A Physician Examines Head Injuries and Survival Tactics

It is a big deal when death and tragedy happen in a remote place. This is especially
true for “extreme sports.” When tragedy strikes it takes on a certain distant
and removed appeal that seems to attract our attention. A tragic accident, if
removed from our presence but within our realm of experience, piques our curiosity
and we view the event in a way that distorts its reality. Tragedy can be told
as a story if distanced just far enough from personal experience.

An avalanche heads in the direction of 3 climbers on Mt. Everest

As it goes, I happen to like a distanced view of tragedy. I’m the first in
line to see a film or buy a book that recounts stories of adventure/death or
hardship in some distant land. Though I participate in various outdoor experiences
(rock and ice climbing/skiing/snowboarding) I would prefer to maintain a healthy
distance between death and myself. I follow closely by book or Internet as first
ascents are attempted in remote areas of Pakistan or Nepal.

The same is true for my experience with avalanches. If removed just enough
from my personal experience, avalanches fascinate me and I like to read detailed
accounts about avalanches that happen elsewhere (say, in Europe). But on a local
scale, I’m basically in denial. I don’t like to hear about local death. A true
acknowledgment of a death that was secondary to an activity I enjoy, in an environment
where I practice the activity, could force me to believe that I could be a victim
of the very activities I enjoy most. That would be tragic.

So, I tend to ignore local events. And paradoxically (or consequently), local
tragedy usually does not phase me. Perhaps because of the circumstances of my
occupation (I am a physician and help care for victims of trauma), I find that
I can easily gloss over tales of death and injury that happen locally. Around
town, death and injury are often too close to allow for careful exam. I’d rather
remain distanced from such things.

Despite this general quirk in my own nature, I was uncharacteristically stunned
by the death of a young snowboarder in the Wasatch Mountains this past year.
Though not very remote or distant, the Wasatch has become a graveyard of insidious
proportions for avalanche victims. Seven people in all died in avalanche related
accidents this last year. Twenty-seven died over the last seven years. I’ll
grant you that it is not Everest or K2, and the deaths did not happen on the
same day, but people are dying in avalanches in a slow, epic fashion, much as
they do on Everest and K2. The difference is that no one is interested in the
IMAX and it just seems too commonplace to write a book about death in the Wasatch.
Hell, it’s like dying in your car. It is too easy, too common.

Life has become a Mountain Dew commercial: it is boring unless extreme. If
you happen to die, fine, but it is less than ideal if you die in a routine fashion
and worse if it is a local occurrence. If you die in some uninhabitable part
of the globe, at least you get something close to your 15 minutes.

Mountain Dew’s advertising simply capitalizes on current trends in our “extreme”
sports. In case you haven’t noticed, there are some interesting things going
on in our own backyards. People are skiing and riding some “sick” lines. The
extreme has hit home and people are achieving some astounding physical feats.
The days of “jack of all trades” are gone. If you aren’t completely devoted
to one (and you get only one) sport, you begin to look like a half-assed weekend
warrior. In other words, climbing 5.12, WI5, skiing/boarding 3,000 vertical
feet down 50-degree couloir is, in the view of some, adding clutter to the backcountry.
Skiing or boarding at a level not likely to cause death with an error is yawned
at in our current state of mind. If you don’t believe me, rent the latest/greatest
ski/snowboarding video and get a taste of the glory of the extreme. If you are
not going to “Do the Dew,” go home.

Generation Dew would scoff at a line of decent I took on a stormy in Utah day
last November 7th. That was the same day the first avalanche victim died. There
were about sixteen inches of fresh powder on top of a rotten pre-season base.
There were a few exposed rocks, and (as the bottom of my board will attest)
plenty of not-so-exposed rocks. I slogged my way to the top of Alta. Early in
the season it is the only place with sufficient snow to allow descent. (And
it is always nice to pick a line down a slope where snowboards will be banned
in a few weeks).

When I reached the top of High Rustler I tested the snow. With provocation
I saw it slough down the face leaving several exposed rocks. I checked my avalanche
beacon, loosened the straps on my pack, put on my helmet (a move I employ in
avalanche terrain only to receive inquisitive looks/comments like, “dude, what’s
the helmet for?”). I then packed up my board, hiked over the ridge, and dropped
down a less presumptuous chute (where the snow was tracked by previous skiers,
not quite so steep, and seemed considerably more stable).

