life elsewhere.  So forgive me if I seem a little robust but this touches a nerve, and frankly, in comments like "lay person necissity" offends.




Posted By: Buzz
Date Posted: 18 Jan 12 at 10:55am
We sail on the sea and our guidance is that in the event of a serious injury we would call the Coastguard. The Inshore Lifeboat carries a spinal board and the crews are all trained in its use. I have never seen such an injury during sailing but have experienced it with a waterskier being hit by another ski boat and one of the club safety boats being asked to assisst.


Posted By: zippyRN
Date Posted: 18 Jan 12 at 2:52pm
Originally posted by sargesail

Over zealous application of a specialist area, undestandly due to exposure to the consequence of spinal injuries.

Lifeguards need training.  People break their necks and backs diving into pools every year.  

as for it'll never happen we've got a girl anaesthetisted in an Australian ICU after a head injury that required Neurosurgery ...

while she's still anaesthetised  we don't know the full consequences of her injury, every textbook on emergency care will tell you that someone who is knocked out  through head trauma has a presumptive spinal injury until proven otherwise , this cannot be ruled out by imaging alone , although stability of the spine can be determined as such. 

there's also Herb Meyer who sustained a C5/6 injury while sailing  , ok Yacht rather than small boat ... 
http://www.accessdinghy.org/ifds_dinghy_worlds/profiles.htm - http://www.accessdinghy.org/ifds_dinghy_worlds/profiles.htm

also what aobut someone who falls from a dock or pontoon into the water  and sustains a neck injury?  while it's not directly as a result of going sailing ... 


In thirty years of sailing I have not heard of a single spinal injury, there is no evidence in them in the water related accident stuff, and I have not even seen anything in the reporting of the  incident that sparked this thread to link it.

 and what are your casualty care  credentials ?  are you  involved in emergency care  as a none incidental  activity , whether professional or paid ...?

More pertinent:  I have twice been involved in CPR in a rescue situation.  Once I gave it in the water.  I'm not sure it was needed, and I'm not sure it was effective: it's near impossible in even the most benign conditions.

it is deemed as such I believe the RLSS still teach it for pool work but only once to the side  ( obviously in a wave pool with a 'beach' you just tow then  drag the casualty  until they are 'landed' )

  But the guy coughed up the water and was OK.  In the second case it was a hard stint in the rescue boat.  No way it could have been done in the water.  It's all about the priorities.

exactly and unfortunately unless a rescue boat has a clear , flat  deck area where you can lay your patient to perform CPR you will not be able to perform effective CPR  ( see debate in the Michael Jackson case  over whether the CPR being done on the bed by Dr. Murray and Jackson's staff was effective  vs the Ambulance crew moving him to the floor  and then to  their  ambulance trolley  which provides a hard surface )

In my professional life I deal with risk management.  It's about probability against consequence then mitigation.  No matter what the serious of the consequence if the probability is nil or next to it then there is no need to treat the risk.

that is simply not the case especially when a 9 figure  Dollar / Euro  or very large 8 figure GBP payout is at stake -  8 million GBP  seems to be a fairly common payout  for those with high tetraplegia or enduring head injuries requiring 24 hour care post incident  and the legal eagles say it;s only a matter of time before there's a 10 million GBP payout ... how much public liability insurance does the average club carry ? 

But I have seen senior practitioners pick up on threads like this and take actions which diverted resources and actually increased risk to life elsewhere.  So forgive me if I seem a little robust but this touches a nerve, and frankly, in comments like "lay person necissity" offends.

so tell me how does ensuring that rescue boats have a two person crew and that people have an awareness of issues and access to equipment  increase the risk in other ways ? 

kit wise you are talking about an investment of a few hundred pounds and that's assuming you can't negotiate access to existing stocks of equipment or find funding for it ... 

providing this training to not for profit / charity clubs would count as a charitable purpose for the likes of SJA , the RLSS or the Red Cross  of course assuming that  we can't find  faculty from within the sailing community itself - how many health professionals, lifeboat and Coastguard personnel , firefighters  etc  sail or have links with the sailing community ? 

when people start talking about putting 'Paramedics' on rescue boats to deliver casualty care that first aiders and firefighters  do  it's obvious there is an understanding gap. 




Posted By: zippyRN
Date Posted: 18 Jan 12 at 3:04pm
Originally posted by zippyRN

Originally posted by sargesail

Over zealous application of a specialist area, undestandly due to exposure to the consequence of spinal injuries.

