At a Colorado ski area last February, a 24-year-old male skier was taking a jump when he landed on his face. Initially, witnesses stated he just lay there, but after a few minutes he became violent with wild movements and incomprehensible speech. Ski patrol was called and within minutes a patroller arrived with a toboggan. The ski patroller stated that he saw blood coming from the man’s mouth and nose and from the level of responsiveness he realized the man had a serious head injury and needed additional help.
Additional patrollers including a paramedic were dispatched and arrived soon with the trauma pack and more equipment. The paramedic patroller took command and directed the patient care, which included placing a nasal tube to protect the man’s airway, starting an IV and administering sedation drugs to relax the patient before he did further harm to himself or others. At that point the injured skier was stabilized on the hill and was ready for transport to the base area.
The above scenario and others like it happen every year at ski areas across the world. Typical patrol procedure would most likely be to “load and go”—to transport this skier to base area and its Advanced Life Support (ALS) personnel (paramedics, EMT-intermediates, nurses, doctors).
But in incidents like this, the ski patrol might consider “staying and playing” on the scene. It is critical for certain patients to be treated with oxygen, airway protection, cardiac drugs, and/or other interventions immediately to save lives and/or brain tissue or prevent other injuries. Brain damage occurs after six minutes without oxygen. With this narrow window, few ski patrols can get a victim to advanced ALS help in time to prevent damage.
In this case, the patient was sedated to prevent further injury and was transferred to the base area clinic with good oxygenation. He was flown to a hospital where he walked out a month later to continue rehabilitation at home.
Advances in Patrol Care
The pre-hospital world of ALS has been in a dynamic state since the 1970s. The paramedic is the standard of care for most pre-hospital Emergency Medical Service (EMS) agencies. Most agencies are using modern equipment, like automatic external defibrillators (AED’s) and heart monitors, as well as cardiac drugs, sedation and pain control drugs, and drugs for other medical emergencies.
The ski patrol industry for the most part has kept pace. Due to the many difficulties involved in delivering state-of-the-art care in the mountain environment, though, on-mountain ALS care is not the standard of care in all areas. But it should be the goal.
State-of-the-Art Care
In general, for areas that have short patient transport times (less than 6 minutes) and a base area clinic with ALS staff, ALS patrollers may be too costly to support. But for larger resorts, some sort of on-hill ALS capability may be warranted.
The minimum ALS level that all ski areas should strive for is cardiac defibrillation (AED) and first-line cardiac drugs on the mountain. To provide it, an area would need to have an AED on the mountain, and all patrollers should be trained to use it. Additionally, ski patrols should have the supplies and training for basic IV start-up capabilities for major trauma and for administering first-line cardiac drugs for heart attacks.
Next is airway management. Patients that are not breathing on the mountain need ALS airway intervention. The best airway ventilation and protection is intubation—placing a tube in the patient’s airway. This is the standard of care in the pre-hospital world for airway protection and providing adequate oxygen delivery. BLS interventions like an Ambu-bag or pocket mask are inadequate in non-breathing patients. The problem is, in many states this skill is allowed only by paramedics. Some states allow EMT-I’s and EMT-basics to intubate within limitations.
And what about narcotics for pain control and sedation drugs for seizures and head injuries?
These drugs are strictly controlled by federal DEA regulations, and most ski patrols can’t afford the drugs, the liability of dispensing them, storage problems required, or skills necessary to administer them. In addition, most areas have physician advisors who are hesitant to allow paramedic patrollers to administer drugs under the advisor’s license.
A paramedic patroller in Telluride told me he carries the drugs on his person and goes to accident scenes to administer pain control routinely for broken legs and other various orthopedic injuries. This practice would be ideal for all our patients to reduce the pain for the ride down. But understandably, the liability and control issues are more than most ski patrols’ physician advisers want to assume.
One possible solution, used by the patrol at Copper Mountain: patrollers can bring nitrous oxide (the same gas used in the dentist’s office) to a scene for pain control. This simple method of pain control requires far fewer governmental controls.
