The Ask Doc! archives.

Eric Lamberts MD, NSP, attending physician.

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Fresh Collection (November 25, 1999)

Posted (November 1, 1998)

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  • 1. Length of Hare Splint
    > Dear Dr.
    > I have just found and read your page-enjoyed it very much but I'm
    > confused on one point. In the length of the hare is was mention that
    > the OEC book calls for the splint to be extended to max.-I can not find
    > it as such-I have always extented it to about 12 inches beyond the good
    > leg. this is also noted chapter 8 page 164 of the second edition.
    > Where can I find the instructions to extent the splint to it longest
    > length?

    Guy

    You've been doing it right. I'm not sure where it said to extend the
    splint all the way, but there is no need--it would just make things more
    cumbersome and less stable for a smaller patient.

    Of course, if the splint were stuck and you were forced to use it fully
    extended, it would still work--the key is the traction. It would just be
    a lot more unwieldy.

    See you on the hill !

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

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  • 2. Instructor talk - Over-teaching? etc.
    > Dr. Eric,
    >
    > I would like to say a quick thank you for publishing your opinions
    > online. They make great reading, and at the same time provoke a good
    > couple hours of thought!!
    > As a member of the Canadian Ski Patrol System, I found the questions
    > posed to you very relavent to both the NSP and the CSPS, differences in
    > the two organizations notwith standing.
    > As a part of my patrol, I have had the "pleasure" of being the First Aid
    > Training Officer for a couple of years now. As a doctor, I'm sure on
    > occasion you have taught or contributed to portions of your OEC course.
    > I would like your opinion on an issue I am faced with. One of our
    > patrollers has recently become a Paramedic 1 (EMT-A I think you would
    > call it). Having graduated in May of 98, her experience is still
    > growing. This year she has become an Instructor (she was an Assistant
    > prior to her new career move) which means she is certified to teach
    > portions of the course w/o assistance. The problem with this is that
    > she knows quite a bit more than the other instructors and for that
    > matter, candidates as well, which, for her job, is rightfully so. With
    > this new knowledge comes the problem... over-teaching, and a verbal
    > dislike for the guidelines of our program. Throwing in the odd story
    > about the drunk you picked up last Friday is great, but going beyond the
    > offical manual is beginning to cause problems... any suggestions?
    >
    > Thanks very much for your time and have a great ski season.
    > Sincerely,
    >
    > Greg McCormick, Training Officer
    > CSPS-Brookvale Ski Park, Brookvale, Prince Edward Island CANADA.
    >

    Greg

    Thanks for the compliments. I'm glad you've enjoyed at least some of the
    posts.

    This question is one that should be asked more often, and I suspect is
    a problem for almost every patrol director/First Aid Training Officer in
    the world. (I do know of one patrol that only has one member, probably not
    a problem for her.)

    Most patrols are made up of many different types of people, or as my
    girlfriend says after the post sweep bar stop, "What an interesting bunch
    of people!" Her actual words might be "strange bunch of people."

    I do sometimes wonder why we do what we do. Get up in the dead of night
    in the middle of winter to spend hours hauling stuff through the snow,
    sitting in a small warming hut waiting for disaster with a bunch of folks
    who's primary diet seems to consist of chili with beans, lots of 'em.

    I think there are a variety of reasons. Some are there for service to
    humanity, some for free skiing, some for comraderie, some are police
    wannabes, and some just to feel important. With most of us it's a
    combination of all the above.

    Probably your instructor has a greater than normal need to feel important.
    The know it all attitude, the endless personal anecdotes are all self
    aggrandizing. The books are not perfect, but are generally written by
    experts who try to keep it simple and easy to implement.

    So, how to deal with your problem child? If she's bad enough, fire her.
    You might check with the students--if they feel the class is valuable
    in spite of her imperfections, just let it slide.

    It might be worth a talk, man to man, so to speak. Take her aside, and
    let her know how much you appreciate her time and expertise. Point out
    that the material is not perfect, but is designed to give someone with no
    previous knowledge the ability to render emergency care, and save lives.
    CPR is a good example. It is taught as if it were handed down from Moses
    himself. If you look at the studies, however there is a great deal of
    controversy over almost every aspect. Unless people are willing to devote
    a thousand hours to learning first aid, the KISS principle must apply.
    (Keep it simple stupid.)

    To put down the material is also counterproductive for the students. Why
    should they bother to study something so flawed? If one thing is flawed,
    isn't it likely the whole is too? We demand a lot of work, and the
    perception should be that it is not a waste of time and energy.

    As far as personal anecdotes--they are wonderful if used sparingly. They
    really help the students focus on the fact that this is NOT just
    book learning BS, but that they almost certainly will be in a position
    where their knowledge and skills (or lack thereof) will either save or lose
    a life.

    The down side of anecdotes is that they often end up as self aggrandizing.
    We must remember that even though we can feel superior as the teacher, the
    point of the class is to transfer knowledge and skills. I fell there is
    not enough time in the course to cover everything well. If you are telling
    too many tales, there is no way you can cover the minimal syllabus
    content.

    I'm sorry it took me so long to get this back to you. It is one of the
    more difficult questions I've received. I hope this will be minimally
    helpful.

    I think your task is one of the most difficult. You must be able to
    acknowledge this person's obvious worth, while providing constructive
    criticism. Give me a femur any day.

    Lonely at the top, isn't it?

    See you on the hill!
    Doc
    Eric Lamberts MD NSP

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  • 3. Safety of ski-boards
    > Dear Dr. Lambert,
    >
    > My 16 yr old son, skiiing since age 5, wants skiboards. These are short
    > devices, 76cm, secured to a skiboot by a nonrelease binding. Are you
    > aware of any safety studies relative to skiboards? Assume the user will
    > be responsible.
    >
    > Thank you for your help.
    >
    > Matt McAlerney mattm@shasta.com
    >

    Matt

    Skiboards? They look so dorky! I'm surprised he's not into boarding.

    I'm not aware of any studies about the safety of these things, however I
    suspect the manufacturers have at least looked at it. Lotsa lawyers
    looking for work you know.

    My opinion, which is worth every penny you're paying for it, is that they
    probably are not that unsafe. My reasoning is twofold:

    First they are very short, which makes the risk of a caught tip less
    likely, as well as giving a shorter lever for twisting your leg off at
    boot top, or wrenching your knee. There is also less likelihood of the
    "Phantom foot", a fall where you end up back over your downhill ski with
    your body lower than your knee. With 200 cm of edge your downhill ski
    pulls the lower leg off the upper leg and rips the ACL, the main knee
    ligament, to shreds.

    My second reason is the legalities, and involves a guilty confession. I,
    uh, bought a pair this year. They are 100 cm Harts with non releasable
    bindings, and surprisingly were top rated by one of the ski magazines.
    Even though they look dorky, they sure look like a hoot to me. Anyhow the
    disclaimer that came with them said nothing about the dangers of non
    releasable bindings. They were very specific, however, regarding who the
    skis were designed for. These skis are NOT designed for a six year old,
    and would put his legs in jeopardy.

    Lastly, these are more suited to beginner and intermediate slopes; if your
    son is getting bored with the black diamonds, these might give him
    something to do that doesn't involve jumping off cliffs or skiing out of
    bounds into avalanche chutes, not that I'm pointing any fingers...

    So, in summation, I think they are reasonably safe, although skiing is a
    hazardous sport, with many obstacles, both natural and manmade. Maybe I
    should let MY 16 year old use them--I might be able to keep up with him!

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

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  • 4. How does an EMT become NSP
    > Hi
    >I don't know if you are the one I should be directing my question
    too but you seem to be the only available resource. I am a pre-med
    student at Colgate University.
    Over the second semester of this school year, I plan on becoming EMT
    certified and participating in an ambulance program. Over the summer
    or the next winter, I am looking to intern as a ski patrol or actually
    become one.
    Do you know how I can go about this? I am looking to work over the
    summer maybe at Mt. Hood or Whistler or over winter break at a local
    area. Do you believe this to be possible? Thanks for your help.
    >
    > Josh
    >

    Josh

    This sure sounds doable with enough lead in. You should be calling patrol
    directors now to get things lined up. NSP is more the training arm of ski
    patrol, each patrol is semi autonomous. What I would do would be to
    contact patrol directors at areas you might like to work at.

    Outline what you'd like to do, how you'd like to perform, and then ask if
    you could go visit sometime this winter. Often what they do is have you
    shadow a patroller. This way you could see if you would like to work with
    that patrol, and they could recognize your fine points and check out your
    skiing ability. I would try to do this at more than one area. Go back to
    the areas you like the best if they seem interested and try to firm up
    your plans. Becoming a skipatroller is about the equivalent of 4-6
    credits in medical school.

    Most area will let you challenge the OEC (first aid) portion of the test,
    and then you can do the on the hill stuff. A trained first aid/EMT is an
    asset to a hill, even if they can't pull a sled; they can respond to
    accidents, do aid room triage, and help with the paper work.

    Good luck, and hope to see you on the hill!
    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

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  • 5. Vaccinations for Patrollers (esp. Hep B)
    > Dear Doc,
    > Greetings from Lakeview, OR. I would like to know your recs on Hep B Vac for patrollers. I am a nurse also and feel that all should have it. But, as you know it is not cheap! Are there official recs for NSP and what do others do? Just fund raise and pay for it??????
    > I'd appreciate your opinion.
    > Thanks,
    > Janine Simms LPN
    > Warner Canyon Ski Patrol
    >

    Janine

    I'm not sure how things are where you patrol, but there are national
    regulations covering this. Not National Ski Patrol, but the national
    government as in OSHA.

    Our patrol is required to have a blood borne pathogens policy manual on
    file, each patroller must complete an annual refresher, and Hepatitis B
    vaccine must be offered.

    I feel very strongly that anyone doing routine first aid should have
    vaccination against Hepatitis B. It is much much more contagious than
    HIV, and potentially every bit as fatal (although I guess fatal is fatal).
    There is a major push on to vaccinate everybody, with this being part of
    routine childhood immunizations, around here it is also being offered to
    all eighth graders.

    Practically, you should all be vaccinated, ethically you should offer it
    to all your patrollers. I work on an all volunteer patrol, and the same
    agency that supplies splints and sleds covers cost of the vaccination.
    Patrolers may refuse vaccination, although they're stupid if they do.

    Legally, I suspect you are subject to the same OSHA regualtions that we
    are. Failure to comply can result in fines of up to $70,000 if the OSHA
    inspector catch you. OSHA can be a major pain, but their red tape is
    designed to save lives, some not so far from Lakeview Oregon.

    To reiterate, working with exposure to blood without the Hepatitis B
    vaccine is akin to playing Russian roulette. Good luck.

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

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  • 6. Should a Juvenile Diabetic Ski?
    > Hello, My 11 year old son was diagnosed with Juvenile Diabetes in early Oct 98. Everything under control, he played soccer as usual this fall. Any tips for cold weather/high altitude testing, etc ? We ski at Crystal Mt. in WA. Have not met anyone in support groups or clinics with any ski experience. Can you help?
    > Thanks, Doug Peckenpaugh dpeck@gateway.net
    >

    Doug,

    This is both an easy one and a tough one. Every diabetic is
    different--some would never be able to make it skiing. Most would have no
    problem. My lawyer and common sense tell me to tell you to ask his
    doctor.

    That being said.

    I suspect he'll have little problem with skiing. I am unaware of any
    complications of altitude on a well controlled diabetic. I've skied
    Crystal (what a mountain, by the way!) and I recall it being at relatively
    low altitude--not 12,000 feet by any means. If you haven't done the
    diabetes education class near you, it is highly recommended, your son's
    life and certainly his longevity depend on a solid knowledge base of
    what's going on. Just by asking the question, my suspicion is that you
    guys went thru that a while back.

    >From class, you recall that exercise lowers the insulin requirement,
    which would put him at higher risk for a hypoglycemic episode. Since he
    played a regular season of soccer without problem, I don't think skiing
    will present much of a problem.

    Lastly, I have mixed feelings about support groups, special camps etc. I
    think they are very useful if a kid has to signifigantly curtail his daily
    activities. They help deal with the sense of loss at not being able to
    participate in normal activities, and with the sense of being "different."
    The converse is that they really feed into the sense of being "different."

    I remember bringing home a "Captain Asthma" comic to my son when he was
    about the age of your boy. He was (is) a moderate asthmatic, on two or
    three meds to achieve control. It has always been pretty matter of fact
    to him--take your meds and do whatever, don't and you can't. As it was he
    had a pretty normal childhood--skis weekly and a major soccer nut, ending
    up as midfield MVP when he hit the JV team in high school.

    Anyway one of the drug companies was passing these comics out and I
    brought it home. He read it and was a bit horrified, "Is this about ME?"

    I'm not advocating downplaying the importance of tight control of his
    sugars, but sure approve 100% your decision to have him lead a normal
    life.

    So. If he were my son, I'd check with his doctor, carry a snack in your
    fanny pack, and maybe a glucagon pen. Make sure he doesn't get too
    excited and miss breakfast or skip lunch. You might buy a couple of those
    Motorola two way radios they have now. Really really handy at an area the
    size of Crystal Mountain where it is all too easy to get separated, a bit
    pricey though. Go shred!

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 7. Transport of head injury victim
    > Recently my daughter was injured skiing. She was hit severly by an "out
    > of control" skier. She sustained a grade 3 concussion. My question is
    > this, if when the ski patol got to her and she had regained
    > consciousness, but was still quite confused, should she have been brought
    > down the mountain on a back board? She was taken down on a snowmobile.
    >
    > I would appreciate a reply to this matter. Thank you
    >
    > Jane Holly
    > jbholly@auracom.com
    >

    Jane

    This is a tough one to answer. I was not at the scene, and don't know
    what she looked like on the hill.

    If a patient has had a head injury and is not responsive, the standard of
    care is to assume trauma to the spine and treat as if there were a
    fracture.

    This is NOT standard in a head injury in a which a patient is
    conscious, but is up to the discretion of the patroller. Your daughter
    was probably lucid enough to tell if her neck was tender during their
    exam.

    Back boards are generally used if there is any question of serious spinal
    trauma. The down side to them is that they are not very comfortable, and
    can be a bit frightening. The other negative is that once they're on
    you're pretty much committed to transport via ambulance to a hospital.

    The short answer to your question is that she probably did not need to be
    back boarded.

    I hope she's doing well. A related fact is that kids who get second head
    injuries are much more likely to die or have consequences far beyond those
    who have not had a head injury in the past. If she were my child I would
    invest in helmets for at risk activities--skiing, bicycling, etc. I would
    even be very wary of soccer.

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 8. Don't ingest these to ward off the cold.
    > WHAT TWO SUBSTANCES SHOULD NOT BE INGESTED WHEN TRYING TO WARD OFF THE
    > BITTER COLD TEMPS.? PLEASE RESPOND TO chking@mmm.com THANK YOU!!

    The traditional answers are nicotine and alcohol. Antipsychotics can
    decrease thermoregulation, particularly in the elderly.

    As far as that goes, I don't think iced tea would be helpful, or
    popsicles...

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 9. Managing cardiac arrest on the hill


    > Dear Doc,
    > I am interested in finding out what speeds would be neccesary to cause a
    > person to go into cardiac arrest after hitting a tree. The skier was
    > 5'8'' and wieghed about 160 lbs. I am also interested in knowing the
    > methods that the N.S.P. uses in treating patients who have gone into
    > cardiac arrest caused by trauma? How do you perform C.P.R. in a tobbogan
    > and how do you get a good seal with a bag valve mask. From what i have
    > seen so far it seems that there are no real chances of a person survivng
    > if he is in such a condition.
    > Sincerely Yours,

    If you've read through the web page, you'll realize that there are several
    methods for managing arrest on the hill. There is a special CPR sled that
    is available; one area has a method for doing CPR in a moving regular
    sled; one area has a method whereby the patroller handling the sled skis
    for 30 seconds and stops for 30 seconds of CPR. With the advent of
    helicopters, all you need is to get the patient to a moderately flat
    landing zone and he is able to be intubated, defibrillated, etc. Some
    areas are even getting automatic external defibrillators for use on the
    hill.

    It would be possible to use a bag valve mask in a sled I suppose, although
    mouth to mouth is easy, effective and involves a lot less paraphenalia.

    That being said, I would put the chances of survival at very low for
    anyone who had enough chest trauma to cause cardiac arrest, even if the
    paramedics were set up to start immediate first aid.

    It takes a lot of trauma to stop a heart, and my question in this case
    would be if the skier's heart stopped because he hit a tree, or if he hit
    a tree because his heart stopped. This seems to be a fairly common
    scenario in motor vehicle accidents.

    Lastly, arrest is pretty dicey even in a hospital setting, but even more
    difficult outside of it. The greatest chance of survival depends on
    getting defibrillated in a timely manner. If someone started CPR
    immediately after the accident and then sent someone to get help his
    chance of survival would be poor. If they skiied down and help did not
    arrive for even five or six minutes--a pretty good response time by the
    way-- his chances of survival would be less than ten percent, and chance
    of not being a vegetable almost nil.

    The bottom line? When all is said and done, there are risks in life, and
    even though they may be small, a million to one, when it happens to you
    it's 100%, no matter how careful you are, or who your doctor is. Your
    friend's fate was probably pretty much sealed when he hit the tree.

    See you on the hill?

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 10. Tibial microfracture procedure


    > My wife and I retire this year and will make our permanent home in the
    > Rocky Mountains. We've already made arrangements with the local ski
    > area to become pro patrollers and ski instructors, so if all goes well,
    > we'll become the ski bums we couldn't afford to be when we were in grad
    > school. The only dark cloud on the horizon is the progressive
    > osteoarthritis in my left knee (which underwent both medial and lateral
    > arthrotomy some 30 years ago). I'd like to explore the possibility of
    > undergoing the tibial microfracture procedure that was evidently
    > pioneered by a Dr. Stedman in Vail, Picabo Street's orthopod. I found
    > very little on a GrateFul Med search, and Dr. Stedman is a very elusive
    > fellow.
    >
    > Any advice (1) as to whether at my age (56) I am a likely candidate for
    > the procedure, (2) where I can find info on the effectiveness of the
    > procedure, (3) how I might reach someone competent to perform the
    > procedure. If it is relevant, I might add that thanks to a very
    > generous retiree's health benefits program the cost of the procedure is,
    > quite literally, no object.
    >
    > Harry Frank
    > (Nat. No. 8682)

    Richard Stedman. He was a pioneer in arthroscopic surgery at Ingham Med
    back in Lansing, Michigan, if I remember right. He then had a clinic at
    Lake Tahoe for quite a while and then went to Vail. He mostly takes care
    of world class atheletes, but when he was a Tahoe had a bunch of
    associates. I would assume that he does in Vail, although I could be
    wrong.

    I think I've heard of the proceedure--involves drilling holes into the
    tibial plateau to stimulate regrowth of cartilege. I did a search on
    Medline with the same results you got--zip.

    I think I'd get persistant calling his clinic, and if they won't see you,
    ask for someone who can.

    Sorry I couldn't be of more help..

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 11. Should 12th grade english students wear helmets?


    > Dear Sir or Madam:
    >
    > I am doing a research paper for my 12th grade English class. The subject I
    > chose is whether or not helmets should be worn while skiing (racing or
    > recreational).
    > If possible, could you please answer the following questions, and/or add
    > any other information you think may be useful.
    >
    > * What are the pros and cons of wearing ski helmets?
    >
    > * What are the views of your organization on wearing ski helmets?
    >
    > * Should helmet use be required for children under a certain age?
    >
    > * What are your predictions for helmet use in the future?
    >
    > Thank you for your time. It is greatly appreciated.
    > Sincerely,
    > Robyn Bell
    > robynbell@ibm.net
    >
    Robyn (sir or madam, most Erics are sirs....)

    If you check the web page you'll find several posts on helmets. I would
    also check the Reader's Guide to Periodical Literature, and if you know
    any patrollers, there was a good article last year in Ski Patrol magazine.

    Helmets help prevent head injuries. Unless you find them uncomfortable,
    there are few cons, although they cost $50-100. They are not effective in
    direct blows above about 12 mph, but are very effective with indirect
    blows.

    The National ski Patrol has no official position regarding helmets. I
    feel they should be used in small children, racers, and anyone who skis in
    places where a mistake can be fatal--I have a friend who likes to jump
    into steep chutes with big rocks at the bottom. Probabaly lift attendants
    should wear them; getting conked with a chair lift is not good for keeping
    industrial insurance claims low.

    There seems to be a movement towards helmet use. I think this will grow
    and grow. I know one ski area that requires all employees to wear helmets
    when skiing/riding, even on off days.

    See you on the hill

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 12. Do I need a knee brace?


    > Dear Doc,
    > I have been skiing about a year and although I love it my knees do not! I
    > have been wearing soft store bought knee support but they don't work for my
    > left knee. Can you recommend the type of brace I should buy, I found many
    > different types and am not sure what to look for. Thanks, Suzanne
    >

    Suzanne,

    It's kind of hard to diagnose over the 'net. If you could just put your
    knee through the monitor...

    Seriously, there are many causes of knee pain. Almost none of them are
    helped by a brace. Barring an accident, skiing is really pretty knee
    friendly. I've had a couple of knee problems and even though I frequently
    have pain, a day of skiing doesn't make them worse, and I almost never
    have knee pain when skiing. That's not to say I don't get a twinge or two
    if I spend a whole day skiing the bumps.

    If you really like skiing (and your knees), you need to see a good Family
    Practioner, Orthopedist, or Sports Medicine doc to find out why you are
    having pain and get some treatment. Mostly, unless you have an injury, it
    will involve physical therapy. You might also go in to a good ski shop
    and have your equipment checked, with attention to canting, the sideways
    angle that the boot meet the ski.

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 13. Head injury complications and recovery


    > Hi Doc, I've a theorectical question regarding head injury recovery.
    > Let's say
    > I've got this friend who has been skiing longer than chairlifts have
    > been around,
    > and just suppose he might have finally blown it, and slammed into a
    > tree, head
    > first or near head first. Now he has some sort of skull bones fracture
    > line
    > extending from the center of his head where a trauma unit zipped up a 4
    > inch
    > gash with a dozen staples, down to below his left ear. Somewhat
    > miraculously
    > he doesn't feel much effect other than a few mild bouts with vertigo
    > after the
    > initial swelling subsided plus a mild back ache due to some activitity
    > around
    > T-6 and T-7 as seen on the xrays but which might have been left over
    > from a
    > more severe back event last year.
    >
    > My questions regarding the skull bone fracture lines: Will this
    > fracture heal
    > similarly to other bone strutures like tib and fib ? How long does the
    > typical
    > skull take to do so, if that is the case ? Is there some sort of need
    > to anchor
    > the bone together across the fracture line, like with screws or spanning
    > plate ?
    > Or is letting nature take its course the basic approach to such a
    > fracture ?
    >
    > Is there a significantly higher degree of future injury risk now that
    > the egg has
    > been cracked, so to speak ? Is this the type of injury that is best
    > attended to
    > by physicians who deal with sports injuries or would any neuro-surgical
    > type
    > doctor do ?
    >
    > Any advice would be appreciated, theorectically of course.
    >
    > Regards, Mike Sphar.

    Mike

    Sorry to hear about your theoretical friend...

    The answer is that this injury is best taken care of by a neurosurgeon,
    NOT a sports medicine specialist, although with his injury he is not
    likely to need surgery.

    Head injury management is based on what is seen clinically, rather than
    X rays, at least in most cases. Skull films are no longer routinely
    ordered in minor trauma without any evidence of neurologic impairment,
    mostly because there is nothing to be done with a skull fracture. In
    general they heal nicely, without pins, screws, or plates.

    Exceptions are fractures of the facial bones, the eye socket, or a
    depressed skull fracture.

    He should do just fine. Late complications include late bleeding,
    sometimes seen in older patients. There are small blood vessels that
    bridge the meninges and the brain. As we get older, our brains shrink
    slightly and these are more likely to break. Symptoms include gradual
    onset of neurologic changes or personality changes in the few weeks
    following the accident.

    He is at greater risk from subsequent head injuries. The same injury that
    caused a concussion this time could cause death the next time. This is
    one case where I can recommend a helmet without equivocation.

