Jim Moonie & Sarah Abraham / Ski Field Doctors
As summer arrived in the northern hemisphere, Jim Moonie and Sarah Abraham finished Core Training, left England and travelled to New Zealand to work as doctors for the ski fields around Queenstown. The tourist epicentre of the Southern Alps has a population of only 30,000, but receives over a million visitors annually. Sadly for these visitors, some of their adventures (and misadventures) will land them in hospital. However, for the doctors, it is a dream job.
When we said we were going to be ski field doctors (a job we’d had our eyes on since an earlier trip to NZ), people looked on it as a holiday. However, it turned out to be the greatest of things – a job that was as enjoyable as a holiday but also the perfect case mix of trauma and musculoskeletal medicine.
Our employers were CoRe Medical Services, a company set up by a group of GPs from Queenstown Medical Centre, the main practice in town. CoRe were contracted by NZ Ski to provide medical cover to the ski fields – Coronet Peak and the Remarkables – from which the name ‘CoRe’ derives. The practice was perched on a hillside at the foot of the summer mountain biking trails, overlooking the lake and gazing up at the Remarkables. Its walls were adorned with photographs of mountains and the pioneers of the gold rush. It was the sort of GP practice you might dream of if you were to dream of that sort of thing. More of a medical centre than a UK-style practice, it had a small emergency department (‘Accident and Medical’), a fracture clinic, x-ray and ultrasound facilities. In the same building were a pharmacy, physiotherapy clinic and a cafe complete with log burning stove.
On the mountain
A typical mountain day started at around 8.30am, after either a short drive up to Coronet Peak or a slightly longer and more precipitous drive to the Remarkables. On occasion, there would be a patient awaiting your arrival, but more often than not the first hour was quiet: time for an hour’s skiing before the real work started.
At the beginning and end of the season work could be sporadic and staggered throughout the day. However during the peak season, especially during Australian and New Zealand school holidays, it was not unusual to see 20-30 patients per day. With a small first aid room, one doctor and one nurse it could easily feel busy, especially when a more severely injured patient presented.
Patients either self-presented or were transported by ski patrol. More rarely, the doctor would be called out to the scene of the incident, in which case we would grab the trauma pack and jump on the back of the skidoo. Equally, we were sometimes first on scene and could radio for help as required and begin initial management.
We saw a wide range of presentations from exercise-induced anaphylaxis to ocular foreign bodies, but the majority of cases were trauma. Common problems included knee injuries, wrist fractures, shoulder dislocations, acromio-clavicular joint injuries, head injury/concussion and potential spinal injuries, though other interesting presentations included tibia/fibula fractures (mainly in children), elbow dislocations, femoral fractures, hip dislocations, pelvic injuries and a number of significant lacerations caused by snowboards.
The Ski Patrollers
The first aid room was shared with the ski patrollers, a dedicated group of experienced mountain professionals, most of whom had many winter seasons behind them. Consequently they were no strangers to potential dangers. Many had attended or experienced horrific accidents. A memorial to a ski patroller lost in an avalanche sits at the top of the Remarkables.
Their skill set was broad and included avalanche control and rescue, weather assessment and reporting, rope access and extrication, working with helicopters and responding to casualties, providing initial management and transporting them to first aid. They were trained in the use of Penthrox (see below) and used it to move and package patients in severe pain, particularly those with limb injuries. They were also trained in primary survey, with an appropriately low threshold for spinal immobilisation.
We worked closely with them over the course of the season. There were joint training sessions which included helicopter safety and the logistics of transferring patients to secondary or tertiary care. We also benefited a great deal from their skills with patrol-led sessions in avalanche training, rope work and double rigging (two rescue sleds strapped together to enable severely injured or unwell patients to be treated on the move). In return, the medical team gave teaching to the ski patrollers covering such subjects as hypothermia, chest and abdominal trauma, spinal injuries, primary survey and lower limb injuries. In the event of a serious incident involving, for example, the doctor being called to the scene or a spinal injury requiring helicopter evacuation direct to the tertiary centre we would debrief and discuss the case at the end of the day.
We also had two evenings of physiotherapy teaching focusing on joint examination and taping, a course of orthopaedic x-ray teaching from the doctors who run the fracture clinic and a two-day induction program.
Not quite A&E
We were well equipped to manage most eventualities, with access to anaesthetic drugs and (basic) equipment, and a full complement of analgesia from ibuprofen and paracetamol to ketamine and intravenous and intranasal opiates.
However, in spite of working in what appeared to be a small, well stocked emergency department we all noticed huge differences between the two environments. Importantly, we only had one nurse and one doctor, sometimes managing multiple patients at the same the time. We had to prioritise effectively and organise a good team around us, often drawing on support from ski patrollers or the receptionists when log rolling or splinting a limb.
