Saturday, September 19, 2020

Trailer Maintenance: Mandatory Fun

All sparkly and clean coming out of the truck wash.

A big part of having a trailer, is trailer maintenance.  It’s not the most fun thing in the world, but it’s a requirement to ensure the safety of the horses.  It’s something that can easily be put off, and shouldn’t be.  Aside from just taking care of your trailer in general (cleaning/greasing), annual maintenance should be a priority.  Not only does it service the parts that needs continuing regular maintenance (brakes/bearings) but it also serves as a thorough inspection of the trailer.  It’s possible for the techs working on it to spot an issue before it gets worse.

Before I left for my work trip I had the annual maintenance done on mine.  The brakes/axles were inspected, bearings packed/greased, and it got a once over.  

I don’t expect any issues out of my current trailer, but you never know.  I have had great luck with Sundowner.  My previous trailer was a Sundowner too and it was a GREAT trailer.  My current trailer is living up to that reputation as well.  I bought my new trailer new in 2017.  Part of why I did this is because I will know its history from the start.  I will know it was taken care of a serviced on a regular schedule.

I also greased all the locks, latches, and springs.  

Some  hinges have grease ports, some don't.

You can use the grease ports on the jack, or you can take the top off and hand grease it.

Using white lithium grease for the hinges that don't have grease ports.

Be careful not to over grease, it can actually just attract more dirt and cause issues.

The two types of grease I used.  If you have a trailer now, you better know what Moly Grease is because you had better be greasing your hitch/coupling at regular intervals.  I always have Moly Grease on hand in the truck/trailer.

The Other half did me a huge favor and power washed the inside of it.  Some truck washes will do it for you if it's empty of all shavings, etc... But some won't.  Blue Beacon here will not.  

I took everything out of my tack room and organized it.  Pulled the mats and scrubbed them, and vacuumed.  The trailer usually gets this type of spa treatment on regular intervals but this time was also in preparation for me to be gone for a few months on a work trip.

This was when I come back it’s ready to go.  My truck is being started regularly too, even though it’s not being drive.  When I get back I’ll still get an oil change and then we’ll be ready to hit the road for some adventures.

Doing what you can on your own will also help you familiarize yourself with how things work and give you the ability to recognize if something isn’t right, just like with horses.  So, being afraid to do some maintenance is bad.  I've sadly seen people who even think it's cute to have someone else to haul their horses around and say how it's that person's "job" and they will be willfully ignorant about the process.  Ok, well maybe it is their "job", but that is still no excuse not to familiarize yourself with equipment that involves YOUR horses.  

Checking fluids, etc on The Beast.  KNOW WHAT IS NORMAL.

Even if your friend/trainer usually hauls you because you don't have a trailer, you really should learn what you can.  What if there is an emergency and that person is unavailable for some reason?  You HAVE to be able to help yourself.  Doing small things like this is where it starts.  Know your equipment's normal.  Even if it is your friend or trainer's equipment, if your horse is in it frequently, make yourself useful.  Know how to change a flat on a trailer, know how to break lugs, know how to tighten lugs in the proper pattern, know the normal squeaks, clicks, bounces, etc... with the truck and trailer.  Know what the normal running temp is on your truck when you're hauling.  Know how to adjust the brake controller, remember to check your fluids regularly.  Know what oil you use in your truck.  Things like this can help you spot a potential issue before it becomes a catastrophe.  I get it, some things just cannot be avoided, but some absolutely can.  Being uneducated isn't cute, it's not funny, it's dangerous.

Saturday, September 12, 2020

Preparation Is Key: Leaving Your Horses For Months

What do I do to get ready to be away for months is another common question I’m asked.  This is more concerning the Super Mares, and not things like my truck and trailer.  The most important thing is to have someone you trust to look after your horses.  Too many times I have seen horror stories after someone left their horse or horses with someone they didn’t know for that long, or personally did not know but was just recommended to them.

An authorized agent is something you need to have in place.  That is someone authorized to make medical decisions on your behalf while you’re away.  Some vets have their own form you can sign that authorizes that person, others require a Power of Attorney to do it.  Either way, do it and make sure your Authorized Agent’s contact information is included in the file.  This guarantees that if for some reason the vet is not able to get a hold of you, there is someone in the local area they can speak with regarding medical care if needed.  I don’t care if you are even just one state away and not on the other side of the world, you need to have this in place.  I have two, obviously The Other Half, and then my friend that is taking care of them.  I recommend you have one in your file even when you’re not gone.  You just never know.  What if something were to happen while you’re in an area with no cell service one day?  

I also always have a card on file with the vet.  I imagine most of you do, some practices require it, but if you don’t, that’s something else you should seriously consider.

Have that hard talk with your Authorized Agent(s) (and your caretaker if they are not the same person) of what your threshold is if serious illness or injury were to occur.  Let them know your limits financially and ethically.  This can be a hard conversation to have, but it needs to happen because it will be much worse of a conversation to have in the middle of an emergency.  I am very fortunate in that my friend and I are on the same page. 

Tell your equine professionals (farrier, chiro, etc…) that you’re leaving as well and who will be caring for your horses.  This way they know who to contact if appointments need to be changed, or if your caretaker needs a random appointment for something like a thrown shoe.

Change your autoships if you need to.  It may be easier to just have things like treats, fly spray, SmartPaks go directly to your caretaker.  Amazon is your friend too.

Make sure your First Aid Kit is stocked up.  That way your horse or horses have supplies if they need it and no one is running around looking for things that aren’t there.  Ask your caretaker where they would like it to be kept, that way they know exactly where it is.

I also left the keys to my truck and trailer with my friend.  

Truck and trailer spotless and prepped to take a break.

An app like Marco Polo is amazing while you’re away.  The beautiful thing about Marco Polo, if you are unfamiliar with it, is that you will always receive the videos.  It’s a video text app, but it can also do live videos if you are watching it while someone is messaging you.  This is super helpful because the videos don’t take up space on your phone.  You don’t have to worry about the quality or if they are too big for a text message, etc…  This way you can see your horse or be present for things like vet visits, even though you can’t be physically present.  

Super B noticing that gorgeous mare looking back at her on the phone.

My friend also has multiple ways of reaching me if she needs to.  It’s not as easy as just calling my phone right now.  If this means you get a Google Voice number, WhatsApp, etc… then do it.  