In today’s extreme view, it was a half-assed descent. It was boring. (Though
I have to admit I have great memories of it.) It was simply safer.

When I arrived home from work the next day my wife had left an article from
the local paper strategically positioned between the door and my cereal bowl.
She knows about my general aversion to local news/events. The newspaper recounted
a story of a kid was killed in an avalanche on Baldy the day before. They were
digging up his body as I sat down for breakfast. His body was found just a ridgeline
down-canyon from my descent.

There were a couple of interesting points about that fateful day. First, there
was not much snow and a clear prediction of danger from the Avalanche Forecast
Center. The body was not buried very deep. There was no ice mask around the
kid’s face. The other members of his party were partially buried by the slide
but were able to free themselves without much difficulty.

I could not stop thinking about the incident. In my mind I ran over my own
descent again and again. Not much snow, lots of rocks. I wondered about his
body. From a medical standpoint, I wondered about his associated injuries. No
snow, lots of rocks, minimal burial depth, no ice mask around the face. To me
it meant one thing: the kid was taken by an avalanche, hit his head on the fall
and was buried. No struggle, no swimming, no air pocket, and no ice mask. A
quick asphyxiation, a bump on the head, that’s all. I was aghast when I saw
the news. No one dies in an avalanche so early in the year. There just isn’t
enough snow. On the other hand, there just wasn’t enough snow to cover any of
those rocks, either.

As I saw the news I wondered whether the kid that died would have seen my line
before he dropped off the other side of Mount Baldy. From the ridgeline, he
could have seen me. It may have seemed odd to him to look across and see a guy
pass up an obvious line, back down to tracked snow, then initiate a slow, deliberate
start with obvious and betraying concern for the surroundings. Then, there was
the obvious problem that betrayed all sense of the extreme: the helmet. I probably
looked just like some jerk that might wake up earlier than you some morning
and steal your line of “freshies” just as you are about to summit – clearly
someone that tracks up the area with mediocre lines wearing a helmet shouldn’t
be allowed on the same slope.

For the next few months, I tried to put the kid’s death in the back of my mind.
But at work I was frequently reminded of a new underlying theme to death and
backcountry skiing. There were two deaths in our ICU that went practically unnoticed
in town. Small obituaries, no news, no book, no IMAX. I was working on the transplant
surgery service, and both kids donated their organs the same week. One was a
skier, the other a snowboarder. Both bonked their heads while doing a sick line
or catching some wicked air. Both were pretty young, pretty extreme. Lots of
tattoos, good livers, kidneys, and hearts.

The donors reminded me of the boy that died in the avalanche on that November
day. In a trauma ICU where I work it becomes painfully obvious how easily a
hit on the head can kill you. And from an avalanche safety standpoint, even
more disturbing is how easily a small head bonk can knock you unconscious.

As the year progressed, more deaths began to accumulate in the Wasatch backcountry
from avalanches. During the same time period, /images of the dead snowboarders
and extreme skiers began to fester in my mind. The two organ donors died of
closed head injuries sustained in their decent. I began to stew about the physics
of avalanches and head trauma in avalanche victims. I festered more when I realized
the assumptions we make about consciousness in our current avalanche survival
tactics.

One assumption implicit in current extreme skiing videos: you can outrun the
slide. Next time you contemplate that first descent you have been dreaming about
think of this: a wet avalanche can reach speeds of 12-60 mph and the average
dry avalanche can go 30-120 mph. Next time you watch your favorite sick ski
video remember that they can edit the film. Remember that most of those guys
aren’t going much faster than 30-40 mph and even though it looks cool to outrun
a slough (a common and bitchin’ scene on video), none of those guys will come
close to 120 mph. Remember this while you watch your video: snow conditions
vary widely from state to state. The cool stuff done in Alaska may not be so
prudent when done in Colorado or Utah because the snow density is different.
Another cool thing about avalanches: they have headwinds that do a fair amount
of destruction before the snow even arrives. If you think you can outrun the
thing like they do on your video, go slog up to the top of the nearest snow-covered
peak on a stormy day to refresh your memory. Another common assumption made
in extreme skiing: we assume we know where the slide will go (down the couloir
along our line of decent would be nice – as opposed to the cliff band just off
to the right). From my observations of current “extreme” skiing practices I
can infer that people are making assumptions about the terrain that may be unwise
(i.e. if this does slide, luckily I am a world class extreme skier and can simply
drop that 100′ cliff in my routine fashion). People get lucky all the time.
Sometimes they are caught on film and become famous. Me? I know from sad experience
that I am simply not that lucky.