    As a humble ski patroller/family practitioner, it sounds as if the care of
    your friend has been exemplarary. I'd sure recommend that he get back
    into skiing, although he probably should hang up the boards for this
    season and maybe leave a little extra in the collection plate at church;
    he's a very lucky fellow.

    See you on the hill! (hopefully your friend too)

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 14. What do I need to become a patroller?


    > I am interested in becoming NSP certified, I have a CPR and First
    > Responder certification. What else should I do to help get certified?
    > Where do I start?
    >

    Zo

    Check out the archives on this one. The basic answer is that you need to
    figure out where you want to patrol. Contact the patrol director at your
    chosen mountain and ask him or her what you need to do. Some places have
    too many patrollers, most need them. There are three main areas you need
    to get certified--skiing ability, toboggan handling, and first aid skills.
    All three have to be pretty much bullet proof for certification. All
    mountains will work with you on first aid skills and toboggan handling,
    and some will work with you on skiing skills. Basic patrollers need to be
    a PSIA 7, and be able to ski all the runs on the mountain with good form.
    If your skiing skill are not up to snuff, get into some lessons and work
    on them, soon!

    The best place to start, though is the director of the place you want to
    work. Getting certified requires time, effort, and money (more of the
    first two than the last), and is worth the effort involved.

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 15. Terrified but recovered ACL owner.


    > Hi! My name is Christa Myers and on Valentines day of 1998, I blew out my
    > ACL on Wintergreen in Va.
    >
    > I had surgery in April of 1998.
    >
    > This November, we are heading to Dillon Co. for a ski vacation.
    >
    > My doc has cleared me, but I am terrified. Are there instructors that will
    > retrain someone like me back to skiing?
    >
    > Are there things that I should know? Will it hurt at all? What are signs
    > that I am pushing it too far??
    >
    > Thanks,
    > Christa

    Christa

    Thank you very much.

    I am a beginner skier but refuse to give up. At 28 I still have too much
    fun in front of me.

    The accident occurred because I got distracted, crossed my right over left
    ski with my left ski downhill. And pop. There it goes.

    I refuse to let fear win, but wanted some experienced advice.

    Bravo for your lady friend. She inspires me.

    Thank you,
    Christa
    One of my favorite questions, and one I've thought a bit about.

    My girlfriend blew her ACL New Year's day 1998, and had surgery in March.
    Although a gentleman never reveals a lady's age, she's catching up with
    me, and I'm 50.

    She skiied Thanksgiving, and before Christmas we did about 18,000 feet of
    black diamond moguls. I'm not recommending that to you, but it does show
    what can be done. (And maybe I'm bragging just a little!)

    This is more the psychology of injury than the physiology. It is pretty
    terrifying to get back on the horse after you've fallen off. If you're
    into reading, the best ski psychology book is Inner Skiing

    I'd recommend that you do your physical therapy religiously. If you still
    see your Physical Therapist, tell her what your goal is. You might also
    look into some techniques to avoid ACL injuries--most are caused by a
    backward fall called the phantom foot syndrome. Learn how to fall--either
    forward or to the side.

    Remember that your new ligament is stronger than your old one and a
    similar fall is not as likely to cause serious injury, at least on the
    repaired side.

    I'm not sure what kind of skier you were before the injury, but on the day
    you start, go on a beginner run and take it easy. You might even want to
    just walk around with ski on for a bit to see how it feels. If you're
    skiing with someone, lose them unless they are quite supportive and are
    willing to gunk around on the green circles for a while. If you were a
    pretty good skier to begin with, move on up to the intermediate runs as
    confidence builds and you become bored beyond belief. Don't push too much
    and don't get over tired--if you've been doing PT the way you're supposed
    to, fatigue will not be a big factor.

    Ski school might be a good idea. I'd get another woman, preferably one
    who's been through what you've been through. Get a private lesson, have
    her review "phantom foot" falls and then go for an easy graded guided tour
    of the mountain. If you call ahead to talk to the ski school director,
    they can probably get someone lined up ahead of time. Ask for an
    empathetic instructor who is well versed in phantom foot, preferably a
    woman who has been through ACL surgery--do be specific, private lessons
    are not cheap, and you don't need a macho teen cliff jumper.

    Second to last, remember that skiing itself is not at all bad for the
    knees. Many ski with no ACLs at all. It's those pesky falls! Also do not
    adjust your bindings to a way low setting. Bindings do not protect knees
    even at ridiculously low settings, and a pre-release can be dangerous.
    There are no signs that you're pushing it too far, although if your knee
    hurts, stop. Pain is not a sign of impending doom, by the way, just
    your body reminding you of limits.
     
    Last, and most important is that I'd like to congratulate you for going
    back out. Life is too short. I have a perfectly healthy 35 year old
    woman who comes to my office and with a straight face tells me she's "too
    old" for skiing. I suspect she will die younger than she should, and not
    as happy as she might be. I also have a guy who's 75 with bad blood
    vessel disease who can't walk more than 200 yards without stopping to
    rest. Skis 3 times a week because of the senior discount.

    So.

    Get on out there, heart in your hand, and have a great time!

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    Hoping to get that senior discount too!

    [ Return to Index ]

  • 16. Jobs for MD's at ski areas?


    > Dear Doctor Lamberts,
    >
    > I am writing to inquire about positions available for MD's as National Ski
    > Patrollers. After reviewing others letters and your response, it seems the
    > best approach is to choose a slope and approach the director of the first aid.
    >
    > I would welcome any advise as I am looking for some adventure to pull me out
    > of the hospital. Are areas such as Aspen or Vail accessible... and/or are
    > you involved in any of the sports medicine research in the Rockies? I realize
    > I will not get rich working on the mountain however will I earn any money to
    > balance the monthly medical school debt payments or are the most desirable
    > areas purely volunteer?
    >
    > I appreciate your time.
    > Sonja

    Most pro patroller get miserable wages for long hours. It wouldn't make
    much of a dent in your medical school debt, and if ou have much wouldn't
    keep up with the interest.

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    To: ewl@med.unr.edu
    Subject: miserable wages, long hours

    Sounds like Residency

    [ Return to Index ]

  • 17. Incidence of Hypothermia in Skiing


    > Dr. lambert-
    > do you have any estimates of what the incidence of Hypothermia is in the
    > skiing setting?
    > Is this a common concern for the Ski Patroller and ,if so, what methods
    > are commonly used for recovery from hypothermia?
    >

    Mike,

    This is an ever present problem on a ski hill. On a cold day, I'd
    estimate as high as 80-90% of our patients have some degree of
    hypothermia.

    Picture it. It's 20 degrees and teh wind is 20 mph. It's getting towards
    lunch and you're a bit cold on the lift, but fine when you're skiing. You
    dig a tip in a mogul on a windy hill, twisting your knee. You are laying
    in the snow, the wind is blowing, and the sweat is starting to evaporate.
    You will get cold very quickly.

    Many of our patients have some degree of hypothermia, mostly mild.

    The treatment? Warming. Get a toboggan there, do a rapid assessment and
    get them off the hill. During transport, wrap in a tarp and blanket. In
    the first aid room get the wet clothes off and keep 'em warm. Many aid
    rooms have a dryer for wet clothes--they also make dandy blanket warmers.
    On the hill, I try to protect my patient from the wind, and have even lay
    down next to the to keep then warm while waiting for the toboggan.
    Although that is not the norm, it can get very scary for a little kid who
    is rapidly getting colder and colder when they are being pelted by snow
    moving 40mph. Our hill has mostly unaccompanied kids, by the way.

    Profound hypothermia must be treated in a hospital setting. It is best
    NOT to agressively rewarm these folks, unless prepared to do cardiac
    support.

    More information is available in any decent first aid text. Advanced
    treatment in a Hospital setting would be found in a textbook of medicine
    or emergency medicine.

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 18. Use of narcotics for pain control?


    > Dr. Lamberts,
    >
    > I am a Paramedic Ski Patroller in XXXX, XX. We have recently been
    > rewriting our EMS guidelines, and we are discussing the use of Morphine for
    > pain control. I am interested to know if you have any information about the
    > use of morphine by ski patrols. If anyone else is using it and who they may
    > be. I would also be interested in your opinion concerning this matter. I
    > would appreciated a reply to my home e-mail address (xx@xx.net) as this
    > patrol computer has been having some problems. I would appreciate a private
    > reply, if you publish this on the "net" please remove identifying
    > information. Thank you for your time in this matter.
    >

    I have not heard of this. Would this be at patroller discretion, or would
    you be in contact with a Doc/ER for orders? Decreasing pain would
    increase patient comfort, and maybe lessen the incidence of shock.

    It certainly should not be used in head injuries, and can cause
    respiratory depression. The patient should be monitored for
    this--sometimes difficult when they are in a toboggan, although talking
    with the patient during transport would be all that would be necessary in
    most cases--kinda hard to talk if you're not breathing.. ReVia, used in
    treatment of alcoholism has the side effect of making narcotics not work
    at the usual doses. Also morphine's a class II narc--careful monitoring
    would be necessary. Malpractice insurance would also be an issue; many
    states protect first aiders with "Good Samaritan" laws. I'm not sure if
    this includes professionals, and doubt that it includes the administration
    of meds for non life threatening conditions (comfort, pain control). Most
    patrols forbid even giving a patient a Tylenol or Advil.

    In the past, I have carried Stadol. Works pretty well, and comes as a
    nasal spray. Does not need injection, class IV (I think) making it less
    subject to scrutiny.

    Kinda rambling here. Bottom line is that it would be a useful tool if
    used occasionally, and appropriately. There are down sides, and is
    certainlynot within the standard of care for a Patroller who has not had
    extensive training in pharmacology and med administration. Liability
    issues are also important to consider.

    Does your patrol use other meds? If I had my choice, my big three would
    be epinephrine, nitroglycerine, and an albuterol inhaler, along with maybe
    glucagon. Practically, the most frequent meds used would be OTC
    stuff--Advil, Tylenol, Cold preps, etc.

    I will send this off to the web page, minus identifying info.

    See you on the hill!

    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 19. Tx goals for immobilized lower extremity


    > I am a Physical Therapy student and a recent case study I was given has left
    > me stumped, What are the tx goals for a non-weight bearing, immobilized lower
    > extremity? I have looked through numerous text and can't seem to find an
    > answer. I hope you can help me thanks.
    >
    > e-mail -->
    > tachybass@aol.com
    >

    Sorry. My gig is ski patrol; besides, even though we docs are supposed to
    know everything, we alas don't.

    That's why some of us are PTs, some MDs, and some other.

    If I had to guess--I'd guess mobility, weight bearing, and return to
    premorbid function. Ask your prof. I was always the stupid question
    asker (still am), and most of the other students were grateful because
    they were too embarrased to ask, but had the same question.

    See you on the hill! (Do you even ski?)

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 20. Shock in accident situation (elementary)


    > How do you treat for shock in an accident situation?
    > Thanks!

    Quinto,

    You really need to check any first aid manual ever published for more
    information on this one.

    In it's simplest terms, shock is the decrease in blood flow for a variety
    of reasons to vital organs. Often it is more fatal than the original
    injury.

    If your patient has not had a head injury, raise their feet and keep them
    warm, provide emotional support. Call an ambulance.
      
    There you have it in one hundred words or less. Massive tomes have been
    written on the subject. Do check out a good first aid or EMT text, OK?

    See you on the hill!

    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 21. Med Interns and Computers on the hill


    > Hi
    > My name is Lucy and I'm a fourth year medical student in Australia. I
    > was reading you're section "Is there a role for physicians in the
    > SkiPatrol" (www.skipatrol.org) and thought you may be able to answer a
    > question for me. During the fifth year of our degree we get to spend 5
    > weeks on an elective overseas. I am very interested in spending this
    > time at a medical clinic in the ski fields in America. I have already
    > spent some time at the ski fields in Australia and found it both
    > fascintating and exciting, and am seriously interested in this as a
    > future career prospect.
    >
    > 1) I am unsure about who to aproach or how to get in touch with
    > organisations who may be interested in letting me spend these 5 weeks
    > with them. (I am not so much interested in being with ski patrol on the
    > slopes, but in the clinic that patients get taken to once rescued.)
    > 2) I have met someone who did a similar thing at Lake Tahoe and was
    > wondering if you knew of any clinics there that I may be able to
    > contact.
    > 3) Also while I am asking.....*grin* .... I am very interested in
    > computers and combining the internet with medicine. As you are
    > obviously online and doing this, would you know of any medical clinics
    > or organisations that may be combining this technology with
    > alpine(skiing) medicine.
    >
    > I would greatly appreciate any information you may be able to give me in
    > answer to these questions.
    >
    > Yours sincerely
    >
    > Lucy Hennington
    > lucyhennington@hotmail.com

    Lucy,

    Sorry, but I'm not going to be of much help on this one.

    I would check with your college regarding how to set up rotations abroad.

    You might then write or call the Emergency Department head at Barton
    Memorial hospital in South Lake Tahoe California, the clinic at Squaw
    Valley California, or the Emergency Department head at Tahoe Forest
    Hospital in Truckee California.

    If you find out some organization that sets this sort of thing up, I'd be
    interested. It seems to be a recurring question.

    See you on the hill! (next year?)

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 22. Snowboarding, a pain in the neck?


    > Dear Dr. Lambert:
    >
    > Your Ask Doc! page has excellent information, but I don't find much about snowboarding, other than powder suffocation, which I had never even considered. Glad to know about this.
    >
    > My concern is neck injury. I'm an intermediate boarder, 35 years old, and I manage to take at least one solid backwards fall at moderate speed every time I go boarding. The large muscles in my neck are always very sore for several days after, and I'm wondering if there is a possibility of cumulative damage from these stresses. Also, what is the likelihood of fracture of cervical vertebrae under these conditions?
    >
    > Thank you.
    >
    > Will Galloway

    Will.

    I think I have a solution to your problem...

    Take up skiing!

    Just a little joke. (heh, heh)

    Sorry about not getting back to you right away, yours was a difficult
    question, and then I went away for a two week vacation without internet
    access.

    This question is a little more immediate to me since I had a trip in the
    ambulance on a backboard during my vacation.

    I am not aware that boarding is any worse for the neck than skiing, and
    have not heard of anyone else with your problem. It sounds more like a
    technique problem to me.

    Can this cause permanent problems? If you land hard enough and flex your
    neck violently enough you can break your neck. Otherwise you'll be
    wandering around with whiplash symptoms, most of which will eventually get
    better.

    My advise? Ask every boarder you meet if they've ever had similar
    problems, and what to do to avoid it. You might also check at your
    favorite shop and make sure your board is long enough and properly set up.
    Analyze the mechanism of the accident--when does it occur? what have you
    been doing? Maybe even a lesson.
     
    Sounds to me like a temporary setback on the road to breaking out of the
    intermediate rut. Good luck!

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 23. Stats on risk of injury


    > Dr. Lamberts,
    >
    > I'm trying to organize a corporate ski weekend with a major New York
    > investment bank. Their employee activity committee is planning on
    > having a meeting to vote on the ski weekend next week. The reason I'm
    > writing you is because it was mentioned to me that they are very
    > concerned about being liable for any ski related injuries. I'm looking
    > for statistics I could give them regarding the risks of injury involving
    > skiing, and information regarding how safe it truly is. I know from
    > reading your other mail that it is relatively safe (safer than
    > bicycling), and the rate of injury is about 3/1000. Is there any other
    > info you have regarding this topic that will convince them to go ahead
    > with the event? What kind of statistics do you have regarding skier
    > deaths? I read somewhere that the rate is about .69/1000000. Is this
    > correct? Any help is greatly appreciated. See YOU on the hill!
    >
    > Brandon Winkler

    Mr Winkler

    I think you have the stats about right, although the rate of serious
    injury is 1/1000. The meaning of this is that for every 1000 skiers days
    there is one serious accident.

    As far a liability, this is more a topic for the company lawyer. I
    suspect there would be minimal liablity unless you had an open bar or
    something, but this is getting to be a problem even with employee
    Christmas parties.

    The other person to check with would be the person who handles groups at
    the area where you're planning on having the event. Corporate ski days
    are common (Heck corporate ski _races_ are pretty common.), and I'm sure
    they have some policy and proceedure set up by their risk managers.

    Last, if you don't serve alcohol, and don't force people to ski, your
    liability should be practically nil.

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 24. Brain injury & Helmet Stats


    > Glad to read your interest and support for helmets when skiing and
    > snowboarding. I have just added up the whole of our 1998 and the first
    > part of 1999 ski and snowboarding injuries from Littleton , NH.... The
    > head injury rate with out helmets is 20% (20.2%), but with helmets is
    > 11%(10.6%). Our numbers are just a hair off being significant, so I
    > cannot publish until I have November /December 1999 data. I will email
    > you with those results in January 2000. I am preempting my own
    > publication, by telling you this, but I think it is so significant, that
    > the ski helmet industry is going to have to help out in promoting them,
    > the way they have improved bindings, boots and quick release mechanisms
    > to reduce ankle and knee injuries. There is no fun in being head
    > injured, even if it is mild. The consumer Product Safety Commission
    > recommends helmets for skiing and snowboarding. Their study in 1998
    > showed that 44% of the reported head injuries COULD have been prevented
    > by wearing a helmet !! I hope you find this as helpful as I did. Now
    > with helmets, coupled with good manners and separating the skiers from
    > snowboarders, maybe we can really reduce the bad injuries on the slopes.
    >
    > Sincerely ,
    > Clare Wilmot MD
    > Littleton Hospital
    > NH

    Dr Wilmot

    Sorry it took me so long to get back to you, but this is a bit the off
    season for the ski patrol!

    I really appreciate your post. The serious brain injury is a nightmare to
    any first responder.

    Suspect that your numbers will be signifigant once you get more data.

    Personally I like the boarders just fine, but the runs are a bit more wide
    open out here...

    Thanks again. Looking forward to your updated results. I'm also going
    to forward this to a fellow patroller who has been having problems with
    his area over helmets...

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 25. Brain injury & Helmet Stats (2)


    > I'm an MD who works at a large Western Ski Area. We see around 5
    > traumatic brain injuries a day on average in the busy season. I feel
    > that most of these could have been prevented or at least made less
    > serious by the use of helmets--it's common sense. My problem is with
    > getting our ski area administration to go along with some simple
    > requests. I've asked that helmets be made available to our employees at
    > cost--this was denied for fear of undercutting the local merchants,
    > until one of the lift ops almost died on the hill after hiiting a tree
    > with his skull. At this point I was given the OK to find helmets--but I
    > was angry that it took a near-fatality to get this done. The
    > administration is also very leery of letting me use any head injury
    > statistics for use in studies about helmet safety. At the same time
    > they tell me that until there are more definitive studies on what
    > exactly constitutes a safe helmet, they have no opinion as to whether
    > their use should be encouraged! My feeling is that anything that might
    > possibly emphasize the dangers of being on a ski mountain is frightening
    > to the administration, lest one less lift ticket be purchased. I just
    > want to make things safer--I'm tired of treating what I feel are
    > preventable and often very serious injuries. Any words of advice on
    > this subject?

    Sevenmile

    Sorry about the delay, but ski season is still a ways off, although there
    was snow in the passes a few days ago!

    Talking to people from corporate anywhere is a frustrating experience.
    Many are bottom line folk, and running a ski area is not as lucrative as
    it might seem.

    Five tramatic brain injuries a DAY!!!! It certainly must be a large
    area.

    I think my plan of attack here would be to talk to the mountain risk
    manager, and get him sold on it. Then go see the Human Resourses person
    and point out the implications of time lost. The risk manager guy is
    maybe the most important. As more and more studies come out, your area
    will look pretty bad in court if no attempt is made to have employees wear
    helmets.

    There is a local area that requires off duty employees to wear helmets. I
    saw a lifty wearing one at Kirkwood while working--actually a pretty good
    idea, if you've seen many lift vs head accidents. I suspect OSHA will
    require them at some future date.

    As far as competing with the local shops... This seems a bit specious to
    me. Number one, most shop employees get heavy discounts (mostly free) at
    big areas. Number two: most shops _like_ to have the area employees use
    the equipment they sell--it's the old pro form deal. It the ski patrol
    and all the employees are using X brand skis or Y brand helmets, the
    tourists and even the regulars will want the same thing.

    Which brings us to plan B. You might go down to some of the local shops
    and identify yourself, asking them if they would be willing to supply
    helmets to anyone with an employee ID at cost or cost plus 5%. Have 'em
    put the shop sticker on it if need be. I bet you'd get some takers. Ski
    shops like selling stuff, and if enough of their helmets are out on the
    hill at cost, there will be an increased demand from the skiing public at
    full retail. The areas I see huge demand are small kids, racers, and
    upper level/expert skiiers and boarders.

    If none of the above work, call the helmet manufacturers for advice and
    the possibility of a pro deal. I've talked to a couple and they are
    generally pretty helpful.

    Last, I'll forward a post from a Doc in VT who is in th midst of ongoing
    research on the topic.

    Good luck!

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

  • 26. MD or Patroller. Vocational advice.


    > I am a freshman at the University of Kansas. I have a pretty strong
    skiing background and I was wandering what route I should take if I
    wanted to work as a physician on ski patrol and who I could talk to
    about it? Would it be better to go into sports medicine, pre med, or
    another field relating to injuries that would occur on the mountain?
    Would you send me information on the options I have?
     sincerly,
    > James
    >
    James.

    My advice would be to figure out what you want to do with your life. If
    you want to be a pro patroller, take an EMT or paramedic course, go
    somewhere where there are some mountains and join the patrol. Or, if
    you're really in a hurry, just join the patrol and skip the courses.
    We'll train you.

    If you want to be a physician, settle down and study whatever turns you
    on, making sure you have the med school prereqs covered. Mostly, even as a
    doc on the ski patrol, you get paid the same as the rest of the
    sledhaulers. Sometimes as much as twice minimum wage!!! Mostly nothing
    but the satisfaction.

    Some mountains have MDs in a clinic at the bottom--Snowbird, Jackson, and
    Squaw, among others. If you think that's what you'd like to do, a family
    medicine or ER medicine residency would be best. Choose in 8 years after
    you finish med school. You can start in 2011, which is forcast to be a
    banner snow year.

    My recommendation to you, as a freshman in college is to get the basics
    down, not worry about the residency just yet, and maybe transfer to a
    college near a ski area where you can join the patrol on a volunteer
    basis--check the archives on how to join the patrol. After a couple of
    years, you might not be so hot to commit your life to it. It's a fair
    amount of work, and not as glamorous when you're actually wearing the
    coat. Hang in there. It's a long haul, but definitely worth it!

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 27. Butt hardware


    > Hi Doc
    >
    > My name is Eric Rauterkus and I am an Occupational Therapist for San
    > Diego City Schools. I have skied since I was 8 years old and in the last
    > 2 years I made the switch to snowboarding. I like everything about
    > snowboarding; the comfortable boots and having one item to carry not 4.
    > The one thing, however, I did not like was sitting on the cold snow to
    > put on my bindings and falling on my butt. I have since invented a shock
    > absorbing insulation pad called BUTT MUFF tm. My question is would
    > this pad reduce or help prevent hypothermia if stranded in the snow? It
    > is made of a closed cell foam that is 1cm thick it goes between your
    > under garment and your shell and acts as a barrier. My thought is that
    > when sitting on the snow much of your core heat is lost by the part of
    > your body touching the snow (butt). This pad also can help maintain
    > circulation to the lower extremities. The pad remains flexible to -40 F.
    > Could you please tell me what you think, or how I could find out how to
    > support that claim? If you E-mail me I will send you a free BUTTMUFFtm.
    > for those cold skiing days or for a snowboarding friend or family
    > member.
    >
    > Thanks for you consideration
    > Eric
    >

    Eric.

    Great idea! I sure see a lot of boarders sitting in the snow as I ski by!

    I'm not sure how to get scientific proof that the Butt Muff tm prevents
    hypothermia, but the ski patrol Outdoor Emergency Care Manual section on
    hypothermia shows someone sitting on the snow, quite unhappy, while a
    second drawing shows her on a rock , obviously much warmer and happier.

    If you really wanted to to a controlled study, you'd have to get people to
    wear the same pants on two separate days, one day with your invention, and
    the next day without. Of course this would have to be in identical
    conditions with identical meals, etc. Have them sit in the snow and have
    a continuous measurement of core temps. Medically we do this with a rectal
    thermocouple.

    Probably couldn't talk snow boarders into doing this unless they were grad
    students or lawyers ;)!

    My suggestion: Most boarders (and skiers) are not on the peer review
    panel for the New England Journal of Medicine, and don't know or care
    about the difference between hypothermia and hypomania.
      
    Just advertise that it will keep them warmer and more comfortable.

    It would help if it were water proof..

    Build a better mousetrap and the world will beat a path to you door.

    Thanks for the offer of the freebie, but professional ethics, and all
    that...

    Besides. I avoid sitting in the snow. I sure don't want MY core temp
    monitored!
     
    Good luck with your enterprise

    See you on the hill.
    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 28. Handling shoulder dislocations on the hill.


    > How do you manage shoulder dislocations on the hill ?
    > Can a subluxed shoulder easily become fully dislocated if mishandled ?
    >
    > I was hit by a car last year and amongst other injuries, I dislocated
    > my left shoulder. It was put back into place in the Trauma room but
    > since then, it has subluxed several times. The doctors have told me
    > that that if you dislocate any joint more than two times, there is a
    > greater chance of it dislocating in the future. Since this was the 2nd
    > time I had dislocated it, there is a good possibility that it could
    > dislocate again. I have not skiied since being hit by this car as I was
    > in hospital for quite awhile after this accident, but I really want to
    > ski this season and have my doctors clearance to do so.
    >
    > I am just wondering if you see many shoulder dislocations on the hill ?
    >
    > Kallum
    >

    Kallum

    We see a fair amount of shoulder dislocations on the hill. First aid is
    to splint in the position found using blankets and triangular bandages. I
    have a hard time imagining any competant patroller making your situation
    worse.

    In my experience, a lot of folks with chronic dislocating shoulders can
    pop it back into place themselves and go about their business.
     
    As a skiier, if your hands are in the correct position and you don't do a
    forward fall, you have little chance of dislocating your shoulder. The
    position you need to do this is the "raise your right hand" position--your
    forearm is bent with your hand above your head. A little backward force
    on your hand and the shoulder pops right out..

    Advice--ski away. You might just dislocate the shoulder, although the
    chances are remote.

    You gotta live!

    See you on the hill!

    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 29. Skiing with a broken arm.


    > Hi there,
    >
    > What would be your advice to somebody who has just had a cast put on
    > their arm and then wants to go skiing ?
    >
    > Is there a certain period of time after which you could safely ski with
    > a cast on ? I mean, there must be a point at which it sets and then
    > would be okay for me to ski without risking permanent damage if I was to
    > fall ?
    >
    > I am not sure how much impact it would take to cause a cast to crack. I
    > do have the choice of switching to a fibre glass cast in three weeks
    > ...would that be safer for skiing or should I ask them just to put
    > another plaster cast on ?
    >
    > The orthopedist said they have to check it out at 3 weeks (as it was a
    > clean break/open fracture) ...so that is why they take the cast off I
    > guess.
    >
    > Kallum
    >
    Kallum.

    HEY! Wait a minute ;}.... Don't I know you????

    You're the lady with the dislocated shoulder, aren't you? Now you've
    broken your ARM?

    Hmmm. With a dislocated shoulder AND a broken arm in one week, maybe
    skiing is not the sport for you...

    But seriously.

    My advice on this one is to consult your orthopedist--someone with whom
    you're obviously building a long term relationship.

    My suspicion is that it will be ok to ski. They can make some very
    strong casts nowadays, and you should be pretty well healed by the time
    ski season get underway in any event. Fiberglass is strongest in my
    opinion--especially if you tell your doctor what you plan to do--He'll
    make the bad *ss mountain lady cast and not the little old lady one.

    I hope your arm (and shoulder) are doing well. Get those skis
    ready--winter is coming soon!

    See you on the hill!
    (I hope)
    Doc

    Eric Lamberts ND NSP
    ewl@med.unr.edu Reno, Nevada USA

    Hi there !

    > Kallum.
    >
    > HEY! Wait a minute ;}.... Don't I know you????
    >
    > You're the lady with the dislocated shoulder, aren't you? Now you've
    > broken your ARM?

    Yep, that's me and yes I have ....the dislocated shoulder injury is from
    being hit from a car last year while I was rollerblading. Since then, the
    damn thing keeps subluxing and stuff. I have to say that it was my first
    dislocation so when the paramedics took me to hospital and the doctor could
    see and hear (I was in quite a bit of pain) that it was dislocated, he told
    me that he was going to go and mobilize some people to help put it back into
    place, I was quite alarmed !!!

    >
    > Hmmm. With a dislocated shoulder AND a broken arm in one week, maybe
    > skiing is not the sport for you...

    No way..I AM skiing....I love skiing and had to miss it last season because
    of that accident referred to above.
    I broke my arm sort of badly...it was an open fracture...very nasty looking
    because a bit of the bone was actually coming through the skin....uggghhh....
    it was pretty bad. I went into shock very quickly according to the
    paramedics...I saw the x-rays which were shown to all the ER residents who
    were ooohing and ahhhing.....

    Is an open fracture that rare ?

    >
    > But seriously.
    >
    > My advice on this one is to consult your orthopedist--someone with whom
    > you're obviously building a long term relationship.

    Hahaha...you're a pretty funny guy you know that eh ? :-)

    > My suspicion is that it will be ok to ski. They can make some very
    > strong casts nowadays, and you should be pretty well healed by the time
    > ski season get underway in any event. Fiberglass is strongest in my
    > opinion--especially if you tell your doctor what you plan to do--He'll
    > make the bad *ss mountain lady cast and not the little old lady one.

    You have a great sense of humour !! I have actually heard about the
    Fibreglass one...it is supposed to be much lighter than this lump of plaster
    I have on now..I actually think he put this one on purposely to try and
    prevent me from pursuing any other fun (and dangerous) sports for a little
    while. It is also supposed to be waterproof right ?

    If I tell him what I plan to do, I think he'll put me in a full body cast
    !!!!!

    BTW...is the cast I have on now, a little old lady cast ????

    >
    >
    > I hope your arm (and shoulder) are doing well. Get those skis
    > ready--winter is coming soon!
    >

    They're all ready !! I can't wait !! I just hope they will let me on the
    ski-lift with this thing...

    > See you on the hill!
    > (I hope)
    > Doc
    >
    > Eric Lamberts ND NSP
    > ewl@med.unr.edu Reno, Nevada USA

    Thank you for your suggestions Eric...I really appreciate your time in
    responding.

    Kallum

    [ Return to Index ]

  • 30. More vocational advice - nursing.


    > Hi Dr.Lamberts,
    > Am writing you on behalf of my daughter who continues in her clinicals for
    > her BSN and working on heart units as she has for years in conjunction with
    > several years on the NSP--she instructs CPR and BLS and is interesting info
    > re: how to further her education relative to Ski Patrol. Is there a program
    > re: how to become an NSP instructor, education for registered nurses,
    > further climbing certification, Southwest programs, etc. or next step in
    > becoming more proficient? She wants to travel, do flight nursing or something
    > that will tie all her interests together.
    > Please send info to her @ this e-mail address. Jamie Clark---BSJLC@aol.com.
    > Thank you!!
    > Barbara Clark

    Barbara,

    This is a tough one, mostly because I'm not sure what the question is.

    If she's in the NSP, she knows how to become an instructor, and how to
    obtain advanced certification. There are a large array of advanced
    training classes offered every year.

    If she wants to travel, she could become an agency nurse-they spend a few
    months at one place and then move on.
      
    A caution--most people who advance in NSP do it more for love than for
    money...i
     
    See you on the hill?
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 31. My dad wants me to wear this dorky helmet....


    > Dear Doc,
    > My parent want me to wear a helmet for snowboarding
    > but i don't go all that fast or do many tricks. What
    > do you think??
    >
    > Thanks a lot
    > Steve

    Hmm. I am a bit biased, being a parent, an MD, and a ski patroller.

    Since your parents are probably paying the bills, I think I'd go a along
    with their wishes. I'm not sure where you live, but out here a lot of the
    semi pros are taking to wearing them.

    I suspect you're still not at the semipro stage, but mostly as you get
    better and better you'll go faster and be trying more radical manuvers.
    Helmets DO save lives and it sounds like your parents are not looking to
    retire on your college fund, and maybe even enjoy having you around!

    The strategy I'd recommend is to be hesitant about it with your parents,
    and then agree to it, making sure you get a cool looking one designed for
    skiing/boarding--No pink bike helmets..

    See you on the Hill!

    Doc
    Eric Lamberts MD NSP
    (Waitin' for snow)
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 32. Reintro to skiing after traumatic injury.


    > Last April I suffered a spiral fracture of my right tibia and fibula at
    > Whistler. I've been trying to figure out what happened. To the best of
    > my memory, the ski never release. I remember topping a rise at a fairly
    > high rate of speed on a blue square, groomed run. I remember seeing a
    > women below me out of control; I deciding to turn sharply to the left. I
    > was near the edge of the trail (Harmony Piste), which runs through a
    > huge snow field. There was snow earlier in the week, so there was a
    > substantial lip along the piste. I suspect the lip was partially
    > solidified, as the there had been freezing and thawing after the fresh
    > snow. My guess is that the left ski carried over the lip but that the
    > tail of the right ski caught against the lip as I came around. Does this
    > sound plausible? What sort of tests should I have done on the bindings
    > before skiing this winter?
    >
    > I ski Atomic 9.18s with Salomon S900 bindings. At the time I weighed in
    > at about 220, so the settings of about 5.5 did not seem excessive. I had
    > the skis tuned and checked out when we got to Whistler, partly because I
    > feared what havoc the airline might wreak with the settings.
    >
    > On a separate but related topic, do you have any suggestions for someone
    > who loves skiing but is now fairly gun-shy? Skiing is the only sport
    > I've taken up seriously. I was born with a congenital heart defect which
    > required two aortic valvotomies and then a valve replacement in June
    > 1997. I've never experienced a sport injury before and so am a little
    > freaked about hitting the slopes again this year. Until '97 most forms
    > of physical activity were verboten (though I did ski green circles for
    > short periods over several years), so I started this sport (in earnest)
    > with 29 years of warnings in my head. Now I'm having a hard time getting
    > them out again.
    >
    > Thanks for any and all help you can offer me.
    >
    >
    > R. Karl Rethemeyer
    >

    Gee, Karl, that's a pretty awful story.

    It sounds to me like the mechanism of injury is as you described. I
    suspect any binding would not work up to snuff in this situation. Tib fib
    fractures were one a very common injury, but have become quite rare with
    modern bindings. Your settings sound about right.

    To prepare your equipment for the season, take your skis and boots to a
    shop that does dynamic testing. Many shops adjust bindings by setting the
    DIN for your body size and ability and sending you on your way. You
    should go somewhere and tell them what happened, and that you need the
    bindings function tested. What they do is to hold the ski in a vice and
    use a torque wrench type device to see if your binding releases according
    to specs. I once had a binding prerelease on an icy hill and ended up
    kissing a tree. The spring in the binding was no good and the only way I
    could ever know was by having it function tested. It seemed OK. (All I had
    was a split lip, but if I hadn't done a self arrest maneuver I probably
    wouldn't be writing this). Have them set the bindings for your height and
    weight and ability, no inflation of your ability, but no deflation
    either.

    On the hill be sure your boot and bindings are clear of snow. Snow
    under the front of the boot could certainly cause a binding not to
    release. There are devices you can mount on the front of your skis to
    scrape off snow--I prefer making a swinging motion with my boot and
    scraping the snow off on the front binding, although this makes it look
    like hell. Do be sure there is no snow there. I'd probably go overboard
    and buy a can of silicone spray--Kmart brand is fine, and spray the
    antifriction part of the binding daily. Keep the snow from sticking and
    adds a bit of lube.
     
    It's good you're going back, as they say, you have to get back on the
    horse after you fall off. It's pretty normal to have some trepidation,
    though. I'd get a copy of "Inner Skiing" by Timothy Galway. It's a quick
    pop psychology read. The thesis is that we are often held back from
    performing our best because of the fear factor. The companion
    counterpoint book is Lito Tejada-Flores' book "Breakthrough on Skis,"
    maybe the best book on ski technique ever written. One book says you
    can't ski because you're scared, and the other says you're scared because
    you can't ski!

    Anyhow, breeze though the first and read a couple of chapters of the
    second.

    Your first day on the hill should be a gradual reintroduction. Ski the
    green circles till you're bored. Now ski them behind a six year old and
    take the jumps and silly stuff he's doing. If there aren't a million
    people go a little fast and practice emergency stops. Practice
    falling--you want to fall sideways. Try to avoid backward falls at all
    cost. Try a groomed intermediate only when you feel up to it. Don't
    knock yourself out the first day, but when a little of your confidence is
    back sign up for a lesson. Don't push yourself too hard.

    Or don't do any of the above. Whatever you do, have fun!

    Now if you just had a summer sport--Windsurfing?

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 33. How to survive an avalanche.


    > how can you survive an avalanche
    >

    The best way to survive an avalanche is not to get in one to begin with.
    The easiest way to do this is to only ski in partolled areas.

    If you are considering skiing back country steeps, you need to take a
    course in avalanche safety, and buy some equipment.

    If you are caught in an avalanche try to out ski it, or use a swimming
    motion to stay near the surface, and use your hands to make an air pocket
    in front of your face. Don't struggle if you can't move--conserve energy
    and Oxygen.

    Say your prayers and make your piece with God--mortality is signifigant
    after six minutes if someone doesn't dig you out

    See you on the hill!
    Doc
    Eric Lamberts MD NSP

    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • 34. Pre-release vs. no-release.

    > Hi,
    > I found your email name via "Ask Doc" on www.skipatrol.org.
    > In January of this year I fell badly skiing and tore my MCL and ACL. I had
    > ACL reconstruction and have been rehabbing all summer. I have had some minor
    > setbacks that have slowed my progress, but the surgeon and physical
    > therapists believe I am close to being ready to return to skiing this year.
    > My question involves the release settings on my bindings. I feel I should
    > adjust them to release slightly quicker to protect my knee this first year
    > back, but wasn't sure about that. I know a pre-release can be just as bad,
    > so I'm a little unsure of which way to go. Any advice appreciated. I know
    > you can't suggest a din setting or anything like that, I'm just looking for
    > ideas on how to go about resolving this, who I might talk to, etc. so that I
    > am as confident as I can be that I have the bindings in the right place for
    > my situation.
    > I'm 37, have skied all my life, I ski (or used to ski) aggressively on steep
    > diamond or double diamond runs, ski comfortably in powder, moguls and
    > outside marked runs, and race giant slalom on a recreational team (but will
    > not be racing this year). I've had a custom CTi2 knee brace made, it comes
    > with a ski boot attachment which I intend to use. I plan on restricting my
    > skiing this year, easing into things, trying to get my legs and confidence
    > back.
    > Oh, I am not a patroller, if this column is only for those folks. (But I
    > would like to be some day, if that counts.)
    > Thanks for any ideas.
    > -Scott Miller, Seattle
    >

    Scott,

    Sorry about your knee.

    I have pretty definite opinions on this. As far as DIN settings, I'd ask
    your orthopedist. My bias is to set the DIN according to the
    manufacturer's directions. If you're skiing as an advanced skiier, set
    'em accordingly. If you will be skiing as an intermediate (you can ski
    black diamonds and still ski as an intermediate, in my opinion) set them
    as an intermediate. It's a fine balance. If you're an expert skier in
    extreme situations, it is not in your best interest to set them loose. I
    had a friend who was well schooled in self arrest techniques almost get
    killed last year when his ski released in an icy mogul field--I chickened
    out at the top, going into survival mode.

    Facts and opinions about ACLs: Fact--skiing is not hard on ACL's unless
    you fall, and no binding curently available can protect your ACL. I
    suspect that even the best brace can do little to protect it.

    Opinion: the replacement ACL is stronger than the one you broke. ACLs
    wear over time, and often the final injury is the culmination of years of
    wear and tear. Maybe you're wearing the brace on the wrong knee??

    Bottom line--ask your orthopedist how to set your binding, and how
    agressively you can ski. My vote is to get back into agressive skiing and
    st your binding accordingly. Last, learn how to fall. Find out
    everything you can about phantom foot syndrome--the way you get
    catastrophic knee injuries. Most good ski schools will have a tape on
    this, plus it's been covered in many of the ski mags. I suspect there is
    something on the net about this.

    You should be able to do anything you did before.

    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, Nevada USA

    [ Return to Index ]

  • Effectiveness of ski helmets in preventing injuries

     > I am interested in finding information on the effectiveness of helmits in
    > preventing head injuries. Any information or advice would be greatly
    > appreciated.
    >

    > >Does the National Ski Patrol have a position on helmet use for children
    > >while skiing? Also, do you have any information on how many children
    > >are injured while skiing each year?
    > >Thank you.

    Dear Gil,

    Sorry it took me a while, but I sometimes like to mull these things over
    for a few days...

    I called Boeri, one of the two major manufacturers of ski helmets. There
    are very few ski specific studies on helmet use. The work has been done
    in other sports, however, and the upshot is that helmets save lives. My
    personal bias are that ski helmets are especially important in the
    following groups:

    Racers. In most places this is non negotiable. If you want to race, you
    must wear a FIS approved helmet.

    Extreme. There are some places where a fall puts you at a high risk for
    head injury. At Squaw Valley there are narrow steep chutes known as the
    "horse trails". In many, the runout leads to VW sized boulders. A fall
    at the top means certain collision with granite.

    Small Kids. These guys often get going too fast for their ability and
    rendezvous with trees. The two catastrophic head injuries I'm the most
    familiar with involved kids. One was a third grader an a beginner run who
    kept building speed until she met with a tree. The other was a 14 year
    old on an intermediate run, who likewise kept gaining speed untill she hit
    a berm, and was launched into a tree, impacting about 10 feet off the
    ground. Both would have survived had they been wearing helmets. The
    suffering of the families and patrollers involved was immense. I remember
    reading an article a couple of years ago stating that kids should wear
    helmets for several reasons--thinner skulls, larger heads in proportion to
    their bodies than adults, and lack of judgement.
     
    Others. People who have had past severe brain injury. The guys who like
    to tuck at a bizillion miles per hour. (In the west we lose about 3 a
    year to the latter at Heavenly Ski Area alone. They don't call it
    Heavenly for nothing...) Maybe everyone should wear one.

    As far as what style to buy, it pretty much depends on personal
    preference. The ones that cover the back of the neck afford more
    protection to the neck, although some of the anti helmet bikers say it
    puts you at increased risk for a broken neck. I think that the increased
    protection far outweighs the slight increased risk. The short helmets are
    lighter, not as warm, but many think they are more comfortable. Any
    helmet offers more protection than no helmet. Be sure they are
    comfortable, which means they are more likely to be worn.

    I hope this is of some help.
     
    See you on the hill.

    Doc
    Eric Lamberts MD NSP

    Shorter NA, Jensen PE, Harmon BJ, Mooney DP

    Skiing injuries in children and adolescents.

    Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New
    Hampshire 03756, USA.

    J Trauma 1996 Jun;40(6):997-1001

    Article Number: UI96251254

    ABSTRACT:

    OBJECTIVE: A study of major skiing injuries in children and adolescents.
    DESIGN AND MATERIALS AND METHODS: A 5-year retrospective study of patients
    18 years old and under admitted to a pediatric trauma center after skiing
    accidents. A follow-up questionnaire was used to obtain additional
    information. MEASUREMENTS AND MAIN RESULTS: Thirty-eight patients, of which
    34 were male. Age range was 5 to 18 years. Fifty-eight percent of the
    accidents were collisions with stationary objects. Alcohol and drugs were
    not implicated. Helmet use was negligible. Head injuries, especially skull
    fractures, were very common (27), followed by extremity fractures (13),
    facial fractures (8), and abdominal (6), thoracic (5), and spinal injuries
    (2). One third had multiple injuries. The average cost was $22,000. There
    were no deaths, but 26% had long-term sequelae. The skill breakdown was 26%
    beginner, 29% intermediate, 45% advanced. Willingness to accept
    responsibility for the accident correlated inversely with skill level.
    CONCLUSIONS: Prevention efforts must target excessive speed and loss of
    control. Beginners must be well supervised on appropriate terrain. The
    frequency of skull fractures suggests that helmet use should be encouraged
    for young recreational skiers.

    [ Return to Index ]

  • Req'ts for medical professionals to become a patroller

     >> >Dear Norman,
    >> > I was recently looking at the NSP web sight and had some questions
    >> >about the requirements needed to be a member of the ski patrol. I am an
    >> >occupational therapy student at University of Texas Medical Branch and
    >> >come graduation I will have a lot of knowledge in hand splinting. I was
    >> >wondering if you had any need for someone with this experience or if it's
    >> >not something you need in NSP. Either way I am interested in seeing what
    >> >the time commitment would be in training to become a member and to know
    >> >what level of skier is required. I have grown up skiing and feel I
    >> >probably have the ability needed, but of course being an obnoxious Texan,
    >> >I probably am overestimating my capabilities on the slopes. Whenever you
    >> >get a chance I would enjoy hearing from you and learning more about your
    >> >organization. Thank you.
    >> >
    >> > Jill

    >Daer Jill,
    >
    >I'm not sure if Norman ever got back to you. If he didn't, I apologize
    >for the length of time getting back to you, but vacations seem to decrease
    >my 'net access.
    >
    >AS an OT, your knowledge would be helpful, particulaly the general anatomy
    >and physiology. As far as your expetise in finger splinting...I'm afraid
    >we're a bit primitive on the hill. Mostly no specialized splints, no
    >alumafoam; If it's broken or a boutonniere deformity, it pretty much gets
    >the popscle stick approach acutely.
    >
    >Sort of interesting, but the most common hand injury on the hill is
    >"skier's thumb aka torn MCL, aka Gamekeeper's thumb. Most of these people
    >are never seen by the patrol and ski off after their injury.
    >
    >As far as joining the patrol...Your major problem in Texas is lack of
    >snow. I remember a whole herd (?) of Texans who showed up on a local hill
    >with hats reading, "If God had wanted Texans to ski, he would have made
    >Bull Sh*t white." Most were great skiiers, and overjoyed to be doing it.
    >
    >Seriously, in order to be a Ski Patroller you have to have a hill to work
    >on. If you have a hill you really like, go up to first aide and ask to
    >talk to the director. They almost always are looking for people with
    >strong skiing skills who aren't afraid to work. A medical backround is
    >icing on the cake. They will take you on as a candidate. What this
    >involves is passing the Outdoor Emergency Care class, the equivalent of an
    >EMT. These are generally given in the fall or summer, and are oriented to
    >winter first aid, but also cover such esoterica as childbirth and Jila
    >monster bites.
    >
    >When snow finally falls, you are expected to be on the hill every weekend
    >for training. This involves skiing skills--you are expected to be able to
    >handle any run in any condition at your area, and most places actually
    >expect you to look good when you do it! You also do practical first aid,
    >with scenarios on the hill, and learn to handle toboggans with blubbery
    >patients on steep inclines. Most become active patrollers by the end of
    >the first season, although a high percentage have to spend another year
    >working on their deficits. Some of us end up being candidates for four or
    >five years.
    >
    >Did I mention the willing to work part. You do have to work, and you have
    >to be at the hill by 8 am, 7 am in some places. It is fun and fulfilling,
    >however, and you never have to pay for a lift ticket while you're working.
    >
    >I hope this is helpful, if you need any more information, pleas let me
    >know.
    >
    >See you on the hill...
    >
    >Doc
    >Eric Wm Lamberts MD NSP
    >
    >

    [ Return to Index ]

  • Dangers of tree skiing

    On Fri, 5 Apr 1996, A-221-09 wrote:

    > My name is Luis De Almeida. I am writing a report about some of the
    > dangers of tree skiing and what precautions resorts can improve on in
    > these ski areas. I was wondering if you can give me some info. I have
    > contacted several resorts and have only received info from Killington. If
    > you can answer some questions I would appreciate it. My e-mail address is
    > s19638ld@umassd.edu Thanks.
    >
    >
    Luis.