Have Zelle, PayPal, Venmo or something similar set up in case unforeseen issues arise or extra supplies are needed for whatever reason.  These apps make sending money quick and easy.  For example, Klein recently broke something in her paddock, I told my friend to let me know what I owe her to get it fixed and I’ll Zelle her immediately. 

Have your grooming supplies stocked.  That way there is plenty of shampoo, conditioner, etc...  

I had all of their sheets, saddle pads, and wraps professionally laundered and bagged up neatly before I left.  All of my tack was deep cleaned and prepped to sit for months (appropriate covers, bags, etc…).

These are just some ideas, I would say veterinary care planning is without a doubt the most important. 

Then...off you go.  

I lost count of the number of sunrises and sunsets I saw in one 24 hour period.  After over 44 hours of traveling, you know what I wasn't worried about?  Things involving my girls.  The peace of mind you get from being well prepared is absolutely priceless when you have a big job ahead of you.  I cannot explain the feeling of massive relief knowing my girls are in the best possible situation while I am not home.  Also, as soon as I go to the airport, the timer reverses and the count down is on until the day I come home.  Leaving is tough but, your mindset makes all the difference in the world.

Sunday, September 6, 2020

What Do You Do With Them While You're Gone?

Enjoying dinner together after a bath.  Of course Super B had already rolled.

I get this question a lot, and since, in case you didn't know, I’m gone right now, there isn’t a better time to revisit the subject.  What do I do with my girls when I’m gone for work?  I let them enjoy a well-deserved vacation.  I don’t let people ride them when I’m there, why would I do it when I’m not there?  There is absolutely no harm in letting them have some down time.  They are with one of my best friends, who is on the short list of people I trust to take care of them.  Her OCD *ahem* I mean, standard of care is the same as mine.  She’ll notice any little thing that’s off with them.  I trust her 110% with them.  She used to ponysit Klein ten years ago when we were in New Mexico together.  Klein loves her Auntie, and Super B does too.  

When Mt. Charleston was on fire earlier this summer.  It never got anywhere close.

So the girls are enjoying just running around doing whatever they want.  Eating cookies, relaxing under their fans, having conversations about horse things over the fence with my friend’s three geldings.  The Other Half visits them regularly as well.

I will be back in the fall when the perfect weather hits the desert.  The girls will be ready to go back to work, and here in a few weeks I’ll write their re-conditioning plans.  I don’t think it’s possible for Super B to ever get very far out of shape.  Klein will require some effort to get back in shape.  That is all part of the fun though.  Re-conditioning means long adventures out in the desert for trot/canter sets and hill work.  Hacks in our favorite new trail area too.  Then once they get back into a routine and get in shape I’ll go back to my jumping lessons with Super B to continue working on our goals for jumpers.  Klein mare and I have some dressage goals we need to finish.  

Part of what I enjoy so much is their training, watching them learn and feeling them get stronger and confident in certain things.  Klein mare is VERY well educated at this point in her training.  The bulk of my work will be getting her in better shape.  Super B is the opposite, while I highly doubt she’ll be what we’d consider out of shape, I would still NEVER ask her to go right back to the level of work she was at right before I left.  So, she will gradually be brought back into work as well but the bulk of my work with her will be continuing her education.  

Something I never worry about is either of them going feral.  They will not be lunged into the ground before I get on them, which is something I’m very highly against.  I will get right on both of them, expect them to behave, and they will.  I’m confident Klein and I could go to the moon and I’d still have the same Klein I have on Earth.  Super B, while she is much more um…excitable, she’s never straight up disrespectful.  

Of course this is all personal preference and knowing your horses, as well as your own abilities, and for me, having others ride them while I’m gone will just never be an option in my mind.  

Two happy unicorns checking in via video.

Saturday, May 23, 2020

What in the World?


I wanted to keep the focus on my last series of posts concerning eventing deaths so I held off on regular posts.  So what in the world have we been up to?

The girls have continued to work regularly, even with the pandemic going on.  We are lucky that we're still able to continue with our usual routine.  They are not at a public barn anymore either, they are on a private property.



I WAS starting to taper them down from work due to a work trip I have coming up.  That got delayed so the work kept up and now it's about time to taper again.  Klein I have kept in shape while working on nothing in specific for a change because I know she won't be showing until at least late fall.  Super B I have kept up with consistent, specific training, because, well, she's not as well schooled as Klein.  Think about it, Klein has about twelve years of training on her.  Super B has two since leaving the track after spending the majority of her life on it.


Super B continues to do extremely well and we recently just had a little celebration for the six month anniversary of her colic surgery.  You would have no idea what she went through.  She's a true super mare.  I was calling her Queen B for quite a while but I have committed to Super B now because she's just a super mare that has got to be one of the toughest horses I've seen, yet while also being one of the most sensitive and emotional at the same time.  I have been planning to get a small bee tattoo for her for over a year now and have finally found the perfect bee for it.

Excuse her sweaty look.  I had just untacked her after a ride and came out of the tackroom to her posed like this.  Something had caught her attention.  She's just such a supermodel of a mare.

Learning to long line.


The weather here has been nothing short of perfect lately too.  Absolutely gorgeous riding weather.  Spring in the desert is unbelievably beautiful, everything is green and all of the desert plants have flowers blooming.  We also recently found a new place with miles and miles and miles of trails.  The trails also give you an unreal view of The Strip.

Watching The Thunderbirds from the best seat in the house, Super B. 

Zuli and Klein.


Zeb and Klein on a beautiful morning out on the trails. 

 Zuli and Klein.

Sunset rides with bff's.  These two are coming up on their 10 year friendiversary this July believe it or not!  I just love that they have been reunited here in Nevada. 












Klein mare looking good as always. 


Klein vs. Super B. 

We llllove the desert.  This was a gorgeous evening trail ride in our new favorite spot!

Wednesday, April 29, 2020

Do Something Eventing, Part 7, In Summary


We have looked closer at some of the issues with the incidents here in the U.S. as well as abroad.  It's obvious that eventing as a whole has problems.  It's not a U.S. problem, it's not a Europe problem, it's not an Australia problem, it's an Eventing problem.