Doctors attempt to revive the victim of a Davos avalanche (Reuters Photo/Andy Mettler)

We make another huge assumption in our current avalanche safety practices:
if we fall down in the slide, we will have the mental capacity to attempt escape.
I fear this may be a dangerous assumption. It does not take much to knock you
down, let alone knock you out (Force winds, a wall of snow moving at 120 mph,
or even a large slab that slips out under you could do the trick). We admit
people to the hospital everyday that crash their car, their bike, or trip on
their shoelace and lose consciousness. They have no lacerations or abrasions.
They just get knocked out – maybe only for a few seconds. But in avalanche safety,
this may be a fatal few seconds.

In the event that you attempt to practice a semblance of avalanche safety,
remember: it doesn’t matter if you are only found under a little bit of snow.
You still asphyxiate; you still die. When you hit your head on a rock, you just
don’t know that there is only a little bit of snow on top of you. You just don’t
know that you maybe could have raised an arm, swam to the side of the slide,
or created a small air pocket. When you hit your head you forget to do all of
those things.

Avalanche statistics are grim. Odds are that you will die from asphyxiation
if buried. 60-70% of victims simply run out of air, turn blue and die. For those
victims, it must be a frustrating way to go. Breathing must be labored at first
with intense pressure from the snow compacted around you. Then a slow fade into
oblivion as you lose the ability to extract oxygen from the surrounding snow
because of the ice mask forming in front of your face. Soon you breathe nothing
but your own expired carbon dioxide. And then you die.

Of course, this year we will all go out and buy the latest and greatest. The
Avalung. I am going to be first in line. It is a great idea. The Avalung is
a new device that allows an avalanche victim to increase their surface area
of gas exchange. The concept is simple (but unfortunately, I was too stupid
to think of it). The buried victim keeps a snorkel-like mouthpiece in position
during an avalanche and when the snow settles, voila, she breaths through the
tube which is connected to a fancy vest which allows exhaled air to leave the
victim along the back of the vest, and inhaled air to come from the oxygen rich
snow surrounding the victim. Hopefully, because of heat dissipation, the formation
of an ice mask and failure of gas exchange are obviated because of the large
surface area for gas exchange. In tests people have allowed themselves to be
buried in snow for up to an hour breathing comfortably with the thing. Time
is crucial when it comes to air. Seconds count. An hour is huge.

Here is the scoop on how much seconds count in avalanche survival. A group
of doctors in Europe took the time to figure it out for us. They studied avalanche
burials there. It is easy in Europe. In Europe they are way ahead of the US
on avalanche fatalities. People there have worshiped the extreme for decades.
This, coupled with a wanton disregard for life, has put them way ahead of our
current trend. Combine this with the added bonus of steep Alps, no trees and
lots of avalanches, has made it so that the European Avalanche groups can amass
a lot of data on avalanche victims.

These guys have done detailed studies on asphyxiation of avalanche victims.
A recent review showed significant differences in survival of avalanche victims
depending on the time of burial. In 1992 a review of 332 complete burials by
avalanche in Europe was published.

More then 100 rescue workers search in the snow for victims after an avalanche on the Meierhoftal ski slope in the area of Parsenn near Davos, Switzerland (Reuters Photo/Andy Mettler)

This study found four phases of avalanche burial; first a “Survival phase,”
this phase included victims found within 15 minutes. These victims had a survival
probability of 93%. They found that “almost all those buried survived this period
of the time provided they were not fatally injured and received first aid.”
So, people survived if they were found quickly (under 15 minutes seems to be
important) and also did not have associated injuries. For example, if they did
not hit their head. This is point number one from the European study: if you
can avoid associated trauma and are found quickly, you have a pretty good chance
of walking away from the scene.

The European study made another important distinction. The second phase of
burial was labeled the “Asphyxia phase.” These victims were buried from 15 to
45 minutes and had a dramatic drop in survival rates – to an abysmal 23%. The
Europeans noted that those “buried under the snow without an air pocket died
of acute asphyxia.” Another group identified in the study, those victims
found in the “latent phase” (>45 minutes of burial) had very few survivