Last Wednesday I posted a video of a pretty impressive collision on a ski slope. I asked you to tell me what you thought, what sorts of injuries and medical conditions you would expect, and how you would manage this situation. If you haven’t seen the video, take a few moments and watch the video. Unlike the previous week, this video is short, only a few minutes. The worst part of the video is the music…
So, here is what I noticed:
- Number of patients: In this case, we are immediately drawn to the obvious patient in red. However, you have at least two patients in this scenario. The individual who takes the legs out from under the other patient is also a patient, and continues into the crowd with a good deal of speed. There is the potential for a minimum of two patients here, with possibly more.
- Scene safety: I worked at a resort for a while, both on the ski patrol and as a lifeguard. With all due respect to people when they go on vacation, vacationers are not always the most mindful bunch. Additionally, while it seems like skiers above would be able to see everything below them, this is not always true. Responders to this scene will be exposed to danger from other skiers/boarders as they work.
- MOI: We always seem to find ourselves considering MOI. This is a very good thing! Consideration of what caused the injury to occur should be a large part of your primary assessment. In this case, the MOI is a high-speed impact between two people, followed by impact into the ground.
- Lots of force directed at the lower extremities: The patient in red gets his legs taken out by a direct hit. What worries me about this is that the edges of skis are sharp, and can really cause a lot of damage. Additionally, while ski boots typically protect the ankle joint from damage, they can produce a fulcrum point on the tibia/fibula, and so “boot top” fractures of the tib/fib are very common in skiers.
- Environmental considerations: A quick look at the area this video takes place in suggests it’s fairly remote and high-altitude; even though it appears to be a resort, getting these patients to stabilizing care and then definitive care may be a challenge. Additionally, it’s obviously snowy and cold. If we’re thinking about treating patients in place, we’ll have to put some thought into keeping them from becoming hypothermic.
So, how would I manage these patients and this scene? Here are my ideas:
- Scene safety, defend your area: As I woud move into this situation, I would have to take some steps to make sure that I’m not going to get hit by other skiers and snowboarders. Pay attention to terrain features that may hide you from view from above; if I’m not able to defend my position by either posting someone above me or blocking the area above me in some way, I’d consider a rapid, safe move to a safer, more defensible location.
- Expect head, neck, and spinal injuries: Spinal injuries and head injuries should be very much on your mind. I wasn’t able to tell if anyone was wearing a helmet; however, that amount of force and the way the patient in red landed on his head make me very suspicious. I’ll at least take control of the patient’s head while I do my primary assessment. I’d hope that eventually I could clear the spine and let the patient sit up/assist with their own evacuation. Bear in mind that a focused spine assessment requires a skin-level assessment of the patient’s back, and that exposing the patients for too long in this situation may lead to hypothermia. I’d also assess for altered mental status or loss of consciousness, and look for signs of brain injury (deterioration in mental status, etc.).
- Airway management: If the patients have altered mental status or is unconscious, be sure to very carefully assess the airway. I’d look inside the mouth for snow, vomit, broken teeth, or blood.
- Soft tissue injuries and bleeding: Some of the worst bleeding I ever saw was caused by a ski edge. A patient fell and landed on the edge of his ski, and caused an avulsed laceration that exposed tendon and bone, and left a 4′ wide puddle of blood on the floor of the ski patrol aid room. Skis are sharp! I’d look for lacerations and soft-tissue damage to the patient’s legs. I may have to move clothing to expose wounds; skiing clothing is very good at hiding blood from view.
- Lower extremity fractures: I’d be looking for boot-top style tib/fib fractures. In order to properly splint these fractures, you may have to remove the boot. Don’t forget to look a bit higher and rule out femur and hip injuries as well!
- Environmental concerns: The area in this video looks cold. The patients have been active, and are likely sweating. They’re suddenly immobile, and not keeping themselves warm through movement anymore. This is a recipe for hypothermia. I’d take steps to protect my patients from the environment; as a WFA instructor I once had said, “win the giant battle against heat loss.” I’d pad under the patient, and avoid removing or cut clothing unnecessarily; if it is necisarry, I can put the clothing back afterwards. Additionally, I’d cover or hypo-wrap (“burrito-ize”) the patient. In this scenario, since it appears it happened at a resort, I may consider stabilizing the patient and evacuating to a more sheltered place.
- What kind of resources will you need? I’m probably going to be calling for a few more people and some equipment. I have at least two patients, and the potential for complicated injuries. Until they arrive, I’ll have to do triage and start with the most seriously injured patient.
- Prepare for evacuation to definitive care: These patients will need evaluation at a hospital. It’s going to take a while to get them to a location where they can be transferred to EMS for the transport to the hospital. Additionally, what kind of transport do they need? Do they need an ambulance, or do they need a helicopter? I’d have to find a way to request these resources. If I had a radio, it’s as easy as calling the base station and asking them to call. If not, I may deputize a bystander, and send a note. The primary and secondary assessment will give the information needed to make an evacuation decision.
Those are my thoughts. If you have other suggestions, I’m always excited to hear them! Next week I’ll give you another scenario!