Just the other week the GoFundMe for Frangible Fences was up to $87,000 with the Manton Foundation now stepping in to match donations up to $250,000.  Now, there is a call for eventers to donate the amount of an entry to the fund.  Also, still crickets from the billionaire that could single handedly fund every xc fence with frangible technology.  The billionaire that will pay for Bloody Mary's shenanigans, sponsor entire events, and provide tens of thousands in division winning prize money.  But nothing to support the safety of life saving measures?  Actions speak louder than words.

This whole global pandemic thing happened right after the latest aftershock from the last death of a horse and rider at an event this past February.  It has distracted the majority of the eventing community away from it again.  Donations will continue to trickle in, but no actual, human, accountability will be demanded, until the next death.

I would sincerely hope that this down time caused by the pandemic was being used wisely by the powers that be at U.S. Eventing to allow for some positive, noticeable, action to be put in motion in the sport when it comes to deaths.  However, I'm definitely not holding my breath.  Why?

Did any of you know there are actual scholarly papers published on the safety of eventing?

The British Journal of Sports Medicine published an article called "Rider injury rates and emergency medical services at equestrian events" back in 1999.  Here is the abstract:

Abstract Background—Horse riding is a hazardous pastime, with a number of studies documenting high rates of injury and death among horse riders in general. This study focuses on the injury experience of cross country event riders, a high risk subset of horse riders. Method—Injury data were collected at a series of 35 equestrian events in South Australia from 1990 to 1998. Results—Injury rates were found to be especially high among event riders, with frequent falls, injuries, and even deaths. The highest injury rates were among the riders competing at the highest levels. Conclusion—There is a need for skilled emergency medical services at equestrian events.

Here is the link to the full article:  https://bjsm.bmj.com/content/bjsports/33/1/46.full.pdf

1999 people.  20 PLUS years ago.  And here we are still losing horses and riders on a regular basis, more than any other equestrian sport.

In 2003, the Equine Veterinary Journal published article called "A retrospective case-control study of horse falls in the sport of horse trials and three day eventing."  Here is the abstract:


REASONS FOR PERFORMING STUDY:

Serious injuries to horses and riders in horse trials (HT) and three-day events (3DE) are usually associated with falls of horses, which invariably involve falls of the riders. Many potential causes for these falls have been discussed.

OBJECTIVES:

The aim of this case-control study was to investigate the risk factors for horse falls on the cross-country phase of horse trials and three-day events.

METHODS:

Using retrospective data, significant risk factors identified with unvariable analysis (P value <0.2) were entered into a multivariable logistic regression model. Significant risk factors (P value <0.05) were included in the final model.

RESULTS:

It was revealed that a number of course, obstacle and rider variables were significantly and independently associated with the risk of falling. Falling was associated with obstacles sited downhill (Odds ratio [OR] 8.41) and with obstacles with ditches in front (OR = 5.77).

CONCLUSIONS:

The relationship between course variables and the risk of falling was characterised and showed a significantly increased risk with increasing numbers of jumps on the course and for jumping efforts later in the course. In contrast, after allowing for the total number of obstacles on the course, an increase in the total number of jumping efforts appeared to have a protective effect. A later cross-country start time was associated with a decreased risk of a horse fall. Amateur event riders were approximately 20 times more likely to fall than professional riders.

POTENTIAL CLINICAL RELEVANCE:

This study has identified a number of risk factors associated with horse falls and highlights areas that can be altered to improve safety in cross-country competitions.
Link:  https://www.ncbi.nlm.nih.gov/pubmed/12638789

Another published again in the Equine Veterinary Journal in 2006 called "The risk of horse-and-rider partnership falling on the cross country phase of eventing competitions."  Here is the abstract:


REASONS FOR PERFORMING STUDY:

Fatalities resulting from horse falls occurring during the cross-country phase of eventing competitions initiated epidemiological investigation of the risk factors associated with horse falls.

OBJECTIVES:

To identify variables that increased or decreased the risk of a horse fall during the cross-country phase of an eventing competition.

METHODS:

Data were collected from randomly selected British Eventing competitions held in Great Britain during 2001 and 2002. Data were obtained for 173 cases (jumping efforts resulting in a fall of the horse-and-rider partnership) and 503 matched controls (jumping efforts not resulting in a fall). The risk of falling was modelled using conditional logistic regression.

RESULTS:

An increased risk of a horse fall was associated with jumping into or out of water; taking off from good-to-soft, soft or heavy ground; fences with a drop landing; nonangled fences with a spread > or =2 m; and angled fences. Other risk factors included riders who knew that they were in the lead within the competition before the cross-country phase; an inappropriate speed of approach to the fence (too fast or too slow); horse-and-rider partnerships that had not incurred refusals at earlier fences; and riders who received cross-country tuition.

CONCLUSIONS:

This study has identified modifiable course- and fence-level risk factors for horse falls during the cross-country phase of eventing competitions. The risk of horse and rider injury at eventing competitions should be reduced by 3 simple measures; maintaining good to firm take-off surfaces at fences, reducing the base spread of fences to <2 m and reducing the use of fences at which horses are required to jump into or out of water. Risk reduction arising from course and fence modification needs to be confirmed by intervention studies.

POTENTIAL RELEVANCE:

Knowledge of factors that increase or decrease the risk of a horse fall can be used by UK governing bodies of the sport to reduce the risk of horse falls on the cross-country phase of eventing competitions, and reduce the risk of horse and rider injuries and fatalities. As one in 3 horses that fall injure themselves and one in 100 horse falls results in fatality to the horse, we suggest that immediate consideration is given to these recommendations.


In 2016 the journal Animals, an international peer-reviewed open access journal devoted entirely to animals, including zoology and veterinary sciences, published monthly.  This article is titled "Look Before You Leap:  What Are the Obstacles to Risk Calculation in the Equestrian Sport of Eventing?"  Here is the abstract:
All horse-riding is risky. In competitive horse sports, eventing is considered the riskiest, and is often characterised as very dangerous. But based on what data? There has been considerable research on the risks and unwanted outcomes of horse-riding in general, and on particular subsets of horse-riding such as eventing. However, there can be problems in accessing accurate, comprehensive and comparable data on such outcomes, and in using different calculation methods which cannot compare like with like. This paper critically examines a number of risk calculation methods used in estimating risk for riders in eventing, including one method which calculates risk based on hours spent in the activity and in one case concludes that eventing is more dangerous than motorcycle racing. This paper argues that the primary locus of risk for both riders and horses is the jump itself, and the action of the horse jumping. The paper proposes that risk calculation in eventing should therefore concentrate primarily on this locus, and suggests that eventing is unlikely to be more dangerous than motorcycle racing. The paper proposes avenues for further research to reduce the likelihood and consequences of rider and horse falls at jumps.
Where are all my "it was a freak accident people at" now?  These "freak" accidents have been going on for so long that the scientific community not only has taken notice of it for over 20 years, but has enough data to statistically analyze it as well?  Again, STOP with the freak accident bs.