The timing of presentations was also very different. Shoulder dislocations, for example, had usually only been out for a matter of minutes at presentation. They would tend to be easily reduced even with entonox or no analgesia at all. It was much easier to make a clear diagnosis of knee injuries as they were seen very early. Prior to the onset of swelling, a positive Lachmann’s or anterior draw is much easier to elicit.
Other injuries, however, could be more subtle with the diagnosis more reliant on a high index of suspicion than anything else. Wrist injuries that appeared entirely benign would often turn out to be fractures when x-rayed based on mechanism alone (typically a snowboarder falling onto an outstretched wrist without wrist guards). Because the mechanism in skiing is so often significant we had a very low threshold for spinal immobilisation and frequently helicoptered patients down for radiological clearance.
We were all surprised by the severity and frequency of concussion, even with the widespread use of helmets. It was not unusual for patients to be brought to us by ski patrol having been found wandering the mountain with no idea of where they were or what had happened. Though the initial physical examination was usually normally, there were many episodes in which total amnesia persisted for a number of hours. These patients would be admitted to inpatient care. At home, they would almost invariably have been scanned, but when we followed them up, they had usually just been kept in hospital overnight and discharged after showing signs of improvement.
Occasionally, they would be scanned, but with the nearest scanner being in a 24-bed rural hospital an hour from Queenstown, this was not often done. Such practice highlighted how resource-availability can define decision making in healthcare. It sat in stark contrast to the ‘American model’ we are heading towards in much of the UK.
Most mountain days ended at around 5pm, allowing time for the mountain to be cleared by the patrol (‘the sweep’) and the last patients transported down, though occasionally a late influx of patients would delay things. The only exceptions were Friday and Saturday nights when one doctor was required to stay on the mountain until 10pm for night skiing. This was usually a relatively quiet time and afforded a few hours of skiing to round off the day.
Aside from working up the hill we also worked one or two shifts per week in the medical centre in town. It was a good opportunity to follow up on injuries that we had sent down, try our hands at GP work and manage injuries that could not be definitively treated on the mountain: reducing Colles’ fractures, liaising with tertiary orthopaedics, arranging ultrasounds for complete UCL ruptures (to rule out Stener lesions).
Queenstown was a great place to live and in spite of being in the middle of nowhere had all we could possibly have required. It is dominated by Lake Wakatipu and surrounded by stunning mountains. The climate could be surprisingly pleasant, allowing rock climbing and mountain biking for much of the season.
A day off work could involve skiing in the morning and mountain biking in the afternoon followed by a steak and some beers town. Alternatively, a day at the winery, a dip at the hot springs or a visit to one of Queenstown’s many excellent restaurants.
Above all, what really made the season for us was working closely with a great group of people from a variety of backgrounds: nurses, doctors, receptionists, pharmacists, physiotherapists, ski patrollers and paramedics. We worked as a team with no hint of ego, helped (no doubt) by the knowledge that we had the best job in the world.
Penthrox (methoxyfluorane) is an inhaled volatile fluorinated hydrocarbon first synthesised in the 1940s, by the team of chemists behind the Manhattan Project. It was first used as an anaesthetic agent, but fell out of favour in the 1970s due to concerns in regarding hepatotoxicity and dose-dependent nephrotoxicity (at anaesthetic doses). Penthrox is not currently licensed in the USA and the UK, though in the UK at least this may be about to change.
It has long been used in Australasia as a pre-hospital analgesic often by first responders such as paramedics, mountain rescuer and ski patrollers. Whilst there is good evidence to avoid its use in anaesthesia, evidence for use as analgesia is scanty. There have been some large retrospective studies from the Australian Ambulance Service, but these were subject to a number of limitations. More recently, the STOP! Trial in UK A&Es found it helpful, but did not compare Penthrox to best standard therapy. Both those for and against tend to base their views on anecdotal evidence.
Penthrox comes in a easy to use, lightweight and portable inhalation device which requires no medical knowledge to use, giving it significant advantages over Entonox and intranasal opioids. In addition, the standard administered dose of 3mls contains less than 1g of Penthrox at inhaled concentrations: far lower than the 20-24g at which toxicity is thought likely.
It seems that Penthrox is set to remain a useful part of the pre-hospital armoury in the southern hemisphere and perhaps elsewhere soon. It may just take a while for the evidence to catch up.
Becoming a New Zealand Ski Field Doctor
CoRe Medical Services have had the contract for the past twenty years or thereabouts, but this year NZ Ski have decided to go it alone. As it stands QMC are recruiting seasonal doctors to work in the Accident and Medical centre, a job that comes with a season pass, whilst NZ Ski will be recruiting directly for the Ski Field jobs.
Jim and Sarah would like to dedicate this article to Stu Haslett: colleague, Ski Patroller, mountaineer and search and rescue climber who died in a fall from Mount Cook on Saturday 13 December 2014.