    My area of expetise is medical, although I am a ski patroller as well.
    My general impression of tree skiing is that by and large, it's pretty
    safe.You'd expect that a lot of the accidents would occur with people
    hitting trees. This does happen, but mostly in skiers traveling a a high
    speed on a groomed run, losing control and getting creamed by a tree.
    This is a common cause of death around here and Heavenly, a ski area with
    immaculate grooming and a preponderance of people who can't ski, has lost
    2 or 3 skiers a year this way. Trees seem to be safer in that they force
    you to make turns, and turns control speed. Less kinetic energy to be
    absorbed by skulls, backs, aortas.

    Interestingly, the most common cause of death in tree skiing is asphyxia.
    and the guys who seem to die the most often are snowboarders. What
    happens is that ther will be a huge powder dump, and after things get
    tracked up a bit, people head for the trees. This is pretty much
    'boarder paradise. Unfortunately, they sometimes go off by themselves.
    They get too near a tree well and get a little forward on the board,
    digging the tip in, catapaulting end over end, landing headfirst in 3-4
    feet of powder. They get disoriented, panic, cannot extricate themselves,
    and drown. The real expert on this is the patrol director a Homewood, a
    medium sized area who is doing research on this. I'd give you his
    address, but our email roster is temporaraily down.

    So how should management make tree skiing safer? Mostly what has been
    going on out here after two back to back snow years, has been a lot of
    education. IE, don't tree ski alone, especially after a big dump, if you
    do fall,stay calm, spit to figure out which way is up, etc.

    Hope this is helpful. If you have any other questions, let me know, I'll
    do my best.

    Eric Lamberts MD NSP

    [ Return to Index ]

  • Safety for beginners.


    > I am a new skier. I am worried about getting hurt. Where can I get info on
    > safety procedures or anything else that could lessen the risk or injury?
    > Anything from stretching, strength exercising, equipment, procedures on the
    > slopes, what to do if you think you are hurt, how to fall, etc.
    >
    > The resorts never have stuff like this (of course). How do you find it?
    >
    > Thanks
    Beth,

    Sorry it took me a bit to get back to you.

    Safety for beginners, hmm? Probably the most important things you can do
    are to learn how to ski, and never lie to a ski tech. Sometimes folks
    are embarrased to admit that they are beginners, and end up with skis
    that are too long with bindings set too tight. The other thing is that
    skiiers just starting out are more prone to leg injuries because they
    can't control their speed and have a tendency to sit back. Lessons
    really help (stay away from the signifigant other, mostly these guys are
    great for a lot of things, but make rotten ski instructors--This is a
    great way to destroy an otherwise great relationship, btw) Practice
    falling on your side, the most dangerous falls are the ones where you
    gain speed, sit back and end up over your skiis. Even though you might
    be jazzed, take a break when exhaustion starts to set in.

    The other thing is to check out your public library. They almost always
    have a bunch of books on skiing. Take out a half a dozen of them, and
    skim thru. My favorite (and I have a collection) is "Breakthrough on Skis"
    by Lito Tejedas Flores. The clearest explanation of what skis can do and
    how to make them do it that I've ever read.

    I guess the last thing, and maybe the most important, is to relax and have
    fun. Skiing has a reputation as being a daredevil sport, when in reality
    the stats prove it remarkably safe. I don't have the numbers right in
    front of me, but the chances of serious injury are remarkably small.
    Skiing is safer than bicycling, horseback riding, football, and many
    other sports that are not considered particularly dangerous. So have
    fun, OK?
    See you on the hill,
    Doc
    Eric Lamberts MD, NSP

    [ Return to Index ]

  • Applying Hare Splint. OEC vs. EMT

       


    > Hello,
    > I am a patroller at Spirit Mountain Ski Patrol, in Duluth, Minn.
    > I've just finished my second year as a patroller and really enjoy it.
    > Great group of people and a nice ski area...
    >
    > My wife and I have had EMT-A level training and are on the medical
    > first responder team with our township fire department. In fact,
    > I joined the ski patrol initially as a way to practice my emergency
    > medical care skills, and discovered that I really enjoy skiing too.
    >
    > Several of us have wondered about the OEC (WEC) protocol for applying
    > the hare splint. In the EMT class, we were taught to first remove the
    > shoe and pant leg, extend the frame to the _estimated position_, and
    > proceed. In the OEC, we've been taught to fully extend the frame
    > (regardless of the patient's leg length) and NOT to remove the boot.
    > The consensus is that the boot would be left on to keep the foot warm.
    > Yet, in our township, we've had mid-shaft femor fractures sustained
    > with snowmobile injuries. When the EMT-P's arrived, the boot was
    > removed from the foot of the injured leg - then the ankle cuff was
    > applied, etc.
    >
    > Can you help me with the issue of boot removal with respect leg and
    > ankle fractures? Are there specific guidelines when the boot should
    > or should not come off - automatically? At this point, I'm inclined
    > to leave boots on unless the patient complains of numbness, loss of
    > sensation, is unable to move toes, or exhibits some other sign/symptom
    > which indicates that the circulation to the foot has been compromised.
    > Please help. Sincerely, Roger Petry.
    >
    >
    Dear Roger,

    I think you already know the answer to this one. You kind of have to
    think about why you're applying the splint. If the goal is to pass a
    test, then the correct answer is whatever the instructor says it is.

    If someone has a midshaft femoral fracture the goal is to stabilize the
    fracture, relieve pain, and prevent further injury. All the above can be
    done with the boot on or off. Many traction harnesses are not designed to
    fit over boots, and you'll be forced to remove the boot. Having the foot
    exposed does have the plus that you can monitor pedal pulses, although
    there is a popliteal pulse that is as easily monitored. The down side is
    that the straps somewhat uncomfortable, and people can get real cold real
    fast. As far as using the splint fully extended, this is wrong. By
    having a foot or two of splint below the foot, the splint would become
    prone to jarring and destabilizing a serious fracture. BTW, the is
    exactly what is recomended in the OEC manual.

    Last is a plea to do whatever it is you're going to do rapidly. People
    with femoral fractures go bad incredibly fast. They get cold and go into
    shock, both from the trauma as well as from blood loss--Two units of
    blood lost is not uncommon. These people need to get off the hill and
    someplace where their shock can be treated. At our area a femur is an
    automatic helicopter ride.

    Anyhow, it sounds like you've got things well in hand. I hope this was
    helpful.

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • Standards of care

    > Dear Eric,
    >
    > Thank you very much for your insightful reply. I have shared your
    > thoughts with others on our patrol. No doubt more (useful) discussion
    > will follow. May I ask you to reply to the second question I asked
    > earlier, which is also of significant importance to me... (I was going
    > to say on the hill and in our township.) But I don't want to draw a
    > distinction between the emergency care for a medical or trauma
    > emergency at Spirit Mountain, and that which I would provide to someone
    > in their living room or on a snowmobile trail in our township. The
    > "care" is essentially the same - with considerations for the
    > surroundings and the materials we have at hand. In other words my job
    > (on the hill or off) is to assess, maintain the airway, treat life
    > threatening conditions, control bleeding, treat for shock, splint,
    > etc. I'm going to treat a femoral fracture, head injury, or cardiac
    > arrest in the same way at Spirit Mountain as I would in our township.
    > A diabetic reaction (coma or insulin shock) does not somehow behave
    > differently in the restaurant at Spirit Mountain than it would in the
    > dining room of a residence in our township. What I'm getting at Eric,
    > is that I hear occasionally "the "WEC" way" being presented with
    > passion in contrast to any other _pre-hospital_ protocol. Why focus on
    > and exaggerate distinctions (if there are any?) Why not focus on and
    > compliment the similarities? Truly, it's not my intention to make this
    > political. Please forgive me for the digression. Could you please
    > offer your (emergency care) thoughts on the following question? Thank
    > you very much. Roger.

    Roger, I guess I need to read between the lines a bit here. It sounds
    like there must be some conflict between the OEC and EMT folks back where
    you live. I have not experience that here. I agree that there should
    be pretty much the same standard of care no matter whom we are taking care
    of. I guess I should point out that although I have worked in bunches of
    ERs (in rural Nevada you are often the only doc for thousands of square
    miles) and I took an EMT course as a medical student, I have never taken
    the OEC course. The bottom line is that we take good care of our
    patients.

    Can you help me with the issue of boot removal in general with >
    respect > to leg and ankle fractures? Are there specific guidelines >
    when the boot > should or should not come off - categorically? At this >
    point, I'm > inclined to leave boots on unless the patient complains of >
    numbness, > loss of sensation, is unable to move toes, or exhibits some >
    other > sign/symptom which indicates that the circulation to the foot >
    has been > compromised. Please help. Sincerely, Roger Petry. >
     > PS. I'm sending a copy of my note along to another interested member
    of > our patrol team. >

    Sorry about not answering this one...I didn't realize this wwas a two part
    question. My tendency is to leave the boot on until I have my patient in
    the warm First Aid room. (You've probably figured out my main thrust is
    rapid assessment, stabilzation, then sled.) Then the boot comes off, the
    socks come off and the leg is exposed for inspection. The advantage is
    that you can see what you're dealing with, you don't get any big
    surprises down the road, and you can ice the injured part. Cardboard
    splints are also easier to apply without a boot on. I might remove the
    boot on the hill under the circumstances you mentioned, but probably not
    even then. You can get a decent dorsalis pedis pulse if you have to by
    opening the boot and sticking your hand in.

    As far as when not to remove a boot... I guess if you have an unstable
    compound fracture and removing the boot would cause more damage. The
    only other time I can think of is when you have a probable sprained ankle
    and will have to walk a ways out on it. If you take the boot off the
    ankle often baloons to the point where it iis impossible to get the boot
    back on.

    I hope this has been of some help. May you dance on snow.

    Doc

    Eric Lamberts MD NSP

    [ Return to Index ]

  • Catastrophic ski injuries


    On Tue, 7 May 1996, Writing Center wrote:

    > Dear Doc,
    > I am a student at the University of Nevada, Reno doing an article for
    > a journalism class on catastrophic ski injury. I am looking
    > specifically for information related to a profile which was recently
    > developed of the typical skier likely to suffer from a catastrophic
    > ski injury, that is resulting in death or paralysis.
    > If you have any information at all regarding this subject, I would
    > greatly appreciate your assistance. Perhaps we could arrange a time
    > for an interview at your convenience.
    > Please feel free to e-mail me any information you may have, or call
    > me at your convenience, and I can arrange to pick it up, sine you to
    > are at UNR, I see.
    > Thank you in advance for your assistance
    > Kendra Howe
    > (702)786-6327
    >
    Dear Kendra,

    My backround is medicine and ski patrollling. I'm aware of the study
    you're talking about; the results came out sometime in the last two years
    or so. I don't remember who did the study, but will send a cc to Norman
    Bookstein, webmaster and font of ski info.

    The profile is not surprising, classic testosterone poisoning. The
    "average" catastrophic ski injury is a young male risk taker. The ages I
    recall were men and boys in their teens and twenties who were doing things
    they probably shouldn't have been doing. Thinking back over recent
    accidents in the Sierra, most fit the "Heavenly" profile-- young guys
    going at warp speed down a groomed trail and hitting a tree. The other
    common accident is the snowboarder alone in the trees who catches the
    front of his board in deep powder, does an end over end and dies of
    asphyxia head down in a tree well. This winter a bunch of guys went out
    of bounds at Donner and avalanched. The famous "avalanche chutes" at Mt
    Rose were closed legally by the county after a bunch of teenagers were
    killed skiing there after a two foot dump in 1972.

    Obviously, when your number's up, demographics don't count for much.
    Season before last, two girls were killed, a 14 year old at Rose, and a 9
    year old at Diamond Peak. Both gained speed on beginner/intermediate
    trails and were essentially dead when they hit the trees.

    I hope this is helpfull. Further information on "official" study results
    would be available at the library--check the Readers Guide to Periodical
    Literature for dates of specific articles in ski magazines. If you have
    any other questions, drop me an e-mail or give me a buzz at home between
    6-7am or evenings, 786-6462.

    Doc
    Eric Wm Lamberts MD NSP

    [ Return to Index ]

  • Is there a role for physicians in the Ski Patrol?

    > I am not sure if this is the appropriate spot to be posting these questions,
    > but I am hoping that I can find some answers here. First, I am an EMT-D in
    > New York. I love skiing and would like to know more information about
    > where and how to become a member of ski patrol. The other question was, is
    > there an actual ski patrol physician? If so, what type of medicine did you
    > specialize in and where? I am interested in becoming a physician in
    > emergency medicine, and am looking into other opportunities that are out
    > there. I hope that someone can help me.
    >
    > Thank You
    > Jennifer
    >
    Dear Jennifer,

    As I read you, you have two questions. First is how to join the Ski
    Patrol, and second is if there is a role for physicians.

    Number one is easy. You must be a proficient skier, able to ski any run
    in any conditons at your chosen mountain, You must then pass the OEC
    course. So pick your favorite mountain, ask to speak to the patrol
    director and tell him (her) that you'd like to join. Be sure to mention
    the EMT. Usually you can challenge the OEC thing--you take a
    written exam and generally a practical exam, kind of like doing the EMT
    final over again. You are accepted as a candidate and spend almost every
    weekend training, learning how to run a sled and run accidents on a ski
    hill. It is a major commitment of time and energy. In return for the
    work, you don't have to pay for your ticket. Most places actively recruit
    candidates, and with your EMT, you are likely to be sought after,
    especially if you can ski. BTW, OEC=Outdoor Emergency Care.

    As far as physician involvement, MDs are even more sought out than EMTs.
    There is no such thing as "ski patrol doctor", but most patrols welcome
    physician advisors. At least two large ski areas have medical staffing at
    the bottom of the hill, Squaw Valley, and Jackson Hole. Ski town ER's are
    also frequently looking for docs to work.

    The last is a bit off topic. Be sure to set some time aside for that road
    trip before you rush off to medical school. Medicine is a gas, but I see
    too many docs who rushed through premed, med school, and residency,
    without taking time to live a bit, ending up successful and bitter. Take
    your time and enjoy life.

    See you on the hill.

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • CPR on a toboggan

    > Could you please advise if anyone has approved C.P.R. while straddling a
    > patient. We have designed an oversized toboggan for the use in doing C.P.R.
    > One patroller is seated at the head of the patient which is up hill, and
    > uses a bag mask connected to a oxygen tank. The second patroller straddles
    > the patient and does compressions. The sceond patroller is faced up hill as
    > to not over compress the chest. Our patrollers have tested the system and it
    > does appear to work. The tobboggan is set up with dual chain brakes to assist
    > in slowing the extra weight of three persons.
    >

    Dear whoever you are,

    I'm not sure if anyone has "approved" toboggan CPR, but there does have
    to be a mechinism for getting full arrest victims off the hill and into
    the EMS.

    Diamond Peak Ski Patrol has done a lot of work on this in the past and
    have a really slick video on CPR in a standard Cascade. It really is
    well done.

    I've not heard about using a special sled, although this sounds
    interesting. One drawback I could envision is not having the proper sled
    in the right place.

    If you're interested, you might drop Diamond a line, they are located at
    Incline Village NV, at Lake Tahoe.

    See you on the hill

    Doc

    Eric Lamberts MD NSP

    [ Return to Index ]

  • Auto defib units

     Hi Cliff

    I'm Chris Horley, the new Patrol Director for Pajarito Mtn in New Mexico.

    We are looking into acquiring a couple of auto defib units. Any info on this
    subject? Will Red Cross certification be OK? Any guidance from our NSP medical
    advisors?

    Any info appreciated.

    Thanks

    Chris,

    How many cardiac arrest patients did you have die at Pajarito Mountain this
    past season? How many in the past 10 years? How many of these would have
    been saved with Automatic External Defibrillation equipment? Would the
    equipment arrive within 4 minutes?

    Ray


    Chris,

    Cliff Chewning and Dr. Eric Lamberts may be additionally responding to your
    inquiry, but I'll give you my information and perspective.

    The NSP does not provide any training or certification in the area of auto
    defib, and this method of treatment is outside the scope of the standard of
    care established by OEC. This method of treatment would need to be something
    that your ski area or local EMS community is imposing upon your patrollers.

    As a care technique for the ski environment it has questionable value.
     Unlike the urban care environment, cardiac arrest on the ski hill is almost
    always associated with trama, and such an arrest is unlikely to be aided by
    defib. Thus, what is a life saver in the urban EMS setting is of little
    value to us. Also, the equipment cost money and increases the training
    burden on the patroller.

    John Clair is the Interagency Liason for the NSP, and keeps an eye on these
    kinds of developments within the EMS community for the NSP. He may be able
    to advise you on how to deal with this requirement. John can be contacted by
    e-mail at jjc02@health.state.ny.us.

    Hope this information helps.

    Ray Bryan
    Far West Division Assistant Director
    National Board Representative

    Dear Cliff,

    Although I'm the Ski Patrol Web advice to the lovelorn Doctor, my opinions
    are my own, and not necessarily those of the National Ski Patrol. I have
    found Ray's comments quite interesting, and to the point. It IS true that
    cardiac arrests are exceedingly uncommon on the ski hill, and most are due
    to trauma and blood loss. As a forty seven year old weekend warrior
    whose grandfather died of an MI at forty five, I sure hope I'm on your
    hill when I have the big one.

    Your follow up on the deadly aspects of V fib were accurate and one of the
    major reasons the earliest step in the CPR algorithm is "Call EMS". It
    is not because they have IV's or O2, but because of the early
    defibrillation. Certainly one of the idiot proof defibrillators is the
    way to go, unless you want to go to medical or paramedic school. As far
    as what kind of training is involved...I'm not sure if this has been
    written into the Red Cross protocols yet. It sure hasn't made OEC.
    I would make the guy who sold the unit supply the training. I do know
    that these are designed to be used by EMT's, the equivalant of OEC
    training.

    I guess the last thing was alluded to by Ray Bryan in his second letter.
    How many arrests HAVE you had in the last 10 years? In medicine we often
    talk about the cost-benefit ratio. Will this be something which sits
    around the shack, but is never used? How far away is your EMS? Would
    your time and money be better spent learning sled CPR? (think I'll send
    you a post on this one) Considering the ratio of trauma to arrest, would
    a pair of MAST trousers be a better investment? Everyone on the patrol
    would have to be comfortable with its use; the key is early
    deployment---having the thing at the top of the hill would be worthless if
    the guy on scene or on bump didn't know how to use it.

    I hope it all works out. See you on the hill.

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • Managing stress levels of patrollers after catastrophinc injuries


    On Thu, 13 Jun 1996, HIROC wrote:

    > Hi:
    >
    > I am interested in learning of (a) Any programs related to
    > investigating stress levels in patrollers who deal with
    > life and death accidents (life threatening injuries,
    > avalanche victims, etc.) and who also carry out avalanche
    > control work in situations that endanger their own lives;
    > and (b) Any stress management programs for patrollers in
    > such situations.
    >
    > Any info is much appreciated
    >
    > Sandy Toronto
    >
    Dear Sandy,

    I'm unaware of any formal programs. Most of the poeple who do avalanche
    control seem to enjoy it and get a bit of an adrenaline rush. It has the
    balance between intellect, physical exertion, and blowing up things the
    many, men especially, seem to enjoy. After a while it becomes routine,
    although not boring.

    A couple of years ago there was a segment in the fall refresher entitled
    "death on the hill" and how to handle it. The thrust was on how to make
    it through the day and ended with the proviso that patrollers might need
    to seek some professional help in dealing with their feelings.

    I do know that two local areas had children hit trees at high
    speed and die of catastrophic head injuries. In both instances, I'm not
    aware of any professional mental health people being called in. In both
    cases however, the rest of the patrol rallied around the patrollers
    involved in running the accident and provided a lot of emotional support.
    Actually, this seems to happen with almost any serious or scary situation.
    Mostly there is a semiformal debriefing with all the patrollers present,
    and in the days and weeks that follow there is a lot of convesation one
    on one or in small groups about the incident. It reminds me in a way of
    firemen who have great esprit de corps/comraderie, and take care of their
    own.

    I am forwarding this to the webmaster of the NSP home page, and to Ray
    Bryan who is much more aware of what is going on at National than I am.

    [ Return to Index ]

  • Ear protection for patrollers

     > I am Rex Mc Lean, Patrol Director, Mountain High, Far West Region.
    > Frequently our mountain makes snow 24 hours a day for several days at a
    > time. I am concerned about the proper way to protect ears and hearing. I
    > beleive National should address this issue with some recommended ways to
    > protect patroller's hearing. I have mentioned this to Karen Wentworth, Div.
    > Oec Advisor and Bill Baxter, Region Director. Opening the mountain in the
    > morning and working accidents under a snow gun is very difficult. Hearing
    > wise, it is a very uncomfortable situation.. Thanks
    >

    Dear Rex,

    Sorry it took me a bit to get back to you, but I've been on vacation and
    then playing catchup.

    I have very little to do with national, policy-wise, although I do pay
    them dues... Since you are patrol director, however, you can certainly
    set policy on your mountain.

    Your point about the noise of snow making is well taken. The noise makes
    patient assessment difficult and radio communication well nigh impossible.
    It would be nice if your mountain staff could shut off, or allow you to
    shut off the guns while you're running an accident. It looks to me like
    it would only be a matter of two valves and maybe 1/2 hour of snowmaking
    lost. You could make it part of your protocol/refresher. It would
    certainly decrease the stress in your patients as well, and reduce the
    risk of potentially fatal hypothermia and the automatic resultant suit.
    That's how I'd portray it to management anyway. Seems like mentioning
    lawyers often help in getting common sense things accepted. :)

    If that isn't possible, cheap earplugs are available at any drugstore
    which cut the intensity by quite a lot; as I recall, around ten
    decibels. Decibels are logrithmic (like the richter scale for you Cal
    guys) and a ten dB drop is considerable. NASA recommends that no one work
    in 105 dB for more than 1/2 hour,110 for 15 min, and 115 for 7.5 min
    without hearing protection. I expect your guns run at about 100 or so
    decibels, so even though they are annoying, they probably are not causing
    permanant hearing loss in most of your patrollers.

    So. This hasn't been too medical. My recommendations are to shut the
    dang things off when running an accident, or failing that, cheap ear
    protection available in the first aid shack like rubber gloves.

    I hope this has been helpful. Skiied with a couple of your ex patrollers
    who made it to the Tahoe basin, BTW. Sounds like you guys got a pretty
    good mountain there.

    Ski safe,
    Doc
    Eric Wm Lamberts MD, NSP

    On Thu, 15 Aug 1996 REXLOCO@aol.com wrote:

    [ Return to Index ]

  • Binding release and complex fracture

    DOC, I need some help PLEASE!!! I need any information you can give me on
    alpine skiing binding not releasing in a twist motion with the right leg
    twisting inward causing a right mid-shaft femur fracture, both comminuted and
    spiral with large butterfly piece, also a compression fracture of the spine,
    T-12, L-1 with disc damage, also right knee damage. The bindings were Look
    Integral and rented. My son felt the pain and heard the crack, like a huge
    tree braking, while he was standing with his right ski tip under the left ski
    causing the right leg to twist 90' , he then fell on his buttox causing the
    spinal compression fracture. All this time the bindings never released. He
    was laying with his right leg turned all the way behind him,90' , with both
    skies still on. The DIN setting was 4 on twist and 4 on forward lean with a
    release indicater range 2 to 7 (twist) and 2 to 7 (forward). The bindings
    were tested after and worked fine, I was told. So now you see why I need
    someone who knows something about femur fractures due to bindings not
    releasing, even if its someone who just has seen a ferur fracture from the
    bindings not releasing would be so helpful because I'm being told that ferurs
    don't fracture from skiing.

    Dear Jamie,
    I received your post. I'd like to mull it over for a day or so. I'd like
    a little more information, as well, if you could. How old is your son?
    How much did he weigh at the time of the accident? What was his skiing
    ability? How fast was he moving? (it sounds as if he were standing
    still.) What is his general health-- he doesn't have any history of
    cancer or any metabolic disease, does he?

    This sounds like a disaster. I'm sorry for your son's pain, and your
    obvious distress. His injuries are out of the ordinary. I can tell you
    that in the accident that you described, there is no binding commercially
    available that would have prevented this. Is he healing and starting to
    do better?