Lifeguards need training.  People break their necks and backs diving into pools every year.  

as for it'll never happen we've got a girl anaesthetisted in an Australian ICU after a head injury that required Neurosurgery ...

while she's still anaesthetised  we don't know the full consequences of her injury, every textbook on emergency care will tell you that someone who is knocked out  through head trauma has a presumptive spinal injury until proven otherwise , this cannot be ruled out by imaging alone , although stability of the spine can be determined as such. 

there's also Herb Meyer who sustained a C5/6 injury while sailing  , ok Yacht rather than small boat ... 
http://www.accessdinghy.org/ifds_dinghy_worlds/profiles.htm - http://www.accessdinghy.org/ifds_dinghy_worlds/profiles.htm

also what aobut someone who falls from a dock or pontoon into the water  and sustains a neck injury?  while it's not directly as a result of going sailing ... 


In thirty years of sailing I have not heard of a single spinal injury, there is no evidence in them in the water related accident stuff, and I have not even seen anything in the reporting of the  incident that sparked this thread to link it.

 and what are your casualty care  credentials ?  are you  involved in emergency care  as a none incidental  activity , whether  volunteer or paid ...?

More pertinent:  I have twice been involved in CPR in a rescue situation.  Once I gave it in the water.  I'm not sure it was needed, and I'm not sure it was effective: it's near impossible in even the most benign conditions.

it is deemed as such I believe the RLSS still teach it for pool work but only once to the side  ( obviously in a wave pool with a 'beach' you just tow then  drag the casualty  until they are 'landed' )

  But the guy coughed up the water and was OK.  In the second case it was a hard stint in the rescue boat.  No way it could have been done in the water.  It's all about the priorities.

exactly and unfortunately unless a rescue boat has a clear , flat  deck area where you can lay your patient to perform CPR you will not be able to perform effective CPR  ( see debate in the Michael Jackson case  over whether the CPR being done on the bed by Dr. Murray and Jackson's staff was effective  vs the Ambulance crew moving him to the floor  and then to  their  ambulance trolley  which provides a hard surface )

In my professional life I deal with risk management.  It's about probability against consequence then mitigation.  No matter what the serious of the consequence if the probability is nil or next to it then there is no need to treat the risk.

that is simply not the case especially when a 9 figure  Dollar / Euro  or very large 8 figure GBP payout is at stake -  8 million GBP  seems to be a fairly common payout  for those with high tetraplegia or enduring head injuries requiring 24 hour care post incident  and the legal eagles say it;s only a matter of time before there's a 10 million GBP payout ... how much public liability insurance does the average club carry ? 

But I have seen senior practitioners pick up on threads like this and take actions which diverted resources and actually increased risk to life elsewhere.  So forgive me if I seem a little robust but this touches a nerve, and frankly, in comments like "lay person necissity" offends.

so tell me how does ensuring that rescue boats have a two person crew and that people have an awareness of issues and access to equipment  increase the risk in other ways ? 

kit wise you are talking about an investment of a few hundred pounds and that's assuming you can't negotiate access to existing stocks of equipment or find funding for it ... 

providing this training to not for profit / charity clubs would count as a charitable purpose for the likes of SJA , the RLSS or the Red Cross  of course assuming that  we can't find  faculty from within the sailing community itself - how many health professionals, lifeboat and Coastguard personnel , firefighters  etc  sail or have links with the sailing community ? 

when people start talking about putting 'Paramedics' on rescue boats to deliver casualty care that first aiders and firefighters  do  it's obvious there is an understanding gap. 




Posted By: Stuart O
Date Posted: 18 Jan 12 at 6:48pm
Whilst there is no argument that the accident is horrific it is rare, thankfully. This thread very much reminds me of the discussions soon after the drowning when lots of people went about shouting that knives should be carried by everyone on a boat...appears that shout has quietened now. However it doesnt stop us from reviewing emergency procedures . Lets review then....and I think zippyRN that nothing will change as a result of that. Sailing has its injuries and thankfully injuries such as spinal injuries are rare. If you want details of injuries I believe that all serious injuries have to be reported to the RYA by the club or class so they have an accurate record. 


Posted By: ASok
Date Posted: 19 Jan 12 at 1:22pm

ZippyRN - you seem to have a clear agenda here and I can't understand why. You've not presented any evidence that would suggest that this is a serious issue that we should be concerned by.