You want to see some examples of freak accidents?  Here, have at it:

https://abc7.com/tag/freak-accident/




I will leave you with this before we get back to our regularly scheduled Klein and Super B programming, and until the next death, when we do this all over again.  Complacency kills.  No matter what your part, rider, organizer, trainer, student, fence judge, etc... Complacency kills.  So, you continue just acting like it's a freak accident and blindly participating in the circus, only thinking about yourself and how it would never happen to you, but remember, you can control you.  You cannot control these organizers, you can't control the TDs, the safety officials, the judges, etc...  Remember the absolute shit show that goes on behind the scenes at a lot of these events and ask yourself if you are ok putting you, and your horse's life, in their hands that day.  If so, well, hopefully they're in a good mood that day, got some sleep the night before, and have the proper life saving equipment onsite, should they need it.

Sunday, April 19, 2020

Do Something Eventing, Part 6, Caitlyn Fischer's Inquest Report


Now we're going to talk about Caitlyn Fischer's report, here it is for reference:

http://www.coroners.justice.nsw.gov.au/Documents/FISCHER%20Caitlyn%20-%20Findings%20%20Final%20(2).pdf

Caitlyn Fischer was an extremely educated rider.  She was competing at the one star level in Australia and was living/working on the property of her trainer, international event rider Christine Bates (short listed for the Olympics, reserve for WEG, etc...).  Christine's website, with her accomplishments listed, is here for anyone interested.  The trainer stated that she constantly coached Caitlyn and her horse, Ralphie, at the two star level and felt they were extremely proficient and well schooled at the one star level.  Caitlyn had completed a couple one stars prior to 30 April 2016, where she was competing in the CCI one star at the Sydney International Horse Trials.

Caitlyn had walked the cross country course several times and had a plan.  Her trainer told her to stick her plan and ride the first fence like she was expecting Ralphie to spook due to her trainer feeling like the first fence wasn't far enough from the start box for Ralphie to establish a strong canter.

Oddly enough, while Caitlyn was in the warm-up, a rider that was two in front of her had a rotational fall at a combination known as the "Lego Boxes" on course and that the course was being held to take care of the horse and rider, as well as remove that combination from the course.  The extent of injury to that rider was not clear.

Caitlyn's coach told her about the fall and that her start time had been moved back by about five minutes, as well as the news that the "Lego Boxes" were being removed from the course.  Caitlyn's coach said she wasn't affected by news of the fall and continued to warm up Ralphie until it was their turn.

Caitlyn had no issues and met the first fence perfectly, however, the second fence, a sloping table, is where the accident took place.  From all accounts (experienced riders spectating, fence judge, etc...) it sounds like Ralphie either got distracted as he was leaving the ground in front of the second fence or simply second guessed himself and missed.  They had a rotational fall where Ralphie landed on Caitlyn.

https://www.abc.net.au/news/2016-04-30/teenage-equestrian-dies-after-falling-from-horse/7373018

As far as that article, can we please acknowledge how ridiculous it is that the organizers gave the standard "it was a freak accident" response?  Are you serious?  The police are responding to your event, there is going to be an inquest, can you not say something like "we're not entirely sure what happened, but we're going to do our absolute best to try and figure it out."

Another issue, Eventing Australia formed their review panel months after the incident, like Olivia's.  MONTHS.  No.  Again, this needs to happen immediately.  You know what happens in a Safety Investigation Board and Accident Investigation Board?  Once the death notifications go up to the appropriate headquarters, phone calls are made IMMEDIATELY to appoint the board members for both.  Maybe this isn't practicable for them, but surely they can cut the time down from months.

I said this in the previous post concerning Olivia, but I'm going to repeat it here.  One thing I do think they should have done, is kept these two cases separate.  The mentioning of both Caitlyn and Olivia in both reports will only cause confusion.  These two girls deserve their own completely separate inquest and report with no mention of the other.  Only the evidence from each specific event should be considered and presented.  There should be no mention of both girls in either report, yet, there is.

13.48 In her notebook statement to the police, Ms. Retallack referred to making only one radio call for assistance. In evidence during the inquest, she referred to making a total of three calls. On her account, the third call was prompted by a lack of movement from the ambulance. Ms Retallack said that she did not receive a response to any of her three calls. Other witnesses state that they heard Ms Retallack’s first call. Dr Golowenko said that he broadcast a response to it which was heard by other witnesses. Only Dr Roche said that he heard a second radio call.

Due to the police response immediately that day after the incident happened, statements were taken.  Ms. Retallack's statement specifically is mentioned.  Normally, in a hearing like this, you would present the witness with their prior written statement while they're on the stand and let them read it, then proceed with questions and confront them on any discrepancies.  It doesn't appear that happened, but we also don't have the transcript, and that would give us that answer.

16.4(e).  Mr. Nicholson wasn't aware he was being interviewed for a review panel. 

That's a massive issue.  Every single interview, with every single witness, should start out with telling the witness who every person in the room is that is listening to the phone call, and that it is being recorded.  It should be standard procedure that every witness interview is recorded, then transcribed, and depending on the content either a summarized or verbatim transcription completed.  Once the transcription is complete it should be sent to every witness to review their interview transcript.  If they have edits they need to discuss them with the interviewers, if not, or when they reach a satisfactory transcription, the witness signs it.  The LAST thing you want is to have the witness' transcript inaccurate in any way, shape or form, as far as the information they are conveying in their interview.

16.4(f) Mr. Kane considered there to be a distinction between a review and an investigation and considered that the panel had been formed to conduct the former. Mr. Kane was asked in evidence about page 4 of the SIEC report. He explained: “Had we been doing an investigation…we would probably have gone through a kind of a cross-examination process, a more robust examination of every witness in potentially a, I suppose a, what’s the right word, a combative way rather than just an understanding of they’re saying way."