    Eric Lamberts NSP MD

    > Thank you very much for responding. My son was 13, 5 foot 4 inches, type 2
    > skier, 160 pounds, size 10 shoe and large boned (He is currently 17 and about
    > 6 foot tall). The DIN # was set at 4. My son was coming down an easy hill
    > going faster than he wanted to, which is of a medium speed, and swishing to
    > the left (ski tips pointing to his left) when his right ski tip caught
    > something twisting the right leg inward and under the left ski. During this
    > twisting 90 degress of his right leg, he heard a loud cracking sound and
    > severe pain. He then fell to the ground on his buttox, all the while having
    > the skis on due to non release. He slide a ways, then lay still screaming
    > for help with his right leg pointing in the opposite direction, 90 degress,
    > with both skis on. I am an RN that works in the ICU, and realize the kind of
    > tortional force that had to be there to cause a severly comminuted, spiral
    > (with large butterfly piece), mid-shaft, femoral fracture. To me a binding
    > with a DIN setting of 4 should have released, in this twisting motion, before
    > the tortional force escalated to the point of scattering his femur. What do
    > you think????? My son is doing pretty good considering he is in pain every
    > day still. He will probably need to have a spinal fusion some day, the
    > doctors want to wait as long as possible. His right knee still hurts and
    > klicks. Also I heard that the Rossignol brand of bindings are a mixture of
    > Look and Geze with Rossignol basically garage saling the failing companies.
    > Is this true as you know it? Were the Look Integral bindings out of date in
    > 1993 when my son rented the equipment? I realize there are alot of
    > questions, but my brother was on the National Ski Patrol and I know your a
    > great bunch of people, and I know if anyone could help me guys could. By the
    > way my brother insists that the bindings malfunctioned causing my sons
    > extensive injuries. THANK YOU SO MUCH!!!!!!
    >

    Dear Jamie,
    Sorry it took a day or so, but I needed to think over the information you
    sent. My backround is medicine and skiing--I'm a family practioner and
    ski patroller, having done both for a long time. I'm not a ski binding
    engineer or an orthpedist, so my comments are based only on what I know.
    I will also forward your letters and my reply to a couple of other
    patrollers with vast experience. One of them works at a hill where they
    use Look integras.

    My first observation is that your son's accident was certainly a disaster.
    Unfortunately, I don't think that there is too much more that could have
    been done to prevent it. Releasable binding got started in the 50's and
    60's. Before that we literally tied our feet to the skis and if we fell
    they often twisted our legs off. The most common fracture was just above
    the top of the boot. Modern bindings have made this almost unheard of.
    Bindings are not perfect however, and there is no binding commercially
    available that can protect knees. I have heard of a computerized binding
    in the R&D stages, but the way things stand now there is no protection
    for knees.

    Sprained knees are by far the most common accident we see as patrollers.
    Sprains of certain ligaments are probably more serious than the old boot
    top fractures of yesteryear. The real weak point of modern bindings is a
    fall during which the skiier sits back over his skis and catches his
    inside edge. Even though there is tremendous force to the knee, there is
    only minimal force at the binding which doesn't release. The fall your
    son took was precisely the one that bindings can't handle.

    Why don't they set the bindings to release and protect the knee? If they
    did, skis would be coming off during normal skiing, and prerelease can be
    as deadly as no release. Are Look bindings bad? Most certainly not.
    Even though the various companies would have you believe that theirs are
    the best, for general skiing, they all perform about the same. Look
    integras, if I remember right use a standard binding boot interface, so
    that the bindings do not have to be custom set for variations in size of
    boot. This is a big plus; there is no chance for human error, and there is
    no chance that a boot binding mismatch can occur. (This was actually
    pretty common in the past, a boot would be of a totally different shape
    than the binding, and the binding would not function.)
     
    The second thing that I've been thinking about is the extent of your son's
    injuries. Most of the discussion on bindings related to knees, not femurs
    and backs. You mentioned that your son did have a knee injury--Id suspect
    an injury to the MCL and ACL, from the description of the fall. Femoral
    fractures DO occur in skiing, but not usually from the accident you
    described. Vertebral compression fractures are very unusual in this age
    group and are usually secondary to a fall, (The chute didn't open, or
    someone jumped off a roof.) Assuming he doesn't have bone cancer or
    severe osteoporosis, I can only infer that tremendous forces were
    generated--this was not a gentle slow fall. Any fall violent enough to
    cause compression fractures in a healthy 13 year old would logically be
    violent enough to break a femur as well.

    I hope this has been of some help. It is kind of difficult to Monday
    morning quarterback. I suspect this might help make some sense of this
    accident on one hand, but leaves unanswered a central question of
    medicine and life. The question, of course, is why bad things happen to
    good people? Why do babies get leukemia? Why did this awful thing happen
    to your son? I guess we all have to figure this one out for ourselves.

    See you on the hill,

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • Heartrate monitor during transport.

     > We are in Casper, Wyoming. We have a nice little alpine area run by the
    > city and 15 miles of groomed x-c trails groomed by the county - all about
    > 20 minutes from downtown. I am on the nordic end, thus my interest in
    > monitors. Once a patient is packaged on a sled, it sure would be nice to
    > have a constant heart rate while in transport, something that may take an
    > hour or possibly much longer.
    >
    > Thanks for the quick reply,


    My wife recently bought a heart monitor for her running and biking. It
    looks like it would be a heck'uv'a useful thing to have if you had a
    critical patient and a long transport time. Has anyone tried using these
    to supplement monitoring heartrate via palpation?

    Interesting idea... see the next post.
    Eric

    Steve,
    I've never heard of anyone using heart rate monitors during transport, but
    it sounds like a great idea! I had two initial reservations-- one was
    that at most hills it is not the patrol who is responsable for transport.
    It sure makes sense in a nordic, backcountry situation though.

    My other concern would be that of losing the monitor. Things seem to get
    lost or eaten in ambulances and ERs. Again, this would not be a problem
    in a backcountry rescue. You'd disconnect when you turned your patient
    over to EMS.

    Anyhow, it sure sounds like a winner to me. I'm going to forward the
    thread to the webmaster ("nordic" norm) for his comments and possible
    inclusion in the FAQ's.

    See you on the hill...

    Doc
    Eric Lamberts MD NSP

    > >. BTW, where IS Casper Mountain? It
    > >doesn't seem to be listed in any of my books, most of which consider
    > >cable bindings to be state of the art...
    > >
    > >Eric Lamberts MD NSP
    >
    >

    [ Return to Index ]

  • Auto defib units on the hill

     > Since the ARC is starting to teach professional cpr people about
    > automatic defrib's is there any talk about putting them on the hill?
    >
    > --
    > YEA GOD

    Len,

    I haven't heard anything much about this. It would make a lot of sense,
    though, as the studies show that CPR doesn't save people, while
    defibrillation does. The last I heard, automatic defibrillators were
    running somewhere between two or three thousand dollars. This would be a
    major dent in the budget for our little hill. For the big mountains you'd
    almost have to have one at each peak. Budget aside, probably every patrol
    should have one. They work, and they save lives with a dramatic decrease
    in mortality. Training is minimal and within the capabilties of all (well
    most) basic patrollers. (These are my opinons only, and don't necessarily
    represent those of the National Ski Patrol.)

    See you on the hill. (Soon, I hope)

    [ Return to Index ]

  • Medical management of asthmatic attack

     > I am seeking information on the treatment of asthmatic skiers.
    > i.e. the medical management of a skier who experiences an asthma attack
    > while on a hill.
    >
    > Are you aware of any protocols for Ski-patrol units regarding the above ?
    >
    > Thank you in advance for any information that you may be able to provide.
    >
    > Amber>
    >
    >

    Dear Amber,

    The NSP's first aid reference is the Outdoor Emergency Care Manual,
    running about 500 plus pages. OEC has little to say on asthma, and groups
    it under "Respiratory Complaints". Recommendations are to assist the
    patient in taking his medication, and if things are bad enough, to treat
    it as any other respiratory emergency--administer oxygen, call an
    ambulance, and transport off the hill.

    Asthma has become much more common over the last 20 years. The most
    common form is excercise or cold induced asthma--both problems on a ski
    hill. These folks are generally treated with inhalers pre excercise, and
    often have mild symptoms.

    The majority of astmatics will never be seen by the patrol--mostly they
    take care of themselves.

    So. What do we do when we encounter a skier/boarder who is having an
    asthma attack?

    In most cases, the patient will be able to tell you what is going on--they
    live with this daily. I'm not sure how you help someone take their
    medication--but you might suggest that they use their inhaler. Diagnosis
    isn't usually too difficult--the patient almost always supplies it. Many
    will have audible wheeze, but don't be fooled--the worst will not wheeze
    at all, if you aren't moving air, you sure won't wheeze.
    Hypeventilation/anxiety can look similar.

    You need to offer transport--someone in respiratory distress is not likely
    to be able to ski themselves off the hill. Vital signs are a big help--If
    someone has a respiratory rate of 40 and a pulse of 120, they are much
    more likely to need intervention than someone with normal vitals. Warm
    moist air is also helpful--you might have them breathe the air inside
    their parka. A drink of water is also helpful--many are dehydrated.

    If they are in great distress, start oxygen, get EMS on their way, and get
    your patient off the hill. Most of these guys do better being transported
    in a sitting position by the way--they brace their chest muscles on
    straight arms. If you are trained and have epinephrine available, this
    can be life saving, and buy you some time. Probably NOT a good idea
    unless you are an MD or paramedic, and have good malpractice insurance!

    Full blown attacks on the hill are rare. In most cases, the maximum that
    will have to be done is to transport and maybe give a little O2.

    See you an the hill.

    Doc
    Eric Lamberts MD NSP

    On Sat, 23 Nov 1996, Amber Robey wrote:

    [ Return to Index ]

  • When skiing, What should I bring?
    > Over christmas vacation, my friend and I are going up to Vermont. We
    > are going to ski at Mount Snow for a week. You could say we are experienced
    > skiers and we can handle anything on the mountain. We will probaly only be
    > on the mountain too. I highly dought we will go out of bounds or anything of
    > the sort. So my question is, for just sking on the main mountain, for
    > saftey, should I bring anything in a pack in case we get in trouble or if we
    > get ourselfs into a bad situation? And if we do get into a bad situation,
    > what kind of situation would it be? What would happen?
    >
    > Thanks a Lot!
    >
    > BullButt3
    >

    Dear BB3,

    I don't expect you need to bring too much technical gear. No avalanche
    shovels or probes. Bring sunscreen, chapstick, and extra clothes. I
    carry a bottle of water and dried fruit. Amazing how a drink of water can
    help at 2 o'clock when you think you might have forgotten how to ski, and
    your legs are shaking on the run you tore up earlier in the day. Bring
    tuned skis, goggles. A good attitude. Leave anything 100% cotton at home,
    or wear it at night when you and your buddy are chowing down by the fire.

    Bad situations. None at Mt Snow. Maybe the guy with the attitude in the
    parking lot. Your chances of a serious injury are less than one in a
    hundred (three in a thousand to be exact). Read and follow the skier's
    responsability code, on your trail map, and your odds get even better!

    If you really want to be obsessive, bring along waterproof matches and a
    cheap compass, in case you ski off the backside of the mountain in a white
    out. Get a book and read about what to do if you have to use them.

    Have a blast!

    See you on the hill,

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • Snowboard injuries

     > Hi,
    > I am a 2nd year university student in the Human Movements department. I
    > am currently undertaking a study on the injuries of snowboarding and I
    > would appreciate any information you could send me. This project is for a
    > Traumatology course, therefore I'm sure any information concerning injuries
    > will be useful.
    > Thank you
    > Chantal
    >

    Dear Chantal,

    I'm not sure exatly what kind of information you need. My home mountain
    does not allow snowboarders, and I am not the most knowlegeable on
    snowboard injuries.

    My suspicion is that it is mostly knees and wrists--probably more wrists
    than thumbs, which seem to be the most popular in skiiers. Snowboarders
    are also more likely to drown in powder. Because snowboarding has not
    been around as long, there are just not as many statistics as in skiing.

    I am forwarding a copy of this to a couple of people who might be more in
    the know than I am. One is Norm Bookstein, who patrols at Boreal, one of
    the first areas to actually welcome snowboarders, and an area that still
    has a very high percentage of riders. A sentimental favorite. In any
    event, a person who has seen a lot more snowboard injuries.

    The other is the director of the patrol at Homewood, an area that is one
    of Tahoe's undiscovered jewels. They have been doing a study on
    snowboarders in conjuction with the ER in Truckee--At least that's the
    rumor.

    I hope this is of some help.

    See you on the hill,

    Doc
    Eric Lamberts MD NSP
    On Tue, 28 Jan 1997, tally wrote:

    [ Return to Index ]

  • Mid-femoral break

     > do you start to pull tracktion before or after your secondary servay
    >

    This is a pretty basic OEC question. If you think about it, the answer
    should be obvious.

    You are called to the scene, or come upon the scene of an accident. Let's
    say you know immediately that your patient has a femoral fracture. You
    apply traction, call for traction splint, wait for it to arrive (it always
    seems like forever. It arrives and you apply it. Now you do your
    secondary, and discover the possible back injury, rib fracture. Now you
    call for a back board, O2. In the meantime your patient is going down the
    tubes, going into shock, and becoming progressively sicker. You have
    converted a bad problem into a potentially fatal one. How embarrassing!

    A secondary assessment should take 90 seconds, max, and is worth every
    second of it. If you are pretty sure of a femoral fracture, call it in
    while completing your secondary. That way the guy on top will be standing
    by to roll ASAP. Also, this is a bona fide medical emergency. Paramedics
    should be called and standing by as you bring your patient in.

    As an aside, you need to spell check and use capitalization, on the
    'net, what and how you write are the oly ways people have of knowing what
    kind of person you are.

    See you on the hill!
    Doc
     
    Eric Lamberts MD NSP


    >

    [ Return to Index ]

  • Shaped skis and knees?
    > At an apres-ski bar I overheard a group of instructors who were
    > finishing their PSIA II and III updates talking about the new shape skis
    > and the increased load that the new skis put on knees. The consensus was
    > the new Rossi's were the best in terms of knee loading. Curious, I asked
    > a friend (a physics and engineering doctor) later in the week about the
    > possibility that while the new skis helped intermediates turn, did they
    > have the potential to exacerbate knee loading and eventually acl
    > problems. His first comment that the load had to go somewhere. His
    > later comments were not helpful to shape skis. The rumor seems to
    > rapidly spreading about the knee problem. At a cocktail party today, the
    > hot topic among the expert skiers was how shape skis blow out knees. As
    > luck would have it a woman showed up in a knee air cast after having
    > skied Killington on the new skis. So, what is the real story?
    >

    Dear Tom,

    I'm not sure what the real story is. I don't know that these skis have
    been around ling enough for the necessary studies to have been done.

    Carl Ettinger, head of Vermont safety Research, has done the most
    eshaustive studies on the mechanism of ACL tears. He notes that the most
    common scenario is a backward twisting fall, with the downhill ski
    twisting the knee while the skier is below the level of his knee. Since
    the catching of the edge is crucial to the injury, and the shaped ski is
    able to deliver a lot of turning power/torque, it would make sense to me
    that shaped skis could certainly have the potential to cause more serious
    knee injuries than the more traditional ski. Whether or not this is the
    case remains to be seen. I does not make any sense that skiiers would be a
    greater risk if they were just skiing down the mountain and have
    spontaneous ACL rupture. Interesting that it was a women with the aircast
    at the party. Women tend to have more ACL tears than men.

    The rumors might be because a lot of us who have grown up on traditional
    skis don't much care for the shaped ski which has had major hype from the
    ski manufacturers. I personally am not dying to go out and buy a pair,
    but I might be more interested if I only skiied 4 days a year.

    Eric Lamberts

    On Sun, 9 Feb 1997, T.J. R wrote:

    > Well, more anecdotal evidence. I spoke to experts and beginners alike
    > while riding the lifts at Waterville (last weekend) and Stowe (this
    > weekend). It seems the experts don't care for the tendency to turn when
    > they really don't want to turn. The beginners thought the skis were
    > terrific because they initiated turns without thought. Intermediates
    > seem to like the quick turns, but did not like the chatter at speed. The
    > Rossignol 9.9 and K2 488 (not sure of the latter designation) seemed to
    > be the preferred parabolic because of lack of chatter at speed and a
    > lesser tendency to make unannounced turns. Now I understand that there
    > is some nationally known "expert" in the industry claiming that
    > beginners on shaped skis should not learn to wedge. Almost every
    > instructor I met thought he was insane. Unfortunately, I did not get his
    > name. As for the torque issue we discussed previously, every
    > intermediate skier I met mentioned that they felt the difference in
    > torque on their knees. I wonder if the parabolics are going to improve
    > the lot of beginners and intermediates, but prevent them from expert
    > status? If I am boring you, please tell me and I will bore someone else
    > with my observations (as unscientific as they are).
    >
    >
    >

    It is the year of the shaped ski. The experts I've been hanging around
    have been grudgingly accepting of the new skis. I've got a couple of
    buddies who have bought Vokl Snow Rangers for busting crud--a more
    common occurence in the West.

    The more I think about it, the more I think your initial hunch was right;
    shaped skis will be causing more serious knee injuries aka ACL's. They
    give a lot more torque to the knee, which in certain situations will
    likely be disasterous.

    The snowplow comment is likely not too far off--at least some of the
    shaped skis are almost impossible to skid, to the point where it is
    difficult, if not impossible to do a hockey stop.

    But what do I know? So what shaped ski ary you looking at?

    See you on the hill.
    Doc

    [ Return to Index ]

  • Ski patrol medical kit

     > Hi,
    >
    > I was wondering what kind of medical supplies do most ski patrol teams carry
    > onto the slopes. Is there something in there they can use to keep a downed
    > skier warm say during a blizzard.
    >
     
    Dear Arroyo,

    We carry tarps and blankets. The typical pack on a tobogggan has a blue
    tarp and two blankets. Hypothermia is a major problem, particularly in
    people with serious injuries. A major focus of training is rapid
    stabilization and transport to someplace warm.
    See you on the hill!

    Doc

    Eric Lamberts MD NSP

    [ Return to Index ]

  • Dangers of Skiing
    > Dear Doctor Lamberts,
    >
    > I am a 9th grade student in New Jersey and I ski often. Next week (3-4-97), I
    > have to do a 5 minute speech on the dangers of skiing. Is there any
    > information you can tell me about this topic. Your help will be greatly
    > appreciated. Thanks again.
    >
    > Mike
    >

    Dear Mike,

    The dangers of skiing, hmm?

    Well, the injury rate in skiing is about 3 per 1000 skier days. What this
    means to you is that if you skiied 333 days (I should be so lucky!), you
    would be likely to have one injury. The most common injuries are thumbs
    and knees, followed by everything else. Serious injuries are relatively
    rare. Deaths are mostly catastrophic head injuries or high neck
    fractures. In the west where there are occaisional massive powder dumps,
    we sometimes have drownings, where a skiier falls head first, asphyxiates
    and dies, although this is more common in snowboarders.

    The biggest danger? Probably that you'll get hooked and be doomed to a
    life of weekends on cold mountains with a pair of ridiculous boards
    clamped to your feet. Squaw Valley, maybe one of the most famous
    moutains in this country, realizes this well. Their first day beginner
    package consisting of a beginner lift ticket, full equipment, and a lesson
    from one of the premier ski schools costs.... Well, actually it's free!

    So, enjoy youself. Follow the skiier responsability code, don't do
    anything too dumb or risky, and your chance of accident is very small.

    See you on the hill!

    Doc

    Eric Lamberts MD NSP

    [ Return to Index ]

  • Splinting Tib-Fib & Femur

    > Recently I was approached by a Ski Patrol member and asked about a scenario
    > that they had taken part in. The scenario was a training scenario. The
    > scenario involved a fracture of the tib/fib and the femur on the same leg.
    > The patroller used a quick splint and was told that had it been an actual
    > test that patroller would have failed that station. It is my opinion that
    > the patroller was right in picking the quick splint as a means of splinting
    > this particular injury. The method that the patroller was told to use was
    > a traction splint applying traction to the injured leg. It is my opinion
    > that the traction splint could be used, but only to immobilize the injured
    > limb. If traction was applied I feel it could do further injury to the
    > limb. Am I correct in assuming this? As an OEC instructor I would like to
    > clarify this so that I pass on the proper information to my patrol and to
    > my candidates.
    > Thank you in advance for you opinion, it will be greatly appreciated.
    > Gary
    >

    Dear Gary,

    Gosh! That's a good one! I hope this was for the senior test, since I
    suspect most of the patrollers I know would have to think a while on this
    one. The mind boggles to think of the accident that would produce
    simultaneous fractures above and below the knee, although I suppose it
    could happen. Suspect that the answer to this one is not in the OEC
    manual.

    My bias would be to go with the traction splint. Why? Because the femur
    is by far and away the most serious injury. Putting a quick splint in the
    tib fib and ignoring the femur is akin to treating a chin laceration and
    ignoring the neck injury.

    Remember that in midshaft femoral fractures the problem is spasming of the
    quadriceps/hamstrings that causes the bone ends to travel past each other,
    causing not only pain, but the potential for severe neurovascular
    compromise. It is not uncommon to lose two units of blood in a femur
    fracture. The ones I've seen have all gone into shock, even with good
    emergency management. A fractured tibia/fibula on the other hand is not
    as serious. The potential for extending an injury using traction is small
    or non existant. It would certainly not be likely to move things out of
    anatomical alignment.

    I'm sorry that this isn't the answer you probably wanted. I'm going to
    forward this to Ray and Jennifer Bryan, OEC gods for a second opinion.
    Great question!

    See you on the hill!

    Eric Lamberts MD NSP

    > Hi Eric,
    >
    > Yes I do realize that the femur is the more serious of the two injuries. I
    > was in no way trying to splint the tib/fib and ignoring the femur. When I
    > stated that I would accept the quick splint, I was inferring that both
    > fracture sites would be immobilized by the splint. I would tend to think
    > that applying traction to such an injury would compromise the femur
    > fracture site even more because the smaller muscles in the area of the
    > tib/fib would be overpowered by the much stronger muscles around the femur.
    > If this were to happen, could it not cause further injury to the soft
    > tissue and possibly sever the femoral artery? By applying enough traction
    > to fatigue the quads and hamstrings, would it cause further injury to the
    > lower fracture site?
    > The quick splints that we use here in this area are long enough to
    > facilitate the immobilization of both the upper and lower leg. I'm sorry
    > that I wasn't clearer in my previous inquiry.
    > Finally, it was one of the clinic scenarios for the senior test. The
    > question was asked of me by a senior candidate. It was one of the clinics
    > that I did not make. (Besides being a OEC instructor I am also a senior
    > T/E.) Looking forward to your response
    >
    > Thanks again,
    > Gary
    >
    Dear Gary,

    I also apologize if my previous answer wasn't clear enough. I'm at home
    and have no reference books available, but am going to fly with the best
    of my recollections, which are generally quite good; my mind seems to be a
    repository of only occasionally worthwhile facts.

    Femoral fractures are the most frequent of the frequently asked questions
    that I deal with.

    A bit of history is in order. As I recall, traction splints were first
    used in World War One. Before that, femoral fracture were a leading
    cause of death. Why? Previously, fractured femurs had been
    splinted with conventional immobilizing splints. The quads/hamstrings
    would spasm, the distracted ends would override with disasterous results.

    The point? The point is that conventional splints don't work to prevent
    furthur injury in fractures of the mid shaft of the femur. To
    reiterate--a quick splint is contraindicated in mid shaft femoral
    fractures. This is why your area has spent big bucks on that Sager in the
    trauma sled. A quick splint does not work for this injury. It would
    immobilize the tib/fib, but would not be adequate treatment for the femur.

    The reciprocal question is what happens to the tib fib with a traction
    splint? Certainly they would be aligned in anatomical position. Would
    furthur injury be likely because of the traction? Very
    unlikely. The ends of the bone might conceivably be separated by a
    little, but certainly not enough to cause damage to the artery, a problem
    which is common in femoral fracture.