Tragic accidents will occur in every sport. Risk needs to be assessed and provisions made to manage them. I just don't believe that the issues are as large as you make them out to be.
 
One accident or a handful of accidents does not form the basis for investing in the prevention methods you have raised.
 
Perhaps you need to write to the RYA and request a grant for funding a study?


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Posted By: themeaningoflife
Date Posted: 19 Jan 12 at 1:24pm
Good to hear a positive update about Tess, let's hope she will make it to the Worlds in August as planned!
http://www.yachting.org.au/?Page=57857 - http://www.yachting.org.au/?Page=57857


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Cambridge University Lightweight Rowing Club
RS800 1128

kindly sponsored by http://www.rwo-marine.com" rel="nofollow - RWO Marine


Posted By: kevg
Date Posted: 19 Jan 12 at 5:56pm
Originally posted by themeaningoflife

Good to hear a positive update about Tess, let's hope she will make it to the Worlds in August as planned!
http://www.yachting.org.au/?Page=57857 - http://www.yachting.org.au/?Page=57857
 
Great news. I hope we have an accident investigation report in due course so we can then learn from this incident.


Posted By: zippyRN
Date Posted: 19 Jan 12 at 7:43pm
Originally posted by ASok

ZippyRN - you seem to have a clear agenda here and I can't understand why. You've not presented any evidence that would suggest that this is a serious issue that we should be concerned by.

Tragic accidents will occur in every sport. Risk needs to be assessed and provisions made to manage them. I just don't believe that the issues are as large as you make them out to be.
 
One accident or a handful of accidents does not form the basis for investing in the prevention methods you have raised.
 
Perhaps you need to write to the RYA and request a grant for funding a study?

Do I have a clear agenda ? perhaps you'd like to inform what my clear agenda is ?

we've seen responses that  'it'll never happen'  despite the Incident Tess Lloyd was involved in  and the fact  that there are  others ( admittedly a relatively small number) who have sustained significant head / neck or back injuries through sailing 

it's interesting that the attitude  of

" it'll never happen " 

and 

" rescue crews are only  volunteers , so it doesn't matter  whether they are adequately trained or not as after all they've 'done their best' "

the second one is what has made me 'upset' for want of better term - this attitude is 20  to 30 years  behind the curve , it seems as though all the prosecutions and legal action involving volunteers  providing a service has passed  the sailing community by 

e.g. the  Issues surrounding the 'Tideway Incident' where St John ambulance were prosecuted  under Health and Safety law  despite  the boats being operated by volunteers, in a volunteer lead unit  in a volunteer lead area  and providing services on a voluntary basis ... 

the various  issues surrounding  failure to deliver effective resuscitation provision   at events e.g. Bath Half Marathon which was SJA again ( settled out of court ) and a similar occurence involving the Red Cross at the Great North Run 

the issues i've raised for discussion still fall short of the minimum requirements for other sports - and not just motorsport - though with the speeds achieved by modern skiff type dinghies the enrgy exchange is approaching motorsport  or equestrian levels   with collisions  or 'ejections'  from craft 

the level of lack of understanding shown by people  claiming to be 'expert'  on the subject is also worrying -  exactly how would some of you defend yourselves in court ( be it civil, criminal or Coroner's ) when   there is an adverse incident  , and this incident  known to be serious / life threatening  but has been ignored  becasue we're only amateurs ... 

is this going to take a death and prosecution ? rather than people  starting discussion in the light of Tess' incident - 



Posted By: Contender443
Date Posted: 20 Jan 12 at 9:52am
Zippy all sailing clubs in the UK take their lead from the RYA and what you are saying is not their advice.
 
You mention running events but you quote a very large probably professionally run event. There are loads of running events held every weekend where they donot have this level of support. Then what about all the amatuer football and rugby clubs holding events on public playing fields with no facilities. Everyone of thos relies on the emergency services. That is what we do in sailing with  the only difference in that we need to get the casualty to them in the first instance.
 
People like you who hide behind the threat of lawyers will kill sport.


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Bonnie Lass Contender 1764


Posted By: ASok
Date Posted: 20 Jan 12 at 10:17am

ZippyRN - you seem to be very aware of spinal injuries cause and treatment. However, I've joined this discussion because I've got a thing about reference weilding. Those references you threw up earlier advocating the use of spinal boards and rescue provision just don't stack up. However, I recognise that they were a 'quick and dirty' search (to use your words).