This is embarrassing.  Why is there any ambiguity to this process?  This is blatantly unacceptable.  Not only that, this "review" concerned the loss of a life.  It should be taken equally as serious no matter if it is a review or an investigation.  This is how much your organizing officials care about you.

16.(l) There appeared to be a lack of meaningful engagement with the parents of Caitlyn and Olivia. Ms Carr explained: “[Mr, Enzinger] and [Mr. Kane] came and met us in our home and spoke to us. They spent approximately two hours with us, but that during that time they made no notes. They took no documentation and when they left Mark and I turned to each other and said we felt that that had been a complete and utter waste of time. They advised us that they weren’t taking formal statements and I think what made us feel, I guess, alarmed was when we received the first draft of the first report into Caitlyn’s - review into Caitlyn’s death, there were so many errors of fact in relation to some simple things, like the day she arrived, which should have been very clearly documented and I suppose for me, given the experiences I’ve had with other health investigations, that - it made me alarmed that they couldn’t get things as - what I felt should have been as straightforward as that correct."

More embarrassment.  The "review panel" couldn't even get the day that Caitlyn arrived at the event right.  That's a basic fact.  A very simple, easily collected fact.  Again, these are the people whose hands you are putting your life and your horse's life into.  This is how much they don't care.  And there were no notes taken, and no interviews recorded?  Additionally, it sounds like they spoke with them while both were present together.  No.  They need to be separated, and interviewed separately.  You have an EYEWITNESS and essentially and outcry witness and you didn't separate them, or record their interviews in any fashion?  Completely unacceptable.

16.5. "I think we need to become more like the airline industry and more transparent. I think it's a, it's a role we have to take on and I think we have tended to hide these things too much, and if there's anything to learn we should learn it as soon as possible. And if that's the next week's event, let's learn it. So, yeah, I'd certainly encourage transparency."  

This paragraph was also in Olivia's report, and I will say the same thing again about it. Novel idea, sir.

18.4 Mr. Backhouse explained that the scoresheet from a horse and rider combination’s performance in the show jumping could be reviewed by the technical delegate (and the course designer and show jumping judge).  However, Mr. Backhouse acknowledged that opinion within the equestrian community was divided on this issue and that a number of considerations needed to be taken into account: (a) that some horses are “lazy” showjumpers but competent cross country jumpers; (b) different skills are required in each discipline; (c) disqualifications will impact High Performance riders seeking to qualify for Olympic and World Championship level events; and (d) show jumping does not always occur prior to cross country and so this would produce inconsistent disqualifications.

So some horses excel in one area and aren't so great in others?  Ok, so having some additional minimum requirements would weed out the ones that aren't an all around horse.  How is that bad?  Shouldn't you WANT an all around horse?  Disqualifications will impact those seeking to qualify for things like the Olympics and World Championships?  Well, thank you for pointing out the obvious.  We shouldn't be actively trying to limit disqualifications.  If they are warranted, they are warranted, that's part of the sport, or...it should be.  Also, we all have been to events where the order is different as far as cross country and show jumping.  They could just require show jumping to take place before cross country.

18.6. Mr. Etherington-Smith thinks that showjumping IS a predictor and that if a horse has a poor showjumping round it is more at risk to have an issue on cross country.  As he puts it "a good jumper is both careful and both brave and that - a horse that is likely to jump regularly jump too low over showjumps doesn’t suddenly stop jumping too low when it’s presented with a cross-country jump. If it’s likely to hit showjumps it’s likely to hit cross-country jumps."

This guys gets it.  They put this in both reports.

18.8.  A policy involving poor showjumping performance had already been in place since 2017 at a HT and the riders received it well, acknowledging that it is a safety tool.  "Mr. Richardson confirmed that this practice was adopted at Scone in 2017. If a rider had a significant number of rails down (five or six) in the show jumping they were disqualified from the cross country but permitted to rider at the grade below. He explained that this did not cause any problems and that riders accepted it once it was explained that it was a safety measure."

Another point repeated in this report as well.

22.8 Dr Davis raised his views with Dr Roche informally, usually at a debrief following an event which he had volunteered at. Dr Davis raised the issue that the paramedics should be supported by a medical officer and that the minimum level of paramedic required was one that was capable of using a laryngeal mask or capable of using an endotracheal tube and laryngoscope. Dr Davis recalled that Dr Roche agreed with him although no concrete steps were taken to implement this prior to 2016.

Dr. Davis went on to explain: “Again, at the end of most of the Sydney events I expressed my view about the level of paramedic cover, which at Sydney I think is appropriate when there’s medical backup, but it always concerned me that there were plenty of events going on that that may not be at a level that could be appropriate to manage the injuries that you could receive”.

This entire statement is alarming.

22.9 Dr. Davis was not alone in his views. Dr. Taylor said that prior to 2016 she had discussed the level of medical coverage with her husband, Dr. Janson. 

She explained: “…we personally were concerned that there was not adequate equipment, that when, when my husband does the event doctor, he brings his own gear as I think most doctors do. And we knew that there was the, the stock carried within the ambulances was less than we would have carried ourselves”.

Important information to be aware of, appalled by, and should make you want to speak up to your event coordinators/organizers.

22.11 Dr. Taylor also said that, like Dr. Davis, the concerns that she and Dr. Janson held were mentioned informally. Prior to 2016 it appears that the views held by Dr. Davis, Dr. Taylor, and Dr. Janson were never raised in a more formal forum by EA or any organising committee. However, following the tragic events of 2016 there was increased discussion amongst medical practitioners who had experience in volunteering their services at events. This culminated in a teleconference on 20 December 2016 involving members of what was described as the NSW Eventing Medical Safety Group. Dr. Davis, Dr. Taylor, Dr. Janson and Dr. Roche were among the participants. 

Dr. Roche explained the genesis of the teleconference in this way: “Look, it, it actually started very informally where a bunch of us just started emailing to one another, as I said, we, we had a heightened awareness that we could do better, both in terms of preparation, response, planning, et cetera. And it, it, it started quite organically as an email from one person to another and they would copy somebody else in, and the thing sort of gathered momentum. I don't think at any stage it was really sort of formally appointed as a subcommittee, but we, we felt that we were the appropriate people to try and give that knowledge to most of the GPs - sorry, most of the doctors who were providing medical response at New South Wales events, were taking part in that. And that it was appropriate that we advise Eventing New South Wales, who had no other doctors, you know, what we felt was, was the best thing”.

22.12 It appears that this teleconference ultimately resulted in the formation of National Medical Consultative Group (NMCG) in June 2017. One of the primary roles of the NMCG was to prepare and implement Medical Guidelines which are intended to formalise the initiatives that State branches and organising committees are actioning, or have actioned, regarding provision of medical care. The Medical Guidelines were published in May 2018. 

I think the above two paragraphs, 22.11 and 22.12, are very important.  It shows what a group of people that care can do.  They can make positive action happen.  You just have to care.

22.41 Both Dr. Cross and Professor Brown agreed that a response time of less than three minutes would be ideal, and that having a time benchmark would also assist in determining where medical teams are located and what vehicles are required to reach the furthest away fence on a cross country course. Professor Brown explained: “I agree that the three minutes is really the, the benchmark for the paramedic doctor crew”.

Important because while Caitlyn Fischer may have had no chance of survival based on a basal skull fracture being one of her injuries, there are various inconsistencies in the medical response time concerning this incident that have been brought to light.

Consolidated Recommendations start on page 73.  Take a look at them.

Tuesday, April 7, 2020

Do Something Eventing, Part 5, Olivia Inglis' Inquest Report

There was some concern about cross country that was a mixture of the type of fence the 8a/8b combination was, as well as Togha's poor showjumping performance the day prior, where he had six rails down.  The concern over that particular combination was shared by other riders as well.  Olivia's mom went and shared her concern with the course designer, in this case someone she knew and was familiar with.  The course designer, Shane Rose, reassured Olivia's mom that the fence was nothing particularly challenging for the level and maintains that to this day.  Other expert riders would testify about that combination in the same manner at the inquest.  That specific combination had been used on the course in years past, and had no issues.  Shane Rose had competed at a HT where it was on his course as well, and he didn't give it a second thought, it rode well for him, and everyone else.

Olivia had no issues through the course up until 8b.  She and Togha jumped 8a perfectly, then Togha hung a knee at 8b.  They fell, and from the jump judge's account Olivia hit the ground first, then Togha fell on top of her.  When Togha managed to get up, Olivia was motionless.

Despite the fact that the ambulance quickly made its way to Olivia, the medic had equipment that was malfunctioning.  He states that he tested the equipment that morning, it was working properly, however when he brought it to Olivia it was not operating properly.  That piece of equipment was an oropharyngeal suction kit.

I have questions that weren't answered in the inquest report.  This is where it would be helpful to read the transcript from the actual proceedings.  He tested the suction kit that morning, that type of kit is battery operated with a rechargeable lead acid battery.  Most of these kits have a battery indicator light on them, did he check it, if it was a model that had one?  Did the company properly maintain the equipment?  Meaning, what was the expiration date on the battery?  Was the suction kit collected into evidence for testing after it failed?  Why not?

Mr. Keys, the medic, also stated that he knew Olivia needed at least one chest tube, but preferably two, in immediately, and that the ambulance was not supplied with the equipment to conduct that procedure.  Another piece of equipment he stated should have been on the ambulance, but was not, was a laryngeal mask airway and/or an endotracheal tube.  Also noted was the fact that he was a Physician's Assistant, so he was more than qualified and capable to properly use any equipment necessary for that particular scenario.  He had all the necessary skills, but was not provided adequate equipment.

More questions, who determines what is on the ambulance?  Is there an inventory, if so is that equipment on it?  If it's not on the ambulance, why not, since it is something a medic would expect to have on hand?

Also, since Mr. Keys was contracted and provided with that ambulance by the company, I would want to see all the requirements of the ambulance from that company.  I would want the inventory reviewed, checklists of equipment (if any existed), information about when the last time the ambulance was in service, and if the previous operators failed to properly restock any of the medical supplies/test the equipment, power it down properly, plug it in to charge, etc...

"11.12. Following the events of March and April 2016, HSI was no longer deemed to be the preferred ambulance or paramedic service for NSW eventing competitions. However, the NSW Eventing Organisers Handbook, which is believed to still be in force, still provides that HSI occupies this status. It is evident, given the events of 2016 and what had transpired since that immediate amendment of the NSW Eventing Organisers Handbook is necessary."

I'm sorry, what?  This fatality happened in March 2016, and as of October 2019 this update had not happened in the Organisers Handbook that is still in use??????

"11.13 RECOMMENDATION: I recommend to the Chief Executive Officer of Equestrian Australia that the NSW Eventing Organisers Handbook be immediately updated to remove reference to Health Services International as the preferred NSW ambulance service for eventing competitions, and that the Handbook be amended to nominate the current preferred service provider (if any)." 

Why does it take an inquest 3 years later to tell this organization to do this????

The organisers (spelled in the Australian version) also had no idea that the doctor they had originally scheduled was unable to be present at the event.  They never contacted him to confirm his presence and there was a folder in the office with his name on it, that he never picked up (no one wondered where he was?).  His wife was there, also a doctor, competing. She was not there in her capacity as a doctor.  However, when Olivia went down, Dr. Taylor (the competitor) overheard the call for a doctor on a radio while she was in the warm-up.  She asked if a doctor was needed, knowing that her husband was not present.  She was informed a doctor WAS needed, so she responded.

She later stated that it was not only entirely inappropriate, but inadequate for the organisers to count her presence as adequate physician coverage, due to the fact she was there to compete.

Think about that.  Sure, she is on the grounds but she is nowhere near in the loop with what is going on at control.  She was in the warm up asking if they needed her ONLY because she happened to overhear a radio call.  Then she has to dismount, find someone to take her horse and find a ride to the accident?!  She also has no clue who else is there, what equipment they have, etc...

Dr. Taylor stated that Mr. Keys had been there quite a bit longer than she had by the time she arrived.  She said he correctly identified all of the issues and injuries but due to the absence of the necessary equipment, neither of them could perform the required effective care.  About the time Dr. Taylor arrived, an air ambulance was inbound.  The trauma team on the air ambulance did have all the necessary equipment and all procedures were performed as soon as they reached Olivia.  By that time, Olivia no longer had a pulse and Dr. Taylor and Mr. Keys had already started CPR.  Another issue that was noted is that if Mr. Keys did not have Dr. Taylor he could not have effectively done CPR and managed Olivia's airway.  There SHOULD have been a dedicated doctor that day, or another medic, as Mr. Keys stated that he did feel uncomfortable not being "two up" in the ambulance, meaning being teamed with another medic that day.

"12.12 Dr. Cross was also asked about his expectations of the organising committee contacting the purported event doctor to ensure that the doctor was aware of their obligations. He explained: “I think the duty, duty of care was not delivered. I would hope this would never happen again so I would - I, I don’t - I think reading of the documents and hearing the evidence I, I think it was inadequate."

So here is where you would call your Subject Matter Expert in an Accident Investigation Board when we conduct them.  In this case, our Subject Matter Expert would be a Emergency Room Physician with no real knowledge of the case and no familiarity with the parties involved.  We would explain what happened, and let the doctor review the evidence.  After this we would ask that doctor after his review, if in his professional opinion as an Emergency Room Physician, if they (Dr. Taylor and Mr. Keys) had the proper medical equipment on site and it was functioning correctly, does he think that Olivia would have likely survived.  Keeping in mind, that's a hard thing to opine about because each case is different, but most times our experts can articulate their opinion extremely well.

"10.4 At the commencement of the inquest Lucy Warhurst, Chief Executive Officer of EA, made the following statement to the court: “We are committed to ensuring that the deaths of Olivia and Caitlyn are honoured by ensuring that all lessons learned will be applied through education and training, the safety of riders, 16 coaches, horses, officials and all participants. Equestrian Australia’s number 1 priority is and will remain the safety of its participants”.  

Really?  And how are you going to do that when you can't even update a handbook?????

"11.4 The President of the organising committee for the 2016 Scone Trials, Blair Richardson, said that he did not turn his mind to what level of medical services was actually going to be provided."

You would HOPE this would be on the top of their priority list, clearly, it's not.  I bet you making sure that every last competitor is paid up for entry is though!

"11.5 Further, Mr Richardson acknowledged that in 2016 he was unaware of the provision in the 2016 EA Rules that a paramedic equivalent or ambulance must be present during the cross country test and a doctor should be present during the cross country test.  He agreed that he did not turn his mind to whether a doctor would be present to assist."

This is the PRESIDENT of the organising committee for that event and he doesn't even know the rules?????

"11.8 After being engaged for the event, Mr Keys collected the ambulance from a location near Bowral. He was told by Mr Taylor that it was fully stocked. Mr Keys said that he briefly looked at the equipment to make sure that the majority of equipment he expected to be available was in fact available."

Key word here, majority.  He made sure the majority of the equipment was there...but not everything he would expect?  Now here, we may have the issue of if Mr. Keys was familiar at all with eventing.  It is extremely possible he had absolutely no actual knowledge of what three day eventing was, meaning he could have thought "ok, people riding horses around" and not realized that people would be jumping solid jumps at speed.  I don't see anywhere that they asked him that question, again a complete transcript would be helpful.

"12.5 Mr Bates explained that at the safety briefing there was an expectation that Dr. Janson would be the event doctor. At the briefing it was indicated that at the last minute Dr. Janson was unavailable but that Dr. Taylor (Dr. Janson's wife) would be present at the event as a competitor. On this basis Dr. Taylor was listed at the event doctor.  Mr Bates said that he did not seek confirmation at the briefing whether Dr. Taylor would in fact be the event doctor. He said that he left that matter for the organising committee to confirm. Mr Bates said that he was “comfortable that there was no requirement under the rules to have a doctor but it was good to know that [Dr Taylor] was at least on the grounds."

Great, here we have miscommunication between the officials as well as an assumption that it would be fine knowing a doctor is present, even though that doctor specifically says in the inquest it would be inappropriate and inadequate for them to assume that by the mere presence of her being there as a competitor, an it is easy to see why.

"13.44(c) Mr. Lochore said that he did not think that a 3% gradient would be considered downhill, and that a 5.5% gradient was not considerable and not something that would be considered inappropriate at the two star level. He acknowledged that, a 5.5% 94 gradient was possibly not in line with the FEI Guidelines. However, he said that he had designed many courses at the two star and three star level that had not adhered to the guidelines in this respect.

(d) Mr. Tapner said that whether the downhill approach could be described as significant or not, the fact remained that the approach was downhill. On this basis he considered that it was inarguable that the FEI Guidelines had been breached.

(e) Both Mr. Johnston and Mr. Etherington-Smith agreed that fence 8A/8B was not consistent with the FEI Guidelines.

(f) Mr. Bates (TD that day) offered this view: “That’s why these are guidelines and not rules because course designers are subject to so many variables and that downhill would be referring to a much a steeper gradient than what that was at 8A/8B”. He explained that the term “vertical” was subject to interpretation and that 8A was not a true vertical because the profile of the fence made it appropriate.

(g) Mr. Rose (course designer for the course that day) did not consider 8A to be a true vertical-faced fence, as it had a sloped profile. He also explained that there was room for interpretation as to what constituted a vertical and what was considered to be downhill with the FEI Guidelines as they are not rules."

And above we have testimony from several course designers to include the one from the day Olivia died, and the TD from that day, arguing about what exactly 8a/8b was and if it was, in fact, considered appropriate.  The sections following that discuss the ground line, the spread, the filler, and frangible technology.  It is great to see this all brought up and discussed on the record.

Another massive issue, Eventing Australia formed their review panel months after the incident.   MONTHS.  No.  This needs to happen immediately.  You know what happens in a Safety Investigation Board and Accident Investigation Board?  Once the death notifications go up to the appropriate headquarters, phone calls are made IMMEDIATELY to appoint the board members for both.  Maybe this isn't practicable for them, but surely they can cut the time down from six months.