More Obstacles
Just providing ALS is hard enough, but there are several more obstacles associated with maintaining ALS level care:
1. Physician advisors/medical directors are required for almost all pre-hospital agencies (like ski patrols) to practice medicine (that is, provide ALS services). Physician advisors put their medical license on the line. If there are major breaches in protocol and a patient is injured because of negligence the patroller, the doctor and the ski area may be liable. Therefore, ski patrols have to keep a good relationship with their physician advisor.
Inadequate record keeping and training can strain relationships with local physician advisors to the point that they no longer trust the patrol to follow the correct medical procedure and won’t support ALS intervention on the hill. The advisors’ solution is to “load and go” to the doctor in the base area. It helps to have an ALS patroller serve as a liaison between the ski patrol and physician advisor because they speak the same language. This adds a lot of credibility to the patrol in the eyes of the physician.
2. The EMS industry has a hard time finding ALS staff, even in populated areas; it’s no wonder ski areas don’t have adequate numbers of ALS patrollers.
To keep wage costs low and to find qualified patrollers, many areas accept OEC (Outdoor Emergency Care) as the entry-level certification; this requires far fewer training hours than most state EMT-B certifications. And OEC is sufficient to handle the 99 percent of all ski area injuries that require skills like CPR, bandaging, and splinting.
But ski areas should also be concerned with the critical one percent of injuries that require ALS-trained responders. All patrols should strive to have some level of ALS response from the top of the mountain.
3. Wages in most areas are higher for paramedic (ALS) patrollers. This can create animosity among the ranks, especially if part-time ALS patrollers are higher-paid than full-time non-ALS patrollers.
4. Training patrollers to be ALS certified and keep their skills current is difficult. Most EMS agencies receive enough calls to keep their skills current by experience. Ski patrols have few actual ALS calls each season and must train regularly to keep medical skills current. Training takes time out of other duties like snow safety, crowd control, and slope maintenance or requires after-hours training, which generally has low turnout.
5. In EMS, ALS patients can’t be handed to lesser-qualified medics for transport. As a result, ALS patrollers will have to accompany a critically injured patient to the hospital if the ambulance that transports the patient is not ALS staffed.
6. ALS supplies, like all medical supplies, are expensive. Patrols need to set up their trauma packs with advanced new equipment and purchase expensive drugs, then trade out expired drugs each year. Trauma packs with AED’s have an average cost of $5,000 to $10,000 to set up. It may cost $200 a year to maintain each trauma pack‘s supplies. Many EMS medical agencies bill patients for these costs; ski areas in America, unlike European areas, have not done so. This equipment expense may be prohibitive for many areas. Solutions may include grants from local and state agencies, ALS patrollers bringing their drugs from the agencies they work for, keeping trauma packs to a minimum in strategic locations, and replacing used materials from the ambulance when they transfer the patient.
Accommodating ALS Care
Faced with the cost of training and/or retaining ALS patrollers, ski patrols have relied on several strategies:
- Structure wage scales to give incentives for ALS certification.
- Recruit patrollers from local fire departments, ambulance services and hospitals.
- Allow ALS patrollers to work flexible shifts so they may keep their “real” jobs.
- Accommodate non-skiing ALS patrollers by allowing them to use snowmobiles.
- Give season passes to local ALS providers such as ER doctors and paramedics. Their obligation is to carry a radio and respond to critical scenes. These providers are also invaluable for providing training seminars in the fall and throughout the year.
- Strive to maintain communications with your local ALS EMS agency and attend ski patrol and emergency care seminars to learn techniques and share ideas.
Despite the obstacles, modern ski patrols should strive to bring their medical practices up to the standard of the rest of the EMS world and be on-the-hill ALS-capable seven days a week. Modern pre-hospital medical care demands ALS interventions within acceptable time periods. There are problems unique to ski areas like logistics, staffing, and budgets, but it can be done.
Bill Koons has been a professional ski patroller for 25 years. He is currently a full-time patroller at Copper Mountain, Colorado. E-mail him at [email protected].