Your agenda seems to be avocating the implementation of this additional level of safety provision when evidence doesn't suggest that its required.
 
However, that said I am not an expert. I have to take my lead from the governing body. Just like I do when I play 5-a-side football in the week and when I used to play rugby.
 
Without a hint of sarcasm - I genuinely believe that experts should be approaching the RYA with this if they believe that there is an issue. That way they can investigate, risk assess and provide guidance.
 
Club committees need to take a lead from somewhere. You cannot expect a group of amateur enthusiasts to start advocating this level of provision unless it really is required. Poorly applied safety procedures are worse than lower levels of safety procedures.


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Posted By: jeffers
Date Posted: 20 Jan 12 at 10:56am
Please do not feed the troll......
 
And remember pretty much evey SC has a clause which states that you sail at your own risk and the club cannot be held liable for death, loss or injury (this is why we have insurance when we sail with large amounts of 3rd party liability).


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Paul
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D-Zero GBR 74


Posted By: ASok
Date Posted: 20 Jan 12 at 12:08pm
Originally posted by jeffers

Please do not feed the troll......
 
 
Fair point Clap
 
Where's JimC's cartoon on 'cant come to bed, someone on the internet is wrong'LOL


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Posted By: r2d2
Date Posted: 20 Jan 12 at 12:10pm
+1


Posted By: Contender 541
Date Posted: 20 Jan 12 at 12:25pm
You're Welcome Wink
 


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When you find a big kettle of crazy it's probably best not to stir it - Pointy Haired Boss

Crew on 505 8780



Posted By: ASok
Date Posted: 20 Jan 12 at 12:51pm
Thats the oneLOL

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Posted By: zippyRN
Date Posted: 20 Jan 12 at 4:08pm
What is apparent is that  people have chosen to take an antagonistic  tone with regard to this discussion  -  such as accusing me have having an agenda  rather than taking the opportunity to discuss something  which has moved from 'it'll never happen'  to headline news  thanks to the incident in Aus 

Jeffers  despite your gratutiously offensive  post , i would point out that  statements about people sailing at their own risk generally aren't worth the paper they are written on, especially once the actions of the club  or it's servants  amount to negligence 

Contender 443 -  i'm not 'threatening lawyers'   comments about   'threatening lawyers kills activities'  are patently not true  or  there wouldn't be any  'amateur' / 'volunteer' activity in the UK at all . 

However  what has become increasingly apparent  elsewhere in the voluntary / not-for-profit / charity sector is that   this status can't be used as an excuse  for poor standards 

How would the RYA  and/or a club defend itself  if the  'other side' in a legal action produced RLSS and JRCALC guidelines saying  that anyone knocked  out  due to a head injury is assumed to have a spinal injury until proven

while the JRCALC guidelines are written including health professional only  procedures, the guidelines minus those procedures are in use for None Paramedic ambulance crews both paid and Volunteer 

http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/neck_and_back_trauma_2006.pdf - http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/neck_and_back_trauma_2006.pdf
http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/head_trauma_2006.pdf - http://www2.warwick.ac.uk/fac/med/research/hsri/emergencycare/prehospitalcare/jrcalcstakeholderwebsite/guidelines/head_trauma_2006.pdf


Posted By: Stuart O
Date Posted: 20 Jan 12 at 6:42pm
Funny I dont see them saying it will never happen what I see people saying here is that it happens VERY rarely and therefore as a risk factor is treated as such and not ignored.
They would defend themselves based on the risk factor...seriously zippyRN quote numbers. I think you will see that serious head injuries are minute in comparison to those that in the sport...in health and safety terms the risk is LOW.
Until told by the RYA that procedures have to altered we should not try and force change based on the back of one tragic accident where there was NO spinal injury and a full investigation has yet to be published.



Posted By: zippyRN
Date Posted: 20 Jan 12 at 7:33pm
do some of you  people have difficulty in reading ? or in comprehension ? 

rather than putting up agressive barriers  where's the discussion?  - because all i see is head burying  and ignorance - 15 -20 years ago the same  was happening in other organisations and it took criminal prosecutions  to shake them out of their complacency . 


Posted By: r2d2
Date Posted: 20 Jan 12 at 8:57pm
Originally posted by zippyRN

do some of you  people have difficulty in reading ? or in comprehension ? 
rather than putting up agressive barriers  where's the discussion?  - because all i see is head burying  and ignorance - 15 -20 years ago the same  was happening in other organisations and it took criminal prosecutions  to shake them out of their complacency . 


ZippyRN there are collectively 100s of years dinghy sailing experience on this forum and in this thread and those people just do not agree with you. You haven't made a convincing argument or presented the evidence for it. Rather than resorting to criticising people, it might be better to think carefly about what they have said.


Posted By: Stuart O
Date Posted: 20 Jan 12 at 10:14pm
Barriers??? Ignorance?????

a discussion is a 2 way thing. I certainly have read your posts with interests....but when we direct you and explain to you why sailing clubs do not follow what you say you round on us.

IF you feel that strongly talk to the RYA as they lead ALL clubs in this country and IF they agree they will direct us. BUT please explain to me why most running clubs dont have spine boards. Its the same reasons as sailing clubs...they HAVE carried out risk assessments and the risk is so low they dont accept them as a risk




Posted By: ex laser
Date Posted: 21 Jan 12 at 1:40am
Originally posted by r2d2

Originally posted by zippyRN

do some of you  people have difficulty in reading ? or in comprehension ? 
rather than putting up agressive barriers  where's the discussion?  - because all i see is head burying  and ignorance - 15 -20 years ago the same  was happening in other organisations and it took criminal prosecutions  to shake them out of their complacency . 


ZippyRN there are collectively 100s of years dinghy sailing experience on this forum and in this thread and those people just do not agree with you. You haven't made a convincing argument or presented the evidence for it. Rather than resorting to criticising people, it might be better to think carefly about what they have said.


could not agree more! Clap


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Posted By: ASok
Date Posted: 21 Jan 12 at 9:06am
ZippyRN - as I understand it from reading your links, head trauma needs to treated in a manner where you assume neck and spinal trauma.

However, your links from earlier cite references that suggest only 39% of injuries were recorded on the upper body. 32% was logged as head injury. This reference (your first link) cites that all injuries 'even minor ones' were recorded.

This study doesn't provide a firm basis for decision making and changing policy. The injuries recorded during the study could be everything from a minor bump to a huge whack. The studies really highlighted that long term injuries (knees, lower back) are the most significant issue.

The collective anecdotal experience on here supports your cited data that serious head and spinal injuries don't occur as often as you may believe. These boards do contain a great deal of reference to long term pains such as knee and back issues. Maybe this is the longer term issue that isn't being adequately addressed.

I'm not saying you are wrong about the spinal treatment issue, but leaping into additional safety cover without calculating the risks seems absurd to me.


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Posted By: Stuart O
Date Posted: 21 Jan 12 at 6:47pm
Could also be that the knee  and lower back injuries are the route cause of neck and spinal pain, and not a head trauma. In my profession whenever someone comes in with neck pain I always check ankles, knees, shoulders and wrists...and I would say it is these are more common and that need better primary care. 


Posted By: zippyRN
Date Posted: 22 Jan 12 at 6:34am
Originally posted by Stuart O

Could also be that the knee  and lower back injuries are the route cause of neck and spinal pain, and not a head trauma. In my profession whenever someone comes in with neck pain I always check ankles, knees, shoulders and wrists...and I would say it is these are more common and that need better primary care. 

that's all valid and think taken as read, 

my attempts at discussion were two fold - given the practice in other sports, and general emergency care practice in the light of the incident which Tess Lloyd has been involved in,  what has become apparent from the discussions is a number of factors 

- some people still think that disclaimers  are worth the paper they are written on - no amount of disclaimers will protect  an individual or organisation from their direct mistreatment of someone 

- that if the risk is small you don't need to think about it despite the possibility of 8 and 9 figure payouts following mismanagement

- it's not in the NGB course therefore it'll never happen and it's not important

- there's a lack of awareness of the abilities or otherwise of other services -  while for the coastal guys and girls  having 'call 999' may well be enough with HMCG and RNLI resources - it might not be  enough for some of the inland clubs  -  as despite  the  step changes  in specialist provision HART has brought around in the ambulance service  water rescue isn't necessarily going to be forthcoming from 999                                         


Posted By: Peaky
Date Posted: 22 Jan 12 at 11:31am
Whilst serious accidents do occasionally occur, the risks involved with dinghy racing are surely tolerable and would be considered ALARP. It would not be practicable for the majority of clubs to introduce new equipment or provide additional training to help in the case of a once every 20 year accident. But of course, the RYA should continuosly monitor best practise and advise as necessary.