Where Safety Investigation Boards (SIBs) and Accident Investigation Boards (AIBs) differentiate from an inquest is they happen MUCH faster.  Evidence is collected immediately for the SIB.  The SIB is meant to be solely to determine the facts and is non-attribution.  The SIB wants to find the cause so that preventative measures (if needed) can be put into place, training can be developed to go out to the field so that lessons are learned and mistakes are hopefully not repeated.  Once the SIB is done, a portion of their report along with the evidence is released to the AIB.  The AIB members (this is the team I am on) will review the evidence, identify their witnesses/victims, locate them and contact them.  They will all be recorded and placed under oath prior to giving their recorded verbal statement.  They will be allowed to review any prior statements made to the SIB and asked if they would like to adopt that statement, then elaborate or add any details they feel are relevant.  If at any point we suspect something incriminating is about to come out of their mouth, we stop them and read them their rights.  At that point the interview is either terminated, if they invoke their rights and request counsel, or it continues once they unequivocally state they decline counsel and wish to continue.

One thing I do think they should have done, is kept these two cases separate.  The mentioning of both Caitlyn and Olivia in both reports will only cause confusion.  These two girls deserve their own completely separate inquest and report with no mention of the other.  Only the evidence from each specific event should be considered and presented.  There should be no mention of both girls in either report, yet, there is.

18.4 (c) Some witnesses, including those mentioned above, were only spoken to over the phone and never asked to make and sign formal statements. Mr. Rees (Caitlyn's case) said in evidence that he would have been happy to participate in an interview with a representative of Eventing Australia (EA). 

(d) Statements that were taken from some witnesses contained inaccuracies which it did not appear were ever resolved. 

(e).  Mr. Nicholson (Caitlyn's case) wasn't aware he was being interviewed for a review panel."  

That's a massive issue.

Every single interview with every single witness should start out with telling the witness who every person in the room is that is listening to the phone call and that it is being recorded.  As I mentioned aboved, not only should it be recorded, every witness should be placed under oath as well.  Every interview should then be transcribed and depending on the content, in either a summarized or verbatim transcription.  Once the transcription is complete it should be sent to every witness to review.  If they have edits they need to discuss them with the interviewers, if not, or when they reach a satisfactory transcription, the witness signs it.  The LAST thing you want is to have the witness' transcript inaccurate in any way, shape or form, as far as the information they are conveying in their interview.

"18.4 (g) In Olivia’s case, no consideration was given to whether an independent course designer should be engaged to review fence 8A/8B.

(h) Mrs. Farrar (safety consultant) was instructed to not pursue certain lines of inquiry, such as attempting to accurately measure the distance between 8A and 8B (because the panel felt that the focus should instead be on rider experience and their striding), and seeking expert opinions from experienced riders such as Mr. Tinney and Mr. Tapner about whether the fence could have been built in a way that posed a lower risk."

Ok, full stop.  If a witness says that she was instructed to not pursue certain lines of inquiry that involved something like accurately measuring the distance between the fences in the combination where a fatal incident took place, you ask who it was that told them to NOT do that.  Then, remember that rights advisement I talked about?  Call up that witness that is the one that instructed the other one not to take the measurement, and prepare to read them their rights.  That, in our world, would be along the lines of an obstruction charge.

"18.4 (j) Some items were removed from Olivia’s final report which appeared to have relevance such as: rider impressions of the ground conditions at Scone, a diagram taken from the Barnett Report showing the risk of horse fall for different fence types, a recommendation that cross country fence profiles be made more forgiving with no vertical faces even on ascending oxers, and details of discussions with Health Services International (HSI).

(l) There appeared to be a lack of meaningful engagement with the parents of Caitlyn and Olivia."

While extremely painful for a witness to have to relive the event by telling it, if you have eyewitnesses, you ask them to make a statement.  Either a signed, sworn written statement or a recorded verbal statement.  In the case of something so traumatic, if the parents stated they had a preference for written or verbal, you let them have their preference.  You NEED this information memorialized.

"18.5. Geoff Sinclair, a Level 3/4 technical delegate, member of the FEI Eventing Committee and chair of the FEI Risk Management Steering Group, was asked at the inquest to provide a view about the matters set out at paragraph (m) above. He said: I think we need to become more like the airline industry and more transparent. I think it's a, it's a role we have to take on and I think we have tended to hide these things too much, and if there's anything to learn we should learn it as soon as possible. And if that's the next week's event, let's learn it. So, yeah, I'd certainly encourage transparency."  

Novel idea, sir.

At paragraph 20.5., Mr. Rose waffles on his opinion about rails down predicting poor cross country performance, though he does agree, further data analysis is necessary.

At paragraph 20.6., Mr. Etherington-Smith thinks that showjumping IS a predictor and that if a horse has a poor showjumping round it is more at risk to have an issue on cross country.  As he puts it "a good jumper is both careful and both brave and that - a horse that is likely to jump regularly jump too low over showjumps doesn’t suddenly stop jumping too low when it’s presented with a cross-country jump. If it’s likely to hit showjumps it’s likely to hit cross-country jumps."

In paragraph 20.8., a policy involving poor showjumping performance had already been in place since 2017 at a HT and the riders received it well, acknowledging that it is a safety tool.  "Mr. Richardson confirmed that this practice was adopted at Scone in 2017. If a rider had a significant number of rails down (five or six) in the show jumping they were disqualified from the cross country but permitted to rider at the grade below. He explained that this did not cause any problems and that riders accepted it once it was explained that it was a safety measure."

"23.8  Dr. Davis raised his views with Dr. Roche informally, usually at a debrief following an event which he had volunteered at. Dr. Davis raised the issue that the paramedics should be supported by a medical officer and that the minimum level of paramedic required was one that was capable of using a laryngeal mask or capable of using an endotracheal tube and laryngoscope. Dr. Davis recalled that Dr. Roche agreed with him although no concrete steps were taken to implement this prior to 2016."  

So medical doctors had suggested this and it was never implemented.  Airway is one of the most important things to manage in trauma and the powers that be never saw it necessary to require a paramedic on site with those skills?  Thanks for caring.

Consolidated Recommendations start on page 95 of the actual marked pages, page 100 according to the page count if you want to type it in the page box at the top of the document to go straight to that section.

I hope that by breaking this report down a bit and highlighting some of the more alarming things, I have helped some of you see the deep issues this sport is facing around the world.  If you think that U.S. Eventing doesn't have these same problems, you are lying to yourself.  Take responsibility for you and your horse's safety.  Educate yourself.  This is just a fraction of the information that could be provided, yet we don't even get this in the U.S.  Is this really something you still want to be a part of and support right now?

The next post will be Caitlyn Fischer's inquest report with the same break down.