    The traction splint would certainly not "compromise the femur fracture
    site even more," and indeed would protect the femoral artery. As a review
    of arterial circulation, the femoral artery starts at the aortic
    bifurcation and ends just above the knee, where it turns into the
    popliteal artery which in turn bifurcates (memory don't fail me now!) in
    to the anterior and posterial tibial arteries. Thus, it is well nigh
    impossible for an injury below the knee to damage the femoral artery.

    To recap. The traction splint would protect both the injury above and the
    injury below the knee, while the quick splint would do an adequate job for
    the tibia/fibula while making the femoral fracture worse. You have to use
    the Sager.

    Unless of course you have a fracture of the very distal femur, in which
    case (sigh!) all bets are off, and the quick splint is again the treatment
    of choice.

    Thanks again for the question. One of the better ones I've gotten since
    I've been doing this.

    See you on the Hill!

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • On skiing safety

     > To whom it may concern,
    > My name is Diane F. and I am doing a project for a high school
    > course called First Aid and Safety. We were assigned to do a project
    > on safety and I choose skiing safety. It would be greatly
    > appreciated if you could send me any iformation on my topic. Any
    > information would be helpful. It would also help if you could give
    > me the names of other places I could look to get more information.
    > Thank you for all your information.
    > Sincerely,
    > Diane F

    Dear Diane,

    I'm not sure exactly where to start on theis one. The things that I would
    mention are the Skiier's Responsability Code, making sure that bindings
    are set correctly, and not over doing it.

    I would go to the library and skim through all the books on skiing for
    sections on skiier safety. A copy of the OEC manual, the skipatroller's
    first aid text might be helpful, although it mostly covers care of
    injuries and illness and not so much safety aspects.

    Last, I'd check the Reader's Guide to Periodical Literature--you should be
    familiar with this--if not, ask your librarian. I'd check over the last
    few years under 'Skier Safety', 'Ski Injuries', etc. You might also
    check out Carl Ettlinger, a doctor in VT who has done a lot of work on ski
    injuries. Also 'Phantom Foot Syndrome' the latest theory on what causes
    serious knee injuries in skiier.

    It looks like New England just got an extension of the ski season...Tell
    your parents that some practical reasearch at your favorite hill is
    mandatory if they expect you to get a good grade, become accepted at a
    good school, become sucessfull in life, and support them in their old age!
    Ski safely. See you on the hill!

    Doc
     
    Eric Lamberts MD NSP

    O

    [ Return to Index ]

  • Stress levels on Patrollers
    > Dear Dr. Lamberts,
    >
    > I just discovered this web site and read the following response you
    > made related to stress levels in patrollers.
    >
    > >I do know that two local areas had children hit trees at high
    > >speed and die of catastrophic head injuries. In both instances, I'm >not aware of any professional mental health people being called in. >In both cases however, the rest of the patrol rallied around the >patrollers involved in running the accident and provided a lot of >emotional support.Actually, this seems to happen with almost any >serious or scary situation.Mostly there is a semiformal debriefing >with all the patrollers present,and in the days and weeks that follow >there is a lot of convesation one on one or in small groups about the >incident. It reminds me in a way of firemen who have great esprit de >corps/comraderie, and take care of their own.
    >
    > I wanted to let you know there is an important service available to
    > patrollers almost anywhere in the country. Critical Incident Stress
    > Debriefing is an educational and stress management service generally
    > provided to emergency services personnel such as law enforcement, fire
    > fighters, and EMS. It can also be used for ski patrollers. Many
    > counties have teams that will respond to a request for service.
    >
    > We have a team for our patrol. I am also a member of a county team
    > that we can access as well.
    >
    > The team was called out this winter for the sudden death of 19 year
    > old lift operator while on duty. This was the first death that
    > occurred at the ski area. The patrollers attempted CPR and were
    > unsuccessful. CPR would not have made any difference since the cause
    > of death was an aneurysm. Some of the patrollers were the same age as
    > the lift op so it was particularly difficult. We did a defusing at
    > the end of the shift which was well received. It was determined that
    > a debriefing was unnecessary.
    >
    > This is some of the written material about our team:
    >
    > "The purpose of critical incident stress debriefing is to provide
    > support to the members of the Boston Mills/Brandywine Ski Patrol when
    > critical incidents or traumatic events occur. A critical incident
    > stress debriefing or defusing is a group meeting or discussion. Its
    > purpose is to lessen the impact of a horrible event and to accelerate
    > normal recovery processes in normal people who are experiencing normal
    > reactions to abnormal events.
    >
    > A typical post trauma debriefing combines an opportunity to talk about
    > disturbing aspects of an incident, along with reassurance that
    > reactions are normal, with education about stress management and
    > coping skills, and referral to follow-up counseling when necessary. A
    > debriefing ideally takes place between 24 and 72 hours after the
    > incident and lasts 2 to 3 hours. A defusing is a mini debriefing
    > conducted at the end of the shift and focuses on giving information
    > about coping with normal stress reactions and avoiding more serious
    > long-term consequences. A debriefing lasts 20 to 45 minutes.
    >
    > These discussions are confidential and nothing said in the meeting may
    > be repeated to anyone. Only people involved in the incident are
    > permitted to attend. It is not therapy. It is not an operations
    > review or investigative in nature. Your status as a patroller is not
    > jeopardized by participation. No reports are made to anyone. Notes or
    > tape recordings are not allowed. The discussions are intended for
    > support and education. The CISD team facilitates the discussion.
    > Every person involved in the event is invited to attend. While
    > everyone involved in the event may not need this service, those who do
    > not need it can be of help to those who would benefit.
    >
    > Events Warranting CISD for Ski Patrol: Any Death, Injury or
    > Death of a Patroller, Multiple Casualty Incident, Significant Event
    > Involving a Child, Any Significant Event not within the Normal Scope
    > of Ordinary Patrol Duties
    >
    > CISD Team Members: Sharon Borror, Gay Jennings, Pat McGarvey.
    > All team members are trained and certified by the International
    > Critical Incident Stress Foundation.
    >
    > To Access the Services of the CISD Team
    > Any member of the patrol may call any team member at any time to
    > request a defusing or a debriefing. A one on one conversation with a
    > team member is also available. Hill Captains are encouraged to call a
    > team member to discuss if a defusing or debriefing is warranted for a
    > particular incident."
    >
    > Sincerely,
    >
    > Gay C. J

    Dear Gay,

    Thank you very much for your intellegent and helpful post. I have a
    couple of questions. First, how would an area go about setting up the
    team you describe? Are these teams available for this sort of thing all
    over the country. I often work in mental health, and when disaster
    strikes locally, the response in nowhere near as formal or organized.

    Also, with your permission, I'd like to send your post along with your
    email address to Norm Bookstien for possible inclusion on the web site.
    What this would mean is that you would get an occasional post in related
    areas.

    Thanks again!
    See you on the hill.
    Doc
    Eric Lamberts MD NSP


    > Boston Mills/Brandywine Ski Patrol
    > Peninsula, Ohio
    >

    [ Return to Index ]

  • Screening injury prone knees
    > Doc:
    >
    > I work for a worker's comp carrier who insures a ski resort in Vermont.
    > While there are a variety of injuries that occur to all employees, I am
    > trying to learn more about how to prevent injuries to the ski patrollers and
    > ski instructors who are on the snow daily. Specifically, are you aware of
    > specific physical fitness training programs (or studies) that document
    > reductions in this skiing population? I have heard that some Western ski
    > areas have tried "pre-screening" of job applicant's knees to prevent hiring
    > someone with injury prone knees. If you are aware of any method that reduces
    > the overall rate and/or severity of injuries to the "skiiing employee", I
    > would sure like to know about it.
    >
    > Fred >

    I'm sorry it took a while to get back to you; I have been pondering this
    one for a while.

    Part of what bothers me is the question about screening out "injury prone
    knees." Statistically the people with the most injury prone knees are
    women and those who have been skiing a while, both of whom are people you
    would logically want to have as patrollers and instructors. I keep
    remembering an article in one of the ski magazines a few years back. The
    author was going out with the Squaw ski patrol at 5 AM to clear the hill
    of avalanche danger for the day. The scene sounded like something out of
    and orthopedics ward, with many wearing braces and Ace bandages. In spite
    of their knees, these are the people I want controlling the hill when I
    ski--the most knowlegeable, and the most experienced.

    I'm not sure if there is any way to screen for injury prone knees. Strong
    thigh muscles help to protect the joint in most cases, but in some
    situations may actually damage the knee. Some patrols have an early
    season fitness test; you might want to consider this.

    You might also want to check with an industrial hygeinist for more ideas.
    Admittedly, you'd need someone with a skiing backround.

    In our patrol we have had some training videos--one on proper lifting
    technique, a rather generic film that would work as well at Wal Mart for
    training employees, as on the ski hill. If you look at what we do ,
    however, it does involve a fair amount of lifting. Back injuries, as I'm
    sure you're aware, are not uncommon.

    The other was a video on how to avoid injuries to the ACL-a very serious
    (and costly) injury. This video is ski specific, and covers six
    situations witch will almost always ruin your knee. It reported findings
    of Carl Ettlinger, at the the University of Vermont, and was designed for
    professional skier--ie instructors and patrollers. It was watched
    attentively--knee injuies, particularly the ACL, are a shared nitemare
    between skiiers as well as insurers. In my opinion, this would best be
    followed by some sort of drill on the snow.

    Lastly, you might try to increase your percentage of volunteer patrollers.
    As uncompensated workers, they are not covered by workman's comp. I am
    aware of one area near LA that has two or three paid patrollers and over
    two hundred volunteers. Obviously, this takes a while to build up,
    amazing organization, and a whole lot of committed people. Many areas try
    to sweeten the pie for those who commit. Heavenly gives a season family
    pass to its volunteer patrollers, after they have demonstrated their
    commitment.

    I hope this has been of some help.

    See you on the hill!

    Doc

    Eric Lamberts MD NSP

    [ Return to Index ]

  • transport an exposed bone fracture?

     > What is the best way to care and transport an exposed bone fracture?
    >

    In general terms, splint it and dress the wound. Obviously, you should
    follow universal precautions, and control bleeding, just as with any
    wound. Do not attempt to put the ends back in, although you might have to
    move the limb if there is distal vascular compromise (ie if there are no
    pulses beyond the fracture.) If the wound is filthy, irrigate and clean
    it. If you have sterile saline, some saline on the dressing to keep the
    wound moist would be helpful.

    Most of these people will be going into shock, so treat for shock. All of
    them will be going to surgery soon, so please don't give them anything to
    eat or drink.

    See you on the hill!
    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • OEC vs. EMT training
    > Dr. Lamberts,
    >
    > I have a question which involves OEC training as compared
    > to EMT training. If you have time to respond for my personal
    > edification I'd appreciate it.
    >
    > Before I start, let me say I have the greatest confidence in and
    > admiration for my OEC instructors. Their skill and knowledge
    > on the hill is outstanding.
    >
    > Within the past year I've completed both EMT and OEC
    > training back to back. Both courses were outstanding,
    > however, the some of the OEC information was directly
    > contrary to the EMT class.
    >
    > First, OEC taught that all fractures should be reduced to proper
    > anatomical position before splinting. EMT taught splint in the
    > position found unless circulation or neurological function is
    > impaired, then reduce only once, splint and transport asap.
    >
    > Second, in the case of a known diabetic with diabetic emergency
    > symptoms, the victim should be given some form of glucose even
    > if he/she is unconscious. Basic emergency rule, NEVER give
    > anyone who is unconscious anything by mouth.
    >
    > If you could share your professional opinion regarding these two
    > questions, it would be appreciated.
    >
    > Thank-you,
    >
    > Mike W

    >
    Dear Mike,

    Intereseting question.

    Maybe both are right? OEC differs occasionally from EMT in that EMTs can
    generally get their patients to an ER in 20 minutes, while on a hill, we
    are sometimes lucky to get them to the ambulance in an hour, much less 20
    minutes.

    As far as the specific questions, for the fracture I'd splint it the way I
    found it unless there are nerve or pulse deficits distally. The manual
    says to reduce for ease of splinting, so if you can splint without
    reduction, go right ahead. If the leg is at a 90 degree angle, it makes
    sense to put it back into position of function before trying to apply a
    splint.

    The diabetic is a bit tougher. On one hand you don't want to compromise
    the airway, on the other hand you have someone who is losing brain cell
    before your eyes. If you are there to manage the airway and can use
    suction, the worst thing that could happen would be aspiration pneumonia,
    although this would be unlikely in an otherwise healthy person (such as
    found on a ski slope). I don't think a neutral sugar solution would be
    terribly harmful, even if aspirated; some sugar might even be absorbed
    through the airway. I certainly would not use orange juice or milk
    however, either might cause a chemical pneumonitis.

    See you on the hill!

    Doc
    Eric Lamberts MD NSP

    [ Return to Index ]

  • Jams & Pretzels

     > I was wondering if you could tell me what this is. It's a question from our refresher open book study pre-testing material. There's a vague reference to it on page 6 in the WEC manual, any insights? Thanks, Susan [Snow Summit]
    >
    Susan

    Jam and Pretzel refers to how you find your patient--I'm sure you've been
    covering it in your refreshers for years.

    The basic scenario is to find the injured skiier wrapped around a tree
    with their legs and arms jammed against the trunk and bent every which a
    way (pretzel).

    Extrication is covered in the WEC manual page 358. There was also a good
    article a year or two back in Ski Patrol Magazine, unfortunately I loaned
    it to my daughter, and it escaped into the 4th dimension.

    The book covers it pretty well--the basic goal is to align head,
    shoulders, and hips, and then maintain that alignment while extricating
    the patient.

    If you need more info, let me know--I have several friends who are WEC
    gurus.

    See you on the hill! (soon maybe?)

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • After ABC's what? (fainting)
    > The other day I saw a situation where a young lady became unresponsive while
    > in class. It was not long before emergency help arrived, but I was confused
    > about the care to give her since she could not tell me her symptoms.
    >
    > My question is in a situation where the patient is unresponsive and no trama
    > is suspected, what kind of care should the first responder concentrate on?
    > (After checking airway, bleeding, and circulation).
    >
    Stefan,

    Sometimes the hardest thing to do is to do nothing.

    In 99% of the cases you describe, the cause is fainting. The treatment is
    the ABC's, airway, breathing and circulation. If you are a patroller,
    this has probably been pounded into you until it's practically a mantra.

    Fainting, curiously enough, is generally scarier in people with training
    than in those without. It is an over reaction of the vagus nerve--sort of
    an anti adrenaline. If you check the vitals, they will have a pulse of 30
    and a BP of 60. The loss of conciousness comes from not enough blood
    supply to the brain. If you are walking along and faint, your body will
    treat you automatically--no blood to the brain, fall down and you get more
    blood up there.

    Treatment should be the same. If someone is lookinng faint in my office,
    I have them lay down on the table, or if they are in the hall have them
    lay down on the floor. Maintain the airway, if there is vomiting, turn
    them on their side immediately to prevent aspiration. Sometimes there
    will be some mild seizure activity, in which case you have to protect the
    head from injury and maintain the airway.

    Mostly you just have to get their head down and they wake up in a minute.
    Nothing fancy.

    Hope this helps!

    See you on the hill!
    Doc

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • Comments from a pro-patroller

    > I just read the letters on semi-automatic defib, boot removal on femur
    > fractures[boot removal in general] and also on asthmatic skiers. Quite
    > frankly i am dissappointed in the general consensus on most of these issue.
    > Semi-automatic defib is becoming the "standard of care" in the prehospital
    > environment. AHA is requiring it to be taught in BLS Provider courses, and
    > an introduction to it in the Heartsaver course. Yet NSP and OEC will not
    > update their protocols and scope of practice to allow this treatment in
    > their program. The Area I work at asked NSP over 4 years ago what they were
    > doing to address the issue. It is in the scope of practice EMT basics in New
    > Mexico. If OEC is "comparable" to EMT then why is this issue being skirted
    > by OEC and NSP? We trained several of our key people to the level of EMS
    > First Responder, which with D-fib training are authorized to use an AED in
    > NM. Along with the EMT's on the Patrol, we can keep up with the "Standard of
    > Care" in NM.
    >
    > As for boot removal for femur fractures it is our protocol to remove the,
    > assess the distals. Splint and transport. Besides the obvious reason of
    > assessment, as soon as EMS arrives they will remove the boot to assess. Why
    > move the injured leg around twice. Also we are much better at removing ski
    > boots than the Emergency Department at the Hosp.
    >
    > As one of the letters mentioned asthma is on the rise, and I have seen a
    > significant increase in the last few years up on the hill. More and more
    > people are involved in physical outdoor sports, and the increase in the
    > number of known asthmatics that forget their inhalers [MDI's] significant.
    > As for suggesting using epinephrine with out licensure, medical control and
    > the required training i.e. a special skill, is really operating outside OEC's
    > scope of practice. A huge liability. Also to my knowledge with the training
    > i have recieved, [ special skill to administer Albuterol] as an EMT-B
    > Albuterol is the front line drug for acute asthma. Epinepherine is secondary
    > with more risks associated with it.
    >
    > Thank you for the time and space here. I wish that OEC would clearly define
    > its Scope of Practice and clear up under what authority this program
    > operates. I can't seem to get a definitive answer.
    >
    > A very concerned Pro Patrol Dir.
    >

    Pro patrol director (whoever you are)

    Somehow you remind me of other pro patrol directors I know...

    I had to go back and read the posts to which you refered. To
    reiterate--these are NOT consensus opinions. They are mine. My backround
    is that I've been a fanily practitioner for 20 years, a ski patroller for
    maybe eight, and have worked extensively as an ER doc in rural
    Nevada--often the only medical help for hundreds of square miles. I guess
    I'd like to address your concerns seperately.

    The first is the automatic defib. OEC does not cover it. This does not
    mean that you can not buy one and require all your patrollers to be
    qualified. I work at Sky Tavern, a very small all volunteer pro
    patrolled area in Reno. We taught the use of the auto defib at our last
    OEC class--taught at the home of one of the NSP board members, btw. YOU
    are the director of your hill. YOU should decide what the standards are.
    Our patrol has not seen a cardiac arrest in over fifty (yup, fifty) years
    of operation. Do we have an automatic defibrillator? No. I wish one
    was in the budget in case some one does over the next fifty, but alas, my
    opinion has not been sought out. Probably more cost effective, however to
    spend the money in different ways.

    Regarding boot removal. If you can get it off, get the patient off the
    hill without hypothermia complicating their shock, go for it. Distals can
    be assesed with the boot on. If you suspect an ankle fracture, you would
    be hard pressed to find a better splint than a boot. If you reread my
    post, I do recommend boot removal, but would prefer to do it in the warmth
    and safety of the patrol room, especially if messing around with it on the
    hill would further compromise the patient's well being. A typical lower
    extremity/knee injury should be splinted and loaded in less than 2 minutes
    after togoggan arrival. Leaving a patient laying in the snow in the harsh
    winter enviornment longer than necessary is inconcionable, in my opinion.
    Again, this is not written on stone tablets--as the director, the buck
    stops there. If you want the boot removed on the hill, let your
    patrollers know. You direct your hill, not the government, NSP, or Eric
    Lamberts. My personal preference is to do a rapid but complete
    assessment, do the minimal stablilzation and get them the heck off the
    mountain where the niceties can be addressed.

    Asthma is a subject that is close to home, as my son has it. If you will
    reread my post, I recommended O2, transport, and assisting the patient
    with the use of his or her inhaler. I most emphatically did NOT recommend
    the use of epinephrine unless you are trained and certified in its use--I
    believe I recommended it for MDs and EMTs with a lot of malpractice
    insurance. Alberterol IS recommended in the first line treatment of
    asthma. The problem is that in severe astmatics (the guys who die on you)
    they have already been taking two or more puffs an hour and their airways
    are so closed down that you can't get anything in there. In these
    people, epinephrine can buy you (me) time. I am very upset that you read
    my post as recommnding it "without lisensure, etc..". I most certainly
    did not, and stand by my original post.

    I am a member of NSP, and share with you some frustrations. Although I am
    an MD, my function on the Ski Patrol is that of a grunt sled runner. My
    director asks and values my opinions, but the final decisions on our
    maoutain are his. I see NSP as a trainer and certifier of basic
    competancy. If you want your patrollers able to do AMD, sled CPR, or
    fancy techniques for lift evac using jumars and cable slides etc it is our
    responsability.

    Your letter was the most thought provking in a long, long time. I hope
    thing settle out in your area. For furthur input on NSP, I am cc'ing a
    copy of this whole mess to Ray Bryant, NSP guy (You should see his car!)
    for further comment.

    See you on the hill!
    Doc

    Eric Lamberts MD NSP

    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • CPR on the mountail

     > Saw the thread for "CPR in a Toboggan".
    > My 2¢:
    > 1. Functional CPR (according to AHA, etc. standards) MUST be performed
    > while the patient is exactly horizontally level; toboggans on mountains
    > are not.
    > 2. The goal of CPR is to transfer as RAPIDLY as possible to Advanced
    > Life Support, ie.: early defribrilation and early theraputic
    > intervention.
    > 3. CPR, etc. success on cardiac arrest from a "trauma code/arrest" is
    > virtually unknown.
    >
    > It would then follow for a non-trauma arrest that there are two
    > alternatives:
    > A. patient should be leveled according to terrain: Ie. adjusted on a
    > long backboard, even as far as being partially loaded over the (single)
    > toboggan (cascade type) handles, etc. to maintain the level. Required
    > precise CPR may be virtually impossible because of the inability
    > produced by motion over unsmooth terrain; and, the compromised
    > 'straddle' position of the compressor. This method will in most
    > probability be very slow in transferring the patient towards ALS/early
    > defibrilation.
    > B. Rapid transport towards ALS - in stages. Although traditional CPR
    > recommends discontinuance for upwards of 15 seconds maximum for
    > movement and ALS intervention, it would seem prudent to perform CPR (in
    > a level position) for several minutes while hyperventilating the
    > patient, then rapidly moving to a prepared second stage location
    > (level/parallel to the fall-line) for upwards of one minute, resume CPR
    > for 1-2 minutes, while hyperventilating,etc. Then sequential movement to
    > subsequent stage areas. The goal should be to move the early
    > defibrilation/ALS and the patient **simultaneously** and rapidly towards
    > each other.
    >
    > The literature indicates that the probable upper time limit of reversal
    > of VFib/VT by defibrilation,etc. is 15 minutes from onset of arrest.
    >
    > Thankfully, CPR on a mountain is extremely rare.
    > My background: 20+ yrs.field paramedic/instructoro, 30 yr. ski patroller
    >

    Richard,

    Interesting post.

    The points you raise are valid in an ideal environment. Unfortunately a
    ski hill does not qualify. The key to recussitation, as you point out, is
    defibrillation and early intervention.

    The caveat to our patients, then is not to have a cardiac arest on a ski
    hill, and if you do, choose one of the rare hills that have portable
    defibrillators and the means to get it to you quickly. On most of the
    hills I've been on this is almost impossible. Even if there were a
    defibrillator on the hill, the scenario would go like this:

    A guy keels over while skiing. His buddy or a passing skier stops and
    asks if he's alright. No response. If he's lucky, maybe the first
    responder knows CPR. If so, it is started, and the next skiier along is
    sent for ski patrol. He reaches the lift in 1.5 min and tells the liftie
    that there is a guy doing CPR on Red Dog run, probably in a non
    horizontal position at that. Assuming the lifie calls it
    in correctly, the patroller makes it on scene with toboggan, O2,
    defibrillator and another patroller in maybe 3 minutes, defibrillates the
    guy and has him at the bottom of the hill where EMS is waiting in maybe
    six minutes.

    More likely the first responder does not know CPR, nor does he know how to
    ski, nor does he know what run he's on, and when he reports it to the
    liftie, the liftie spends a good minute chair loading and turning down his
    ska' on the boom box, before calling it into the ski patrol who send a
    patroller down to ckeck things out, although he's on the wrong run so
    another patroller is sent down finally finding the patient and calling for
    O2 and defibrillator and EMS on a guy who is already cold. This on the
    hill with the defibrillator.

    What about my hill? Like 99% of hills, we have no defibrillator. If you
    keel over on MY hill, you better hope we can get your ass to the bottom of
    the hill and have EMS waiting in a short time, or you are certainly dead,
    dead, dead.

