Are Equestrian Injuries Inevitable?

Lindsay has been bugging me for a horse again. She's only been doing that for nine years. I knew it was coming. On the way home from our first ultrasound -- when we discovered we were having a girl -- my first thought was "oh now, now we're going to have to get a pony."

I grew up around horses and I've recently seen the sort of injuries a horse can inflict both in my ambulance and in the Emergency Department. So I was pretty interested in Dr. John Mayberry's presentation at the Northwest States Trauma Conference last week asking whether horse injuries are inevitable or preventable.

Horses used to be prey animals and as such still retain that fight or flight instinct despite a couple thousand years of domestication. Most horses are 5 - 15 times larger, 20 - 40 times stronger and three times faster than we are, Mayberry explained. They way an average of 800 pounds. Sit your little but on top of one and you head is 10 feet off the ground.

Not surprising then that according to the American Medical Equestrian Association, we see upwards of 74,000 Emergency Room visits including 14,000 children thanks to horses. You chances of getting injured riding horseback is higher -- on a per-hour basis -- than riding a motorcycle or racing a car, according to the CDC.

So does it have to be that way? Are injuries preventable?

Mayberry's review of the available research came to a couple important conclusions:

Increasing skill can decrease injuries. One study looked at the United States Pony Clubs where helmet use is required and systematic testing and skill development is practiced. Even though these riders were jumping their horses and invovled in other sporting activities, the overall injury and severity was 1 incident per 169,000 hours of horse-related activities. Of those injuries 8 percent required no treatment while 17 percent required hospitalization. Close to half the injuries happened to students at the lowest skill level with a somewhat even distribution across ages. Researchers made a point to note that skill level did not equate to experience or hours in the saddle -- even idiots can ride a horse. Dr. Doris "Bixby Hammett concluded that experience does not constitute skill," Mayberry notes. "In fact, injuries seem to decrease with increased knowledge, skill and ability rather than with age and experience."

The Pony Club study highlights two things rare in the horse-riding world - helmet use and an intensely structured training regimen. (Although advocacy organizations are increasingly pushing helmet use.)  Outside the pony club, head injuries are higher and the incidence and severity of injuries are higher.  Another study found that horse-related injuries are greater in severity than car wrecks and similar in severity to bicycle crashes.

Moreover one in five equestrians "will be seriously injured during their riding career and that approxamately 100 hours of experience are required to achieve substantial decline in the risk of injury." Novice riders are five times more likely to have a serious injury from a horse compared to a more advanced rider.

Mayberry's group asked experienced riders what they would tell those novices. Here's a sample of the advice they gave:

• Don't ride an unfamiliar horse alone
• Make sure your skill level and the horse skill level mix
• Don't buy a big horse for a little girl
• Never get on a horse you don't know
• Wear long pants and gloves
• Wear a helmet even for leading a horse
• Boots are the best safety item
• Be aware of other animals
• Watch your footing when leading a horse, if you stumble the horse will spook
• Watch out for dogs, children, goats -- all of which can spook horses
• Do not ride in a muddy field
• Be patient when training a horse
• Treat each horse as a individual
• Pay attention to the horse's body language

Mayberry also included some great quotes from the experience equestrians. Here's my favorite:

"I train BLM Mustangs, Only God Herself can protect me."

Etomidate vs. Ketamine for RSI

We use the drug Etomidate all the time as a sedative prior to paralyzing patients for intubation. As part of our Rapid Sequence Intubation kit, it is a great little drug. Works fast, has proven very safe and the effects don't last long. We also use it for moderate sedations procedures. It is a forgiving and easy drug to use.

When I first started doing moderate sedations on kiddos at a different hospital, I often used a different drug -- Ketamine. It can be given IM or IV and works great for pediatric sedations. That said, it sometimes has side effects that can make it a little less fun for patients and parents when the sedation is over. When coming out of Ketamine sedations -- especially when the drug is given IM or higher IV doses -- it can produce hallucinations and recovery agitation. Sometimes these hallucinations are disturbing -- and can be particularly so for a parent watching and holding little Johnny while he goes through this bad trip.

So why are some researchers proposing that we drop Etomidate in favor of Ketamine?

As presented at the 21st Annual Northwest States Trauma Conference, Etomidate appears to have an effect on cortisol levels that can linger long after the rapid, single bolus used for induction. This adrenal suppression that results from Etomidate has been known about for some time. Researchers wanted to know if the single bolus used for RSI could do the same. When a Harborview Medical Center study compared Etomidate RSI with a benzo/narcotic combination -- "patients given Etomidate had a nearly fourfold greater risk of respiratory failure and an average of three more days of mechanical ventilation."

Another study -- published in the Lancet -- compared Etomidate and Ketamine. By studying two groups in a randomized trial - one using Ketamine for induction and the other use Etomidate, a study found that adrenal function was significantly lower when Etomidate was used for RSI (86% vs 48 %). However, there was no significant change in mortality (35% for Etomidate vs 31% for Ketamine) or clinical outcome for trauma patients.  Given these results, the researchers concluded that "Ketamine is a safe and valuable alternative to etomidate for critically ill patients, particularly for septic patients."

So are we going to start seeing a switch to Ketamine for RSI?

OHSU Professor of Surgery Richard Mullins picked this study as one of his Trauma Top Ten at the Northwest States Trauma Conference, but expressed some doubts given that there was no significant change in outcome.

"The reality is, hundreds or thousands of people have been intubated using Etomidate over the years and we don't have hundreds of thousands of dead bodies," Mullins said.