Harriet Gray-Stephens / CT1 Anaesthetist / Edinburgh
Harriet is bang in the midst of her first year of anaesthetic training in the south east of Scotland. For the past nine years, in-between the ubiquitous night-shifts, day-shifts, exams and general life tasks of medical training, she’s been taking to the hills with Ski Patrol in Scotland. Here, she gives Adventure Medic some fascinating insight into the equipment the mountain first response teams have at their finger tips. That, plus a few tips for your own trip off-piste.
Many of you may know that skiing in Scotland can be somewhat variable. Beautiful sunshine in the morning can often be followed by torrential rain, washing away the snow in minutes; a firm or icy slope can rapidly turn into sticky, heavy snow. Heather-bashing and rock-hopping provide memorable experiences. These varying conditions give rise to very different injury types, and thus management strategies. When injured, you become reliant on ski patrol services to get you back down to the base station: whether that be for a cup of warming hot chocolate, or further medical help.
I’ve been involved with Ski Patrol in Scotland for 9 years, having completed a British Association of Ski Patrol (BASP) training course as a medical student. Currently as a CT1 in Anaesthetics, I enjoy spending my free time and weekends off in the mountains volunteering with Glenshee ski patrol, as well as collecting data on Scottish ski injuries. I cannot think of a better way to pass a weekend than enjoying both the first and last run of the day, and working with a truly inspiration group of fellow patrollers.
Ski patrolling in Scotland provides many different challenges to the majority of Europe and Australasia. All of the evacuation and medical services that we provide are volunteer-run and funded, rather than through insurance companies. In such harsh mountain environments, poorly manufactured equipment often breaks so we use plenty of basic resources to help manage casualties. Sometimes the most simple splint and equipment can prove to be the most valuable. The classic balance between “ staying and playing” and “grabbing and going” must often be reached; in cold and often windy environments the priority is to evacuate the patient safely to the treatment room for further assessment and definitive management. Each ski patroller carries their own basic first aid kit, primarily bandages, slings and splints. We have several “majors bags” including a trauma bag with spinal immobilisation equipment, a haemorrhage control pack (celox gauze and lots of dressings), an airway and cardiac arrest bag and a lower limb grab bag containing a traction splint.
The majority of casualties are evacuated from the piste by Tremont sledges: a simple 2-handled sledge driven by a single patroller, with the assistance of a back rope on particularly steep or icy slope. Braking is provided by a chain which can be deployed under the belly of the sledge, but once deployed the sledge has to be lifted to release it on any flat slope. Casualties are packaged in the sledge on an insulating mat, wrapped in a thick casualty bag. This is relatively easy on the main slope faces, but within a distant valley can be difficult with the casualty having to be taken uphill by a patroller (which is exhausting) or behind a skidoo.
Seriously injured casualties can be loaded onto a snow groomer, either within a specialised front loaded cab adapted to contain a loaded stretcher and patroller, or on the back of a groomer. The former method has the significant advantage of reducing exposure to snow and the cold in adverse conditions.
Orientated, ambulant casualties may be evacuated by skidoo by one of the operating “Oscars”, the on site mechanical engineers. This in itself can be quite an experience, and one that the majority of casualties really quite enjoy. A ski patroller often follows the casualty down afterwards, carrying their skis and equipment.
Spinal or trunk injuries require immobilisation in a vacuum mattress: a plastic-coated bag full of polystyrene balls. Removing air from the splint forms it firmly around the casualty, providing an immobilising and comforting cocoon. Hard backboards are seldom used now, owing to discomfort and subsequent risks of long transfer to hospital (often 2-3 hours). However we still occasionally use scoop stretchers for shorter transfers. Increasingly, cervical collars are not being used, replaced with good immobilisation; they are now frequently deemed unnecessary by using NEXUS criteria to exclude cervical spine injury.
The most effective method of splinting used on the hill is a simple, home made box splint: 2 pieces of foam attached to marine grade ply, joined together to form a sandwich. The whole leg, knee or lower leg can be splinted within the box to provide stabilisation, and thus good analgesia and a bit of protection. Soft tissue knee injuries are the most common type of injury within Scotish resorts, occurring particularly in beginners and in soft snow conditions. Knees can be stabilised very well within these boxes. Some resorts are also moving onto more expensive vacuum style limb splints which work in a similar way to the spinal splints. However in our experience these splints are relatively expensive and can often leak, reducing support provided.
Seldomly, traction splints are used on the slopes, with modified foot straps for use with large ski boots. Both Thomas and Kendrick splints are used, and I personally prefer the Thomas splints – despite them being more cumbersome, they provide more stability and protection from external blows than the lower bulk Kendrick splints.
Upper limbs are generally splinted with simple measures including SAM splints and bandages. Triangular bandages can be used as slings, or simply inverting the bottom of a ski jacket can provide good support too. Improvisation is very much the order of the day.
Basic Life Support (BLS) and Immediate Life Support (ILS) equipement is kept on site: there are 3 defibrillators in the resort (one in each main cafe; one at base). We have oxygen and a basic airway kit, up to and including i-gel laryngeal mask airways which ski patrollers are trained to use annually. Our main problem in a cardiac arrest situation is organising retrieval from such a remote location. Thankfully in the last 10 years we havn’t had to organise this, although Glencoe have used theirs for a gentleman having a heart attack. The prospect of using resus equipment on the steel platform of a piste groomer is somewhat daunting.
Of note, the International Committee for Alpine Rescue have produced comprehensive guidelines for hypothermic cardiac arrest, which provide definitive guidelines for first responders in these situations.
Analgesia, drugs & gases
Simple analgesia is available within most resorts for casualty self administration within treatment facilities. Currently entonox is the only strong analgesic available on the hill, which can provide good, rapid pain relief. However, caution has to be used owing to separation of the gases on particularly cold days. Occasionally, a local GP may be called if no patrol doctors are available on the day to administer stronger analgesia. As an organisation, BASP is currently looking at expending analgesia options, and this year we are trialling Penthrox for the first time (methoxyflurane, a hand-held inhalational pain killer), which should be interesting.
First aid top tips
My top tips for those who are off skiing in a remote area or are heading off-piste are:
- Keep it light and simple, most kit can be improvised from other items you are carrying. Ski poles and ice axes make great splints; clothing good bandages or slings.
- Wrap some gaffa tape around a ski pole or water bottle – such a handy piece of kit.
- Always carry an emergency shelter or warming blanket: the worst thing is the cold whilst waiting for help to arrive. It can also be used for an improvised carry out if needed.
- Plan for the worst. Know what medical resources are around and how to contact them.
- Be aware of pre-existing medical conditions in your group, and think about the kinds of injury you may be faced with – plan ahead!
If anyone is interested in getting involved volunteering with Ski Patrol, I’d recommend visiting the British Association of Ski Patrollers (BASP) website and attending their annual training course to develop some of the basic casualty evacuation skills needed for the job!
Photos are credited to Harriet Gray-Stephens unless otherwise stated. Taken with casualty permission.