    At this point it might be a good idea to remember where the protocols come
    from. American Heart, and Red Cross developed their protocols from people
    in the field trying various things, and then analyzing survival data. In
    the days of informed consent, these studies are increasingly difficult to
    do, btw. Most were not done on ski hills. The point is that we are not
    sure what happens when CPR is done in a sled. The point of CPR, however
    is to maintain blood flow to the heart and the brain. Logically, CPR done
    with the head down should supply both.

    So in answer to your question, and this from a guy who skis a lot, is 49
    years old with a grandfather who died of an MI at 45--- get me to a
    defibrillator ASAP. Don't put me on the handles, don't stop to level the
    sled, start CPR as soon as possible, and continue it in the sled for the
    2-3 minutes it takes to get me to the bottom of the hill where the
    paramedics will be (hopefully waiting with defibrillator, ET tube, O2, and
    IV meds... There are special sleds made for CPR, but to my mind, it is
    better to have patrollers trained in how to do CPR in whatever is
    available.

    So. I guess the answer to your question is that we should all have
    implanted automatic defibrillators. Until that happens, however, we are
    stuck with the imperfect alternative.

    Thanks for your thoughtful question--best I've had this year!

    See you on the hill!

    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • 10 most common injuries/conditions

     > Dr. Lambert,
    > I am a former ski patroller, now in graduate school to become a Nurse
    > Practitioner and am doing a project on Ski Area injuries. What are the
    > 10 most common injuries/medical conditions seen? Do on the hill Medical
    > Clinics Save lives and reduce injuries and medical problems?
    >
    > Thank you, Mary Beth

    Did you know that 87.3% of statistics are made up on the spot?

    That being said, the most common injuries are knees and thumbs, at least
    among skiers. Most common knee injury is a MCL sprain. Same in the
    thumb, at the MP joint. The other 8, I'm not sure of; Colles fractures
    are quite common, as are lacerations from ski edges. I review all the
    accident reports at our area, and I'd say the most common injury is knees,
    and more knees.

    Medical conditions--almost certainly hypothermia, mostly mild, but
    occasionally more severe. An interesting observation is that the number
    of knees needing transport soars on a really cold and windy day. Asthma
    would be number two, and then maybe altitude sickness, although again
    mild, and of course, depending on the elevation of your area. We also see
    a diabetic or cardiac once in a blue moon.

    On the hill medical clinics probably save lives at remote areas. If
    conventional EMS/paramedics are available, I'd suspect that the clinics
    are expensive conveniences. In life threatening trauma, the goal is to
    fluid recusitate and get to a trauma center ASAP. In this regard, on the
    hill medical clinics could contribute to an adverse outcome, at least if
    you consider dying an adverse outcome.

    As far as the scientific statistics, a MEDLINE search should turn up at
    least some data.

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • Hare splint length

     On Wed, 30 Sep 1998, Guy
     Lombardo wrote:
    > Dear Dr.
    > I have just found and read your page-enjoyed it very much but I'm
    > confused on one point. In the length of the hare is was mention that
    > the OEC book calls for the splint to be extended to max.-I can not find
    > it as such-I have always extented it to about 12 inches beyond the good
    > leg. this is also noted chapter 8 page 164 of the second edition.
    > Where can I find the instructions to extent the splint to it longest
    > length?

    Guy

    You've been doing it right. I'm not sure where it said to extend the
    splint all the way, but there is no need--it would just make things more
    cumbersome and less stable for a smaller patient.

    Of course, if the splint were stuck and you were forced to use it fully
    extended, it would still work--the key is the traction. It would just be
    a lot more unwieldy.

    See you on the hill !

    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • Compiling injury statistics
    > I am a Sports Medicine Fellow interested in researching injuries in
    > snowboarding. I located your names and addresses from the National Ski
    > Patrol Web Sites. I am hoping that you could get me started or point me in
    > the right direction. Specifically, I am interested in gathering statistics
    > on injuries to the upper limbs, along with statistics on the use of
    > protective gear. How does the National Ski Patrol go about gathering its
    > data. Do they gather specific data on types of wrist/forearm/elbow/upper
    > arm fractures and if wrist guards were worn at the time of injury? Is so,
    > is there a way to access this data? If not, is there a preferred method to
    > begin collecting it? Your help is greatly appreciated.
    >
    > Thank,
    >
    > Timothy P. Manson

    Timothy,

    I don't think that NSP has a data base for injuries. It is more
    concerned with the training and certification of ski patrollers--kinda
    like the American College of Surgeons, or whatever.

    The best way to do a retrospective study would be to ask a ski area to be
    able to review accident reports. One is filled out on each injury
    reported to the ski patrol. Accident reports generally supply most of the
    data you need.

    Some patrols are already compiling data. In the Sierra, I think the
    patrol director at Homewood (a relatively undiscovered gem, btw) might be
    able to help you.

    I'm going to forward a copy to Ray Bryant, who may be able to help you
    with a name or email address, also Norm Bookstein, webmeister
    extraordinaire.

    See you on the hill!

    Eric Lamberts MD NSP
    ewl@med.unr.edu

    [ Return to Index ]

  • CPR on the hill (leap frogging}

     On Wed, 14 Oct 1998, wbsimms wrote:

    > We have a method to use CPR on the hill called leap frogging, if your
    > readers are interested.
    > We set up a relay to our LZ, 1 minute of CPR, 30 seconds of travel, we have
    > found it to be very effective. We do not need to alter any sleds or have
    > patrollers ride along in the sled. All staged from the point of the accident
    > to the LZ extremely fast.
    > Bill Simms
    > wbsimms@micron.com
    See you on the hill!
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu Reno, NV

    [ Return to Index ]

  • Tongue tied.

    > Hi! I really need to know how to treat somebody whose gotten their
    > tongue stuck on a frozen pole. THIS IS NOT A JOKE! Do you pour warm
    > water over the frozen area, or just tell them to tug, or what? If you
    > could e-mail me with your reply a.s.a.p, my address is > Thank you!
    >

    Gee, this one was never covered in the Ski Patrol Manual. Interesting,
    because it does cover Gila Monster bites, not generally a huge problem on
    a ski hill.

    Anyhow, if you pull the tongue away, you'll be (maybe) minus a few taste
    buds. Running warm water would be the most humane, alhough is not
    generally available at short notice. Everyone seems to affect a complete
    recovery.

    The best thing is to avoid doing this, even if someone triple or (gasp)
    quadruple dog dares you...

    I hope this makes it in time for you to get unstuck!

    See you on the hill.
    Doc
    Eric Lamberts MD NSP
    ewl@med.unr.edu, Reno, Nevada USA

    [ Return to Index ]

Archives:

  • Hare Splint protocol, boot removal protocol.

    
> Hello,
> I've just finished my second year as a patroller and really enjoy it.
> Great group of people and a nice ski area...
> 
> My wife and I have had EMT-A level training and are on the medical
> first responder team with our township fire department.  In fact,
> I joined the ski patrol initially as a way to practice my emergency
> medical care skills, and discovered that I really enjoy skiing too.
> 
> Several of us have wondered about the OEC (WEC) protocol for applying
> the hare splint.  In the EMT class, we were taught to first remove the
> shoe and pant leg, extend the frame to the _estimated position_, and
> proceed.  In the OEC, we've been taught to fully extend the frame
> (regardless of the patient's leg length) and NOT to remove the boot.
> The consensus is that the boot would be left on to keep the foot warm.
> Yet, in our township, we've had mid-shaft femor fractures sustained
> with snowmobile injuries.  When the EMT-P's arrived, the boot was
> removed from the foot of the injured leg - then the ankle cuff was
> applied, etc.
> 
> Can you help me with the issue of boot removal with respect leg and
> ankle fractures?  Are there specific guidelines when the boot should
> or should not come off - automatically?  At this point, I'm inclined
> to leave boots on unless the patient complains of numbness, loss of
> sensation, is unable to move toes, or exhibits some other sign/symptom
> which indicates that the circulation to the foot has been compromised.
> Please help.  Sincerely
> 
> 
Dear Roger,

I think you already know the answer to this one.  You kind of have to
think about why you're applying the splint.  If the goal is to pass a
test, then the correct answer is whatever the instructor says it is.

If someone has a midshaft femoral fracture the goal is to stabilize the
fracture, relieve pain, and prevent further injury.  All the above can be
done with the boot on or off.  Many traction harnesses are not designed to
fit over boots, and you'll be forced to remove the boot.  Having the foot
exposed does have the plus that you can monitor pedal pulses, although
there is a popliteal pulse that is as easily monitored.  The down side is
that the straps somewhat uncomfortable,  and people can get real cold real
fast.  As far as using the splint fully extended, this is wrong.  By
having a foot or two of splint below the foot, the splint would become
prone to jarring and destabilizing  a serious fracture.  BTW, the is
exactly what is recomended in the OEC manual.

Last is a plea to do whatever it is you're going to do rapidly.  People
with femoral fractures go bad incredibly fast.  They get cold and go into
shock, both from the trauma as well as from blood loss--Two units of
blood lost is not uncommon.  These people need to get off the hill and
someplace where their shock can be treated.  At our area a femur is an
automatic helicopter ride.

Anyhow, it sounds like you've got things well in hand.  I hope this was
helpful.

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • Lessening the risk of injury.

    
> I am a new skier.  I am worried about getting hurt.  Where can I get info on 
> safety procedures or anything else that could lessen the risk or injury?  
> Anything from stretching, strength exercising, equipment, procedures on the 
> slopes, what to do if you think you are hurt, how to fall, etc.
> 
> The resorts never have stuff like this (of course).  How do you find it?
> 
> Thanks
> 
Beth,

Sorry it took me a bit to get back to you.

Safety for beginners, hmm?  Probably the most important things you can do 
are to learn how to ski, and never lie to a ski tech.   Sometimes folks 
are embarrased to admit that they are beginners, and end up with skis 
that are too long with bindings set too tight. The other thing is that  
skiiers just starting out are more prone to leg injuries because they 
can't control their speed and have a tendency to sit back.  Lessons 
really help (stay away from the signifigant other,  mostly these guys are 
great for a lot of things, but make rotten ski instructors--This is a 
great way to destroy an otherwise great relationship, btw)  Practice 
falling on your side, the most dangerous falls are the ones where you 
gain speed, sit back and end up over your skiis.  Even though you might 
be jazzed, take a break when exhaustion starts to set in.

The other thing is to check out your public library.  They almost always 
have a bunch of books on skiing.  Take out a half a dozen of them, and 
skim thru.  My favorite (and I have a collection) is "Breakthrough on Skis"
by Lito Tejedas Flores.  The clearest explanation of what skis can do and 
how to make them do it that I've ever read.

I guess the last thing, and maybe the most important, is to relax and have 
fun.  Skiing has a reputation as being a daredevil sport, when in reality 
the stats prove it remarkably safe.  I don't have the numbers right in 
front of me, but the chances of serious injury are remarkably small.  
Skiing is safer than bicycling, horseback riding, football, and many 
other sports that are not considered particularly dangerous.  So have 
fun, OK?
See you on the hill,
Doc
Eric Lamberts MD, NSP

    • [Return to index.] 
  • Dangers of tree skiing.

    
> I am writing a report about some of the 
> dangers of tree skiing and what precautions resorts can improve on in 
> these ski areas. I was wondering if you can give me some info. I have 
> contacted several resorts and have only received info from Killington. If 
> you can answer some questions I would appreciate it. 
>
Luis. 

My area of expetise is medical, although I am a ski patroller as well.  
My general impression of tree skiing is that by and large, it's pretty 
safe.You'd expect that a lot of the accidents would occur with people 
hitting trees.  This does happen, but mostly in skiers traveling a a high 
speed on a groomed run, losing control and getting creamed by a tree.  
This is a common cause of death around here and Heavenly, a ski area with 
immaculate grooming and a preponderance of people who can't ski, has lost 
2 or 3 skiers a year this way.  Trees seem to be safer in that they force 
you to make turns, and turns control speed.  Less kinetic energy to be 
absorbed by skulls, backs, aortas.

Interestingly, the most common cause of death in tree skiing is asphyxia. 
and the guys who seem to die the most often are snowboarders.  What 
happens is that ther will be a huge powder dump, and after things get 
tracked up a bit, people head for the trees.  This is pretty much 
'boarder paradise.  Unfortunately, they sometimes go off by themselves.  
They get too near a tree well and get a little forward on the board, 
digging the tip in, catapaulting end over end, landing headfirst in 3-4 
feet of powder. They get disoriented, panic, cannot extricate themselves, 
and drown.  The real expert on this is the patrol director a Homewood, a 
medium sized area who is doing research on this.  I'd give you his 
address, but our email roster is temporaraily down.

So how should management make tree skiing safer?  Mostly what has been 
going on out here after two back to back snow years, has been a lot of 
education.  IE, don't tree ski alone, especially after a big dump, if you 
do fall,stay calm, spit to figure out which way is up, etc.

Hope this is helpful. If you have any other questions, let me know, I'll 
do my best.

Eric Lamberts MD NSP

    • [Return to index.] 
  • OEC way vs ? way.

    
> Dear Eric,
> 
> Thank you very much for your insightful reply.  I have shared your
> thoughts with others on our patrol.  No doubt more (useful) discussion
> will follow.  May I ask you to reply to the second question I asked
> earlier, which is also of significant importance to me... (I was going
> to say on the hill and in our township.)  But I don't want to draw a
> distinction between the emergency care for a medical or trauma
> emergency at Spirit Mountain, and that which I would provide to someone
> in their living room or on a snowmobile trail in our township.  The
> "care" is essentially the same - with considerations for the
> surroundings and the materials we have at hand.  In other words my job
> (on the hill or off) is to assess, maintain the airway, treat life
> threatening conditions, control bleeding, treat for shock, splint,
> etc.  I'm going to treat a femoral fracture, head injury, or cardiac
> arrest in the same way at Spirit Mountain as I would in our township.
> A diabetic reaction (coma or insulin shock) does not somehow behave
> differently in the restaurant at Spirit Mountain than it would in the
> dining room of a residence in our township.  What I'm getting at Eric,
> is that I hear occasionally "the "WEC" way" being presented with
> passion in contrast to any other _pre-hospital_ protocol.  Why focus on
> and exaggerate distinctions (if there are any?)  Why not focus on and
> compliment the similarities?  Truly, it's not my intention to make this
> political.  Please forgive me for the digression.  Could you please
> offer your (emergency care) thoughts on the following question?  Thank
> you very much.  

Roger,  I guess I need to read between the lines a bit here.  It sounds
like there must be some conflict between the OEC and EMT folks back where
you live.  I  have not experience that here.  I agree that there should
be pretty much the same standard of care no matter whom we are taking care
of.  I guess I should point out that although I have worked in bunches of
ERs (in rural Nevada you are often the only doc for thousands of square
miles) and I took an EMT course as a medical student, I have never taken
the OEC course.  The bottom line is that we take good care of our
patients. 

Can you help me with the issue of boot removal in general with >
respect > to leg and ankle fractures?  Are there specific guidelines >
when the boot > should or should not come off - categorically?  At this >
point, I'm > inclined to leave boots on unless the patient complains of >
numbness, > loss of sensation, is unable to move toes, or exhibits some >
other > sign/symptom which indicates that the circulation to the foot >
has been > compromised.  Please help.  Sincerely, Roger Petry.  >
 > PS.  I'm sending a copy of my note along to another interested member
of > our patrol team.  >

Sorry about not answering this one...I didn't realize this wwas a two part
question.  My tendency is to leave the boot on until I have my patient in
the warm  First Aid room. (You've probably figured out my main thrust is
rapid assessment, stabilzation, then sled.) Then the boot comes off, the
socks come off and the leg is exposed for inspection.  The advantage is
that you can see what you're dealing with,  you don't get any big
surprises down the road, and you can ice the injured part.  Cardboard
splints are also easier to apply without a boot on.  I might remove the
boot on the hill under the circumstances you mentioned, but probably not
even then.  You can get a decent dorsalis pedis pulse if you have to by
opening the boot and sticking your hand in.

As far as when not to remove a boot...  I guess if you have an unstable
compound fracture and removing the boot would cause more damage.  The
only other time I can think of is when you have a probable sprained ankle
and will have to walk a ways out on it.  If you take the boot off the
ankle often baloons to the point where it iis impossible to get the boot
back on.

I hope this has been of some help.  May you dance on snow.

Doc

Eric Lamberts MD NSP

    • [Return to index.] 
  • Ski Patrol Physicians?

    
> I am not sure if this is the appropriate spot to be posting these questions,
> but I am hoping that I can find some answers here.  First, I am an EMT-D in
> New York.  I love skiing and would like to know more information about
> where and how to become a member of ski patrol. The other question was, is 
> there an actual ski patrol physician?  If so, what type of medicine did you
> specialize in and where?  I am interested in becoming a physician in 
> emergency medicine, and am looking into other opportunities that are out
> there.  I hope that someone can help me.
> 
> Jennifer
> 
Dear Jennifer,

As I read you, you have two questions.  First is how to join the Ski
Patrol, and second is if there is a role for physicians.

Number one is easy.  You must be a proficient skier, able to ski any run
in any conditons at your chosen mountain,  You must then pass the OEC
course.  So pick your favorite mountain, ask to speak to the patrol
director and tell him (her) that you'd like to join.  Be sure to mention
the EMT.  Usually you can challenge the OEC thing--you take a
written exam and generally a practical exam, kind of like doing the EMT
final over again.  You are accepted as a candidate and spend almost every
weekend training, learning how to run a sled and run accidents on a ski
hill. It is a major commitment of time and energy.  In return for the
work, you don't have to pay for your ticket. Most places actively recruit
candidates, and with your EMT, you are likely to be sought after,
especially if you can ski. BTW, OEC=Outdoor Emergency Care.   

As far as physician involvement, MDs are even more sought out than EMTs.
There is no such thing as "ski patrol doctor",  but most patrols welcome
physician advisors.  At least two large ski areas have medical staffing at
the bottom of the hill, Squaw Valley, and Jackson Hole.  Ski town ER's are
also frequently looking for docs to work.

The last is a bit off topic.  Be sure to set some time aside for that road
trip before you rush off to medical school.  Medicine is a gas, but I see
too many docs who rushed through premed, med school, and residency,
without taking time to live a bit, ending up successful and bitter.  Take
your time and enjoy life.

See you on the hill.

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • CPR on a toboggan.

    
>     Could you please advise if anyone has approved  C.P.R. while straddling a
> patient. We have designed an oversized toboggan for the use in doing C.P.R.
>  One patroller is seated at the head of the patient which is up hill, and
> uses a bag mask connected to a oxygen tank. The second patroller straddles
> the patient and does compressions. The sceond patroller is faced up hill as
> to not over compress the chest. Our patrollers have tested the system and it
> does appear to work. The tobboggan is set up with dual chain brakes to assist
> in slowing the extra weight of three persons. 
> 

Dear whoever you are,

I'm not sure if anyone has "approved" toboggan CPR,  but there does have
to be a mechinism for getting full arrest victims off the hill and into
the EMS.

Diamond Peak Ski Patrol has done a lot of work on this in the past and
have a really slick video on CPR in a standard Cascade.  It really is
well done.

I've not heard about using a special sled,  although this sounds
interesting.  One drawback I could envision is not having the proper sled
in the right place.  

If you're interested, you might drop Diamond a line, they are located at
Incline Village NV, at Lake Tahoe.

See you on the hill

Doc

Eric Lamberts MD NSP

    • [Return to index.] 
  • Info on defib?

    
Hi Cliff


We are looking into acquiring a couple of auto defib units. Any info on this 
subject? Will Red Cross certification be OK? Any guidance from our NSP medical 
advisors?

Any info appreciated.

Thanks


Chris,

Cliff Chewning and Dr. Eric Lamberts may be additionally responding to your
inquiry, but I'll give you my information and perspective.

The NSP does not provide any training or certification in the area of auto
defib, and this method of treatment is outside the scope of the standard of
care established by OEC.  This method of treatment would need to be something
that your ski area or local EMS community is imposing upon your patrollers.

As a care technique for the ski environment it has questionable value.
 Unlike the urban care environment, cardiac arrest on the ski hill is almost
always associated with trama, and such an arrest is unlikely to be aided by
defib.  Thus, what is a life saver in the urban EMS setting is of little
value to us.  Also, the equipment cost money and increases the training
burden on the patroller.

John Clair is the Interagency Liason for the NSP, and keeps an eye on these
kinds of developments within the EMS community for the NSP.  He may be able
to advise you on how to deal with this requirement.  John can be contacted by
e-mail at jjc02@health.state.ny.us.

Hope this information helps.

Ray Bryan
Far West Division Assistant Director
National Board Representative



Chris,

How many cardiac arrest patients did you have die at Pajarito Mountain this
past season?  How many in the past 10 years?  How many of these would have
been saved with Automatic External Defibrillation equipment?  Would the
equipment arrive within 4 minutes?

Ray



Dear Cliff,

Although I'm the Ski Patrol Web advice to the lovelorn Doctor, my opinions
are my own, and not necessarily those of the National Ski Patrol.  I have
found Ray's comments quite interesting, and to the point.  It IS true that
cardiac arrests are exceedingly uncommon on the ski hill, and most are due
to trauma and blood loss.  As a forty seven year old weekend warrior
whose grandfather died of an MI at forty five, I sure hope I'm on your
hill when I have the big one.

Your follow up on the deadly aspects of V fib were accurate and one of the
major reasons the earliest step in the CPR algorithm is "Call EMS".  It
is not because they have IV's or O2, but because of the early
defibrillation.  Certainly  one of the idiot proof defibrillators is the
way to go, unless you want to go to medical  or paramedic school.  As far
as what kind of training is involved...I'm not sure if this has been
written into the Red Cross protocols yet.  It sure hasn't made OEC.
I would make the guy who sold the unit supply the training.  I do know
that these are designed to be used by EMT's,  the equivalant of OEC
training.

I guess the last thing was alluded to by Ray Bryan in his second letter.
How many arrests HAVE you had in the last 10 years?  In medicine we often
talk about the cost-benefit ratio.  Will this be something which sits
around the shack, but is never used?  How far away is your EMS?  Would
your time and money be better spent learning sled CPR?  (think I'll send
you a post on this one)  Considering the ratio of trauma to arrest, would
a pair of MAST trousers be a better investment?  Everyone on the patrol
would have to be comfortable with its use; the key is early
deployment---having the thing at the top of the hill would be worthless if
the guy on scene or on bump didn't know how to use it.

I hope it all works out.  See you on the hill.

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • Hearing protection during snow making.

    
>  Frequently our mountain makes snow 24 hours a day for several days at a
> time.  I am concerned about the proper way to protect ears and hearing.  I
> beleive National should address this issue with some recommended ways to
> protect patroller's hearing.  I have mentioned this to Karen Wentworth, Div.
> Oec Advisor and Bill Baxter, Region Director.  Opening the mountain in the
> morning and working accidents under a snow gun is very difficult.  Hearing
> wise, it is a very uncomfortable situation..  Thanks
> 

Dear Rex, 

Sorry it took me a bit to get back to you, but I've been on vacation and
then playing catchup.

I have very little to do with national, policy-wise, although I do pay
them dues...  Since you are patrol director, however, you can certainly
set policy on your mountain.

Your point about the noise of snow making is well taken.  The noise makes 
patient assessment difficult and radio communication well nigh impossible.
It would be nice if your mountain staff could shut off, or allow you to
shut off the guns while you're running an accident.  It looks to me like
it would only be a matter of two valves and maybe 1/2 hour of snowmaking
lost.  You could make it part of your protocol/refresher.  It would
certainly decrease the stress in your patients as well, and reduce the
risk of potentially fatal hypothermia and the automatic resultant suit.
That's how I'd portray it to management anyway.  Seems like mentioning
lawyers often help in getting common sense things accepted. :)

If that isn't possible, cheap earplugs are available at any drugstore
which cut the intensity by quite a lot;  as I recall, around ten
decibels.  Decibels are logrithmic (like the richter scale for you Cal
guys) and a ten dB drop is considerable.  NASA recommends that no one work
in 105 dB for more than 1/2 hour,110 for 15 min, and 115 for 7.5 min
without hearing protection. I expect your guns run at about 100 or so
decibels, so even though they are annoying, they probably are not causing
permanant hearing loss in most of your patrollers.