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Posted By: Stuart O
Date Posted: 22 Jan 12 at 3:33pm
I think Zippy you are also harping on and on about what people went through 20 years ago...Yes the culture has changed and we have entered a blame era...however the RYA keep all clubs up to date on best practise and constantly review situations. 

You also forget about the claims IF equipment isnt used properly. We enter a whole legal minefield.

This is what all have said to you


Posted By: Buzz
Date Posted: 24 Jan 12 at 11:38am
Originally posted by jeffers

Please do not feed the troll......
 
And remember pretty much evey SC has a clause which states that you sail at your own risk and the club cannot be held liable for death, loss or injury (this is why we have insurance when we sail with large amounts of 3rd party liability).
We took legal advice regarding such disclaimers and were told that they wouldn't protect the club or an individual from their duty of care.
Safety boats, briefings, informing the Coastguard, contingency planning etc. are how we fulfill our duty of care. The level of training crews require will depend on the risk and the probability of that risk occurring. To have all safety boat crews trained to a high medical standard would mean that we would be unable to find volunteers and therefore run events.
 


Posted By: jeffers
Date Posted: 24 Jan 12 at 2:12pm
Originally posted by Buzz

We took legal advice regarding such disclaimers and were told that they wouldn't protect the club or an individual from their duty of care.
Safety boats, briefings, informing the Coastguard, contingency planning etc. are how we fulfill our duty of care. The level of training crews require will depend on the risk and the probability of that risk occurring. To have all safety boat crews trained to a high medical standard would mean that we would be unable to find volunteers and therefore run events.
 
 
I would suggest your club speak to the RYA in that case. The disclaimer does mean a lot as it is the individuals decision to go on the water in the first place (which is key).
 
If the Safety boat crew were deemed to then be negligent, not suitably qualified (relevant RYA cert or equivalent) or not follow established procedures than that is a different matter. This is why you must ensure you club is fully up to date with the latest guidance from the RYA and your Safety Policies are worded appropriately (and all members are aware of them, ignorance is no excuse). 
 
The RYA have a good and powerful legal team, your club pays a fee to be affiliated, make sure you get value from it. They are likely to know more than your high street solicitor as marine law is a specialist area.
 
As a foot note, there is no requirement to be First Aid Qualified for the RYA Safety Boat course ( http://www.rya.org.uk/coursestraining/courses/powerboat/Pages/Safetyboat.aspx - clicky ). This is probably because it is damn near impossible to Administer First Aid on a Rib/Dory even on the calmest of days. Even the first aid you have to do for the DI cert is very basic by comparison.


-------------
Paul
----------------------
D-Zero GBR 74


Posted By: winging it
Date Posted: 24 Jan 12 at 9:02pm
If the Australian assessment process is anything like what happens here in the uk after a major incident (such as Kielder Water) then there will be a thorough investigation of the circumstances surrounding the accident (a collision between a windsurfer and a sailor) and then the findings of that investigation will be circulated to all clubs and centres, along with recommendations of any actions thought necessary to prevent such an accident happening again.  Should a succession of similar incidents take place then recommendations can become legislation.

Assuming that this poor girl suffered a head injury, I would think the most likely recommendation would not be that safety crews receive better training, but would rather be that sailors wear helmets.  This is already required in organisations such as scout sailing, and in many sailing schools.  This is similar to the way in which the NSSA demand trapeze crews wear quick release hooks following fatalities caused by crews being unable to unhook themselves following inversions.

It has to be said that even for trained crews, recovering a disabled or unconcious person from the water is extremely difficult without causing further injury.  At the moment best practice seems to be using a net or sling into which the person in the water is floated, then rolled up the side of the rib.  Those that I have spoken to who have been recovered in ths way have reported that it is extremely painful (though clearly better than drowning) and possibly would cause further injury to spine or brain due to the clumsy nature of the recovery process. 

Following the recent incident on the Dart concerning the inversion of the Hawke 20, this is something which must continue to be investigated, but the investigations must be done by those who can implement a sound knowledge of what is possible in any safety operation, given the limitations of safety crew ability, sea conditions, and resources.  Unfortunately we cannot prepare for every single eventuality.