So.  This hasn't been too medical.  My recommendations are to shut the
dang things off when running an accident, or failing that, cheap ear
protection available in the first aid shack like rubber gloves.

I hope this has been helpful.  Skiied with a couple of your ex patrollers
who made it to the Tahoe basin, BTW.  Sounds like you guys got a pretty
good mountain there.

Ski safe,
Doc
Eric Wm Lamberts MD, NSP

    • [Return to index.] 
  • How to be a member of the ski patrol.

    
> >Dear Norman,
> >     I was recently looking at the NSP web site and had some questions 
> >about the requirements needed to be a member of the ski patrol. I am an 
> >occupational therapy student at University of Texas Medical Branch and 
> >come graduation I will have a lot of knowledge in hand splinting. I was 
> >wondering if you had any need for someone with this experience or if it's 
> >not something you need in NSP. Either way I am interested in seeing what 
> >the time commitment would be in training to become a member and to know 
> >what level of skier is required. I have grown up skiing and feel I 
> >probably have the ability needed, but of course being an obnoxious Texan, 
> >I probably am overestimating my capabilities on the slopes. Whenever you 
> >get a chance I would enjoy hearing from you and learning more about your 
> >organization.  Thank you.
> >



Dear Jill,

I'm not sure if Norman ever got back to you.  If he didn't, I apologize
for the length of time getting back to you, but vacations seem to decrease
my 'net access.

AS an OT, your knowledge would be helpful, particulaly the general anatomy
and physiology.  As far as your expetise in finger splinting...I'm afraid
we're a bit primitive on the hill.  Mostly no specialized splints, no
alumafoam; If it's broken or a boutonniere deformity, it pretty much gets
the popscle stick approach acutely.  

Sort of interesting, but the most common hand injury on the hill is
"skier's thumb aka torn MCL, aka Gamekeeper's thumb.  Most of these people
are never seen by the patrol and ski off after their injury.

As far as joining the patrol...Your major problem in Texas is lack of
snow. I remember a whole herd (?) of Texans who showed up on a local hill
with hats reading, "If God had wanted Texans to ski, he would have made
Bull Sh*t white." Most were great skiiers, and overjoyed to be doing it.

Seriously, in order to be a Ski Patroller you have to have a hill to work
on. If you have a hill you really like, go up to first aide and ask to
talk to the director.  They almost always are looking for people with
strong skiing skills who aren't afraid to work.  A medical backround is
icing on the cake.  They will take you on as a candidate.  What this
involves is passing the Outdoor Emergency Care class, the equivalent of an
EMT.  These are generally given in the fall or summer, and are oriented to
winter first aid, but also cover such esoterica as childbirth and Jila
monster bites.

When snow finally falls, you are expected to be on the hill every weekend
for training.  This involves skiing skills--you are expected to be able to
handle any run in any condition at your area, and most places actually
expect you to look good when you do it!  You also do practical first aid,
with scenarios on the hill, and learn to handle toboggans with blubbery
patients on steep inclines.  Most become active patrollers by the end of
the first season, although a high percentage have to spend another year
working on their deficits.  Some of us end up being candidates for four or
five years.
 
Did I mention the willing to work part.  You do have to work, and you have
to be at the hill by 8 am, 7 am in some places.  It is fun and fulfilling,
however, and you never have to pay for a lift ticket while you're working.

I hope this is helpful, if you need any more information, pleas let me
know.

See you on the hill...

Doc
Eric Wm Lamberts MD NSP

    • [Return to index.] 
  • Helmets?

    
Janet
I'm  a physician and active patroller.  Unfortunately, I'm not a  study
saver.  I know that studies of ski injuries have been done, the  results
are often published in the ski magazines.  There is a large on-going study
 being done in New Hampshire, also this kind of study is often reported
in The Physican and Sports Medicine.  You also might check  with the
Steadman Clinic in Colorado, an orthopedic group specializing in  world
class skier's knees, who are also likely to have some studies going.  
Lastly, if you called some of the ski helmet companies, I'm sure they would
 supply you with abundant stats, albeit somewhat biased, on how wonderful
 helmets are.  Over the last couple of years no one in the youth ski
races has been able to start with out one.  Good luck
 Eric Lamberts M.D.

    • [Return to index.] 
  • About catastrophic ski injury.

    
> Dear Doc, 
> 	I am a student at the University of Nevada, Reno doing an article for 
> a journalism class on catastrophic ski injury.  I am looking 
> specifically for information related to a profile which was recently 
> developed of the typical skier likely to suffer from a catastrophic 
> ski injury, that is resulting in death or paralysis. 
> 	If you have any information at all regarding this subject, I would
> greatly appreciate your assistance.  Perhaps we could arrange a time 
> for an interview at your convenience. 
> 	Please feel free to e-mail me any information you may have, or call 
> me at your convenience, and I can arrange to pick it up, sine you to 
> are at UNR, I see. 
> 	Thank you in advance for your assistance 

> 
Dear Kendra,

My backround is medicine and ski patrollling.  I'm aware of the study
you're talking about; the results came out sometime in the last two years
or so.  I don't remember who did the study, but will send a cc to Norman
Bookstein, webmaster and font of ski info.

The profile is not surprising,  classic testosterone poisoning.  The
"average" catastrophic ski injury is a young male risk taker.  The ages I
recall were men and boys in their teens and twenties who were doing things
they probably shouldn't have been doing.  Thinking back over recent
accidents in the Sierra,  most fit the "Heavenly" profile-- young guys
going at warp speed down a groomed trail and hitting a tree.  The other
common accident is the snowboarder alone in the trees who catches the
front of his board in deep powder, does an end over end and dies of
asphyxia head down in a tree well.  This winter a bunch of guys went out
of bounds at Donner and avalanched.  The famous "avalanche chutes" at Mt
Rose were closed legally by the county after a bunch of teenagers were
killed skiing there after a two foot dump in 1972.

Obviously, when your number's up, demographics don't count for much.
Season before last, two girls were killed, a 14 year old at Rose, and a 9
year old at Diamond Peak. Both gained speed on beginner/intermediate
trails and were essentially dead when they hit the trees.

I hope this is helpfull.  Further information on "official" study results
would be available at the library--check the Readers Guide to Periodical
Literature for dates of specific articles in ski magazines.  If you have
any other questions, drop me an e-mail or give me a buzz at home between
6-7am or evenings, 786-6462.

Doc
Eric Wm Lamberts MD NSP

    • [Return to index.] 
  • Stress levels in patrollers with life & death accidents.

    
> Hi:
> 
> I am interested in learning of (a) Any programs related to
> investigating stress levels in patrollers who deal with
> life and death accidents (life threatening injuries,
> avalanche victims, etc.) and who also carry out avalanche
> control work in situations that endanger their own lives;
> and (b) Any stress management programs for patrollers in 
> such situations.
> 
> Any info is much appreciated
> 

Dear Sandy,

I'm unaware of any formal programs.  Most of the poeple who do avalanche
control seem to enjoy it and get a bit of an adrenaline rush.  It has the
balance between intellect, physical exertion, and blowing up things the
many, men especially, seem to enjoy. After a while it becomes routine,
although not boring.

A couple of years ago there was a segment in the fall refresher entitled
"death on the hill" and how to handle it.  The thrust was on how to make
it through the day and ended with the proviso that patrollers might need
to seek some professional help in dealing with their feelings.

I do know that two local areas had children hit trees at high
speed and die of catastrophic head injuries.  In both instances, I'm not
aware of any professional mental health people being called in.  In both
cases however, the rest of the patrol rallied around the patrollers
involved in running the accident and provided a lot of emotional support.
Actually, this seems to happen with almost any serious or scary situation.
Mostly there is a semiformal debriefing with all the patrollers present,
and in the days and weeks that follow there is a lot of convesation one
on one or in small groups about the incident.  It reminds me in a way of
firemen who have great esprit de corps/comraderie, and take care of their
own.

I am forwarding this to the webmaster of the NSP home page, and to Ray
Bryan who is much more aware of what is going on at National than I am.

    • [Return to index.] 
  • Safe bindings?

    
DOC, I need some help PLEASE!!!  I need any information you can give me on
alpine skiing binding not releasing in a twist motion with the right leg
twisting inward causing a right mid-shaft femur fracture, both comminuted and
spiral with large butterfly piece, also a compression fracture of the spine,
T-12, L-1 with disc damage, also right knee damage.  The bindings were Look
Integral and rented.  My son felt the pain and heard the crack, like a huge
tree braking, while he was standing with his right ski tip under the left ski
causing the right leg to twist 90' , he then fell on his buttox causing the
spinal compression fracture.  All this time the bindings never released.  He
was laying with his right leg turned all the way behind him,90' , with both
skies still on. The DIN setting was 4 on twist and 4 on forward lean with a
release indicater range 2 to 7 (twist) and 2 to 7 (forward).  The bindings
were tested after and worked fine, I was told.  So now you see why I need
someone who knows something about femur fractures due to bindings not
releasing, even if its someone who just has seen a ferur fracture from the
bindings not releasing would be so helpful because I'm being told that ferurs
don't fracture from skiing.


Dear Jamie,
I received your post.  I'd like to mull it over for a day or so.  I'd like
a little more information, as well, if you could.  How old is your son?
How much did he weigh at the time of the accident? What was his skiing
ability?  How fast was he moving? (it sounds as if he were standing
still.)  What is his general health-- he doesn't have any history of
cancer or any metabolic disease, does he?     

This sounds like a disaster.  I'm sorry for your son's pain, and your
obvious distress.  His injuries are out of the ordinary.  I can tell you
that in the accident that you described, there is no binding commercially
available that would have prevented this.  Is he healing and starting to
do better?

Eric Lamberts NSP MD


> Thank you very much for responding.  My son was 13, 5 foot 4 inches, type 2
> skier, 160 pounds, size 10 shoe and large boned (He is currently 17 and about
> 6 foot tall).  The DIN # was set at 4.  My son was coming down an easy hill
> going faster than he wanted to, which is of a medium speed, and swishing to
> the left (ski tips pointing to his left) when his right ski tip caught
> something twisting the right leg inward and under the left ski.  During this
> twisting 90 degress of his right leg, he heard a loud cracking sound and
> severe pain.  He then fell to the ground on his buttox, all the while having
> the skis on due to non release.  He slide a ways, then lay still screaming
> for help with his right leg pointing in the opposite direction, 90 degress,
> with both skis on.  I am an RN that works in the ICU, and realize the kind of
> tortional force that had to be there to cause a severly comminuted, spiral
> (with large butterfly piece), mid-shaft, femoral fracture.  To me a binding
> with a DIN setting of 4 should have released, in this twisting motion, before
> the tortional force escalated to the point of scattering his femur.  What do
> you think?????  My son is doing pretty good considering he is in pain every
> day still.  He will probably need to have a spinal fusion some day, the
> doctors want to wait as long as possible.  His right knee still hurts and
> klicks. Also I heard that the Rossignol brand of bindings are a mixture of
> Look and Geze with Rossignol basically garage saling the failing companies.
>  Is this true as you know it?  Were the Look Integral bindings out of date in
> 1993 when my son rented the equipment?  I realize there are alot of
> questions, but my brother was on the National Ski Patrol and I know your a
> great bunch of people, and I know if anyone could help me guys could.  By the
> way my brother insists that the bindings malfunctioned causing my sons
> extensive injuries.  THANK YOU SO MUCH!!!!!! 
> 

Dear Jamie,
Sorry it took a day or so, but I needed to think over the information you
sent.  My backround is medicine and skiing--I'm a family practioner and
ski patroller, having done both for a long time.  I'm not a ski binding
engineer or an orthpedist, so my comments are based only on what I know.
I will also forward your letters and my reply to a couple of other
patrollers with vast experience.  One of them works at a hill where they
use Look integras.

My first observation is that your son's accident was certainly a disaster.
Unfortunately, I don't think that there is too much more that could have
been done to prevent it.  Releasable binding got started in the 50's and
60's.  Before that we literally tied our feet to the skis and if we fell
they often twisted our legs off.  The most common fracture was just above
the top of the boot.  Modern bindings have made this almost unheard of.
Bindings are not perfect however,  and there is no binding commercially
available that can protect knees. I have heard of a computerized binding
in the R&D stages,  but the way things stand now there is no protection
for knees.

Sprained knees are by far the most common accident we see as patrollers.
Sprains of certain ligaments are probably more serious than the old boot
top fractures of yesteryear.  The real weak point of modern bindings is a
fall during which the skiier sits back over his skis and catches his
inside edge.  Even though there is tremendous force to the knee, there is
only minimal force at the binding which doesn't release.  The fall your
son took was precisely the one that bindings can't handle.

Why don't they set the bindings to release and protect the knee?  If they
did, skis would be coming off during normal skiing, and prerelease can be
as deadly as no release.  Are Look bindings bad?  Most certainly not.
Even though the various companies would have you believe that theirs are
the best, for general skiing, they all perform about the same.  Look
integras, if I remember right use a standard binding boot interface,  so
that the bindings do not have to be custom set for variations in size of
boot. This is a big plus; there is no chance for human error, and there is
no chance that a boot binding mismatch can occur. (This was actually
pretty common in the past, a boot would be of a totally different shape
than the binding, and the binding would not function.)
 
The second thing that I've been thinking about is the extent of your son's
injuries.  Most of the discussion on bindings related to knees, not femurs
and backs.  You mentioned that your son did have a knee injury--Id suspect
an injury to the MCL and ACL, from the description of the fall.  Femoral
fractures DO occur in skiing, but not usually from the accident you
described.  Vertebral compression fractures are very unusual in this age
group and are usually secondary to a fall, (The chute didn't open, or
someone jumped off a roof.)  Assuming he doesn't have bone cancer or
severe osteoporosis,  I can only infer that tremendous forces were
generated--this was not a gentle slow fall. Any fall violent enough to
cause compression fractures in a healthy 13 year old would logically be
violent enough to break a femur as well.

I hope this has been of some help.  It is kind of difficult to Monday
morning quarterback.  I suspect this might help make some sense of this
accident on one hand, but leaves unanswered a central question of
medicine and life.  The question, of course, is why bad things happen to
good people?  Why do babies get leukemia?  Why did this awful thing happen
to your son?  I guess we all have to figure this one out for ourselves.

See you on the hill,

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • Heart rate monitors on the sled.

    
On Mon, 9 Sep 1996, Steve Lovelace wrote:
> We are in Casper, Wyoming.  We have a nice little alpine area run by the
> city and 15 miles of groomed x-c trails groomed by the county - all about
> 20 minutes from downtown.  I am on the nordic end, thus my interest in
> monitors. Once a patient is packaged on a sled, it sure would be nice to
> have a constant heart rate while in transport, something that may take an
> hour or possibly much longer.
> 
> Thanks for the quick reply,
> 
> 
> 

> >.  BTW, where IS Casper Mountain?  It
> >doesn't seem to be listed in any of my books,  most of which consider
> >cable bindings to be state of the art...
> >
> >Eric Lamberts MD NSP
> 
> 

Steve,
I've never heard of anyone using heart rate monitors during transport, but
it sounds like a great idea!  I had two initial reservations-- one was
that at most hills it is not the patrol who is responsable for transport.
It sure makes sense in a nordic, backcountry situation though.

My other concern would be that of losing the monitor.  Things seem to get
lost or eaten in ambulances and ERs.  Again, this would not be a problem
in a backcountry rescue.  You'd disconnect when you turned your patient
over to EMS.

Anyhow, it sure sounds like a winner to me.  I'm going to forward the
thread to the webmaster ("nordic" norm) for his comments and possible
inclusion in the FAQ's.

See you on the hill...

Doc
Eric Lamberts MD NSP




Interesting idea... see the next post.
Eric



My wife recently bought a heart monitor for her running and biking.  It
looks like it would be a heck'uv'a useful thing to have if you had a
critical patient and a long transport time.  Has anyone tried using these
to supplement monitoring heartrate via palpation?

    • [Return to index.] 
  • Automatic defibs on the hill?

    
> Since the ARC is starting to teach professional cpr people about
> automatic defrib's is there any talk about putting them on the hill?
> 
> -- 
> YEA GOD		
> 

Len,

I haven't heard anything much about this.  It would make a lot of sense,
though, as the studies show that CPR doesn't save people, while
defibrillation does.  The last I heard, automatic defibrillators were
running somewhere between two or three thousand dollars.  This would be a
major dent in the budget for our little hill.  For the big mountains you'd
almost have to have one at each peak. Budget aside, probably every patrol
should have one.  They work, and they save lives with a dramatic decrease
in mortality.  Training is minimal and within the capabilties of all (well
most) basic patrollers. (These are my opinons only, and don't necessarily
represent those of the National Ski Patrol.)

See you on the hill. (Soon, I hope)

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • Treatment of asthmatic skiiers.

    
> I am seeking information on the treatment of asthmatic skiers.  
> i.e. the medical management of a skier who experiences an asthma attack
> while on a hill.
> 
> Are you aware of any protocols for Ski-patrol units regarding the above ?
> 
> Thank you in advance for any information that you may be able to provide.
> 


Dear Amber,

The NSP's first aid reference is the Outdoor Emergency Care Manual,
running about 500 plus pages.  OEC has little to say on asthma, and groups
it under "Respiratory Complaints".  Recommendations are to assist the
patient in taking his medication, and if things are bad enough, to treat
it as any other respiratory emergency--administer oxygen, call an
ambulance, and transport off the hill.

Asthma has become much more common over the last 20 years.  The most
common form is excercise or cold induced asthma--both problems on a ski
hill.  These folks are generally treated with inhalers pre excercise, and
often have mild symptoms.  

The majority of astmatics will never be seen by the patrol--mostly they
take care of themselves.

So.  What do we do when we encounter a skier/boarder who is having an
asthma attack?

In most cases, the patient will be able to tell you what is going on--they
live with this daily.  I'm not sure how you help someone take their
medication--but you might suggest that they use their inhaler. Diagnosis
isn't usually too difficult--the patient almost always supplies it.  Many
will have audible wheeze, but don't be fooled--the worst will not wheeze
at all, if you aren't moving air, you sure won't wheeze.   
Hypeventilation/anxiety can look similar.

You need to offer transport--someone in respiratory distress is not likely
to be able to ski themselves off the hill. Vital signs are a big help--If
someone has a respiratory rate of 40 and a pulse of 120, they are much
more likely to need intervention than someone with normal vitals.  Warm
moist air is also helpful--you might have them breathe the air inside
their parka. A drink of water is also helpful--many are dehydrated.

If they are in great distress, start oxygen, get EMS on their way, and get
your patient off the hill.  Most of these guys do better being transported
in a sitting position by the way--they brace their chest muscles on
straight arms.  If you are trained and have epinephrine available, this
can be life saving, and buy you some time.  Probably NOT a good idea
unless you are an MD or paramedic, and have good malpractice insurance!

Full blown attacks on the hill are rare.  In most cases, the maximum that
will have to be done is to transport and maybe give a little O2.

See you an the hill.

Doc
Eric Lamberts MD NSP

    • [Return to index.] 
  • Effectiveness of helmets.  Helmets for ski-wees.

    
> I am interested in finding information on the effectiveness of helmits in
> preventing head injuries.  Any information or advice would be greatly
> appreciated.  
> 
> Thanks,
> 


Dear Gil,

Sorry it took me a while, but I sometimes like to mull these things over
for a few days...

I called Boeri, one of the two major manufacturers of ski helmets.  There
are very few ski specific studies on helmet use.  The work has been done 
in other sports, however, and the upshot is that helmets save lives.  My
personal bias are that ski helmets are especially important in the
following groups:

Racers.  In most places this is non negotiable.  If you want to race, you
must wear a FIS approved helmet.

Extreme.  There are some places where a fall puts you at a high risk for
head injury.  At Squaw Valley there are narrow steep chutes known as the
"horse trails".  In many, the runout leads to VW sized boulders.  A fall
at the top means certain collision with granite.

Small Kids.  These guys often get going too fast for their ability and
rendezvous with trees.  The two catastrophic head injuries I'm the most
familiar with involved kids.  One was a third grader an a beginner run who
kept building speed until she met with a tree.  The other was a 14 year
old on an intermediate run, who likewise kept gaining speed untill she hit
a berm, and was launched into a tree, impacting about 10 feet off the
ground.  Both would have survived had they been wearing helmets.  The
suffering of the families and patrollers involved was immense. I remember
reading an article a couple of years ago stating that kids should wear
helmets for several reasons--thinner skulls, larger heads in proportion to
their bodies than adults, and lack of judgement.
 
Others.  People who have had past severe brain injury.  The guys who like
to tuck at a bizillion miles per hour.  (In the west we lose about 3 a
year to the latter at Heavenly Ski Area alone.  They don't call it
Heavenly for nothing...)  Maybe everyone should wear one.

As far as what style to buy, it pretty much depends on personal
preference.  The ones that cover the back of the neck afford more
protection to the neck, although some of the anti helmet bikers say it
puts you at increased risk for a broken neck.  I think that the increased
protection far outweighs the slight increased risk.  The short helmets are
lighter, not as warm, but many think they are more comfortable.  Any
helmet offers more protection than no helmet.  Be sure they are
comfortable,  which means they are more likely to be worn.

I hope this is of some help.
 
See you on the hill.

Doc
Eric Lamberts MD NSP


> >Does the National Ski Patrol have a position on helmet use for children
> >while skiing?  Also, do you have any information on how many children
> >are injured while skiing each year?
> >Thank you.
> >


Dear Ms O'Donnell,

Here's the forwarded post on helmets.  As far as I know, there is no
official stance by National Ski Patrol on helmet use.

There is also an attachment, an abstract of an article on skiing injuries
in children and adolescents.  Your software should be able to read it with
little problem.  If not, let me know, and I'll figure out some other way
to get it to you. 

I hope this is helpful.
 
Doc

Eric Lamberts MD NSP

---------- Forwarded message ----------
Date: Sun, 24 Nov 1996 16:04:24 -0800 (PST)
From: Eric William Lamberts 
Cc: Norman Bookstein ,
    Eric William Lamberts 
Subject: Re: Helmets for SkiWee's

Dear Gil,

Sorry it took me a while, but I sometimes like to mull these things over
for a few days...

I called Boeri, one of the two major manufacturers of ski helmets.  There
are very few ski specific studies on helmet use.  The work has been done 
in other sports, however, and the upshot is that helmets save lives.  My
personal bias are that ski helmets are especially important in the
following groups:

Racers.  In most places this is non negotiable.  If you want to race, you
must wear a FIS approved helmet.

Extreme.  There are some places where a fall puts you at a high risk for
head injury.  At Squaw Valley there are narrow steep chutes known as the
"horse trails".  In many, the runout leads to VW sized boulders.  A fall
at the top means certain collision with granite.

Small Kids.  These guys often get going too fast for their ability and
rendezvous with trees.  The two catastrophic head injuries I'm the most
familiar with involved kids.  One was a third grader an a beginner run who
kept building speed until she met with a tree.  The other was a 14 year
old on an intermediate run, who likewise kept gaining speed untill she hit
a berm, and was launched into a tree, impacting about 10 feet off the
ground.  Both would have survived had they been wearing helmets.  The
suffering of the families and patrollers involved was immense. I remember
reading an article a couple of years ago stating that kids should wear
helmets for several reasons--thinner skulls, larger heads in proportion to
their bodies than adults, and lack of judgement.
 
Others.  People who have had past severe brain injury.  The guys who like
to tuck at a bizillion miles per hour.  (In the west we lose about 3 a
year to the latter at Heavenly Ski Area alone.  They don't call it
Heavenly for nothing...)  Maybe everyone should wear one.

As far as what style to buy, it pretty much depends on personal
preference.  The ones that cover the back of the neck afford more
protection to the neck, although some of the anti helmet bikers say it
puts you at increased risk for a broken neck.  I think that the increased
protection far outweighs the slight increased risk.  The short helmets are
lighter, not as warm, but many think they are more comfortable.  Any
helmet offers more protection than no helmet.  Be sure they are
comfortable,  which means they are more likely to be worn.

I hope this is of some help.
 
See you on the hill.

Doc
Eric Lamberts MD NSP

Eric Lamberts MD, NSP

© 1996, 1997, 1998, 1999 Eric Lamberts MD, Norman Bookstein