Zippy, if your expertise can provide any detailed guidance on the recovery of disabled or unconcious persons from the water I would be glad to read them here.




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the same, but different...



Posted By: zippyRN
Date Posted: 25 Jan 12 at 5:07pm
Helmets are a two edged sword 

while they may be of benefit  in reducing  head injuries  they  raise as many problems as they solve - see the constant ongoing  debate and discussion about helmet use in  on-road cycling 

There is also a school of thought that helmets can worsen concussion and contra-coup type injuries by adding mass to the to the 'loosely', in relative terms, held on Head  (  speaking to long established  clinicians in Spinal injury care  they noted an increase in neck injuries following the introduction of mandatory seatbelt wearing  in the UK - which dropped off again when head restraints became a common fitment to cars - and  dealing with neck injuries has been an ongoing aspect of safety  reform in motorsport with neck rolls  and now HANS devices to reduce the effect of the head + helmet  shaking around.  

before jumping one way or the other on the helmet issue  the types of head injury  need to be considered 

this also has the issues of appropriate equipment  for the task, at one time IIRC  sailing schools were required to use the then contemporary  equivalent of a 150N  foam + air lifejacket  rather than buoyancy aids for students  ... ( i'm talking 20 + years ago here)  and there being debate at  the time over  whether it was acceptable to move towards 50N BAs  that were deemed more than adequate for club and 'private' sailing and were being worn by instructors in  these same sailing schools ... 

Last week i was listening to radio 4 / world service in the small hours and they were talking about the 'enforcers' in the NHL and how there was evidence of  of brain changes in these players  similar to the brain changes seen in boxers  from repeated concussions 

In terms of recovery into a rescue boat it would be interesting to look at movement  in an 'inert'  body between the methods winging it  describes and a variety of approaches using an Aquabaord or conventional Long Extrication Board - perhaps our RLSS colleagues may be of use hear  as well as people with a 'health' background ? 


Posted By: winging it
Date Posted: 25 Jan 12 at 5:59pm
What a disappointing answer.  Given the amount of expertise expounded over the previous pages I had assumed there was some practical expertise behind it that could have been of use.   Instead, just theorising and not on the issue I'd asked about.

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the same, but different...



Posted By: zippyRN
Date Posted: 26 Jan 12 at 2:50am
Originally posted by winging it

What a disappointing answer.  Given the amount of expertise expounded over the previous pages I had assumed there was some practical expertise behind it that could have been of use.   Instead, just theorising and not on the issue I'd asked about.

from my previous reply 

"In terms of recovery into a rescue boat it would be interesting to look at movement  in an 'inert'  body between the methods winging it  describes and a variety of approaches using an Aquabaord or conventional Long Extrication Board - perhaps our RLSS colleagues may be of use hear  as well as people with a 'health' background ? "

I've not had a huge amount to do with on the water for a few years now and certinaly not since i've been involved in emergency care both in and out of hospital as Health Professiojnal, working trackside at motorsport events in both green and orange and more recently working in specialist rehab 


Posted By: Stuart O
Date Posted: 26 Jan 12 at 8:51am
I think you have the answer right there zippyRN you are trying to apply the same 'code' you use in motorsport to the sailing world, especially as in motorsport you have 'control' of the immediate conditions. In the water it is an ever changing situation. Unlike motorsport where you can lay someone flat and control that persons neck you cannot do this in the sea, even professional lifeguards say this, what works in a pool does not work in the sea.
And in answer to Winging it IMHO the only way to get casualties out of the water using a long board or aquaboard without causing injury to to those in the rib is with a helicopter or using a hoist. You could try to fully deflate 1 side of a rib and float a person on but I would say this isnt practical on most club ribs which arent wide enough. 


Posted By: winging it
Date Posted: 26 Jan 12 at 9:31am
I do know the techniques available - I'm SI at a sailability centre where recovery of disabled persons is something we have to train ourselves for.  Fortunately it's not something we often have to put into practice.  The truth of the matter is that it's actually an incredibly difficult thing to do unless you can call in a helicopter, and thus risk the person drowning or dying from hypothermia while you wait for it, or you risk serious harm to the safety boat crew.

I think the point of my post was to demonstrate to zippy that while what he was expounding was all good in theory, would be almost impossible to put into practice.  I think he sees that now.


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the same, but different...



Posted By: zippyRN
Date Posted: 26 Jan 12 at 4:55pm
assumption central here again ladies and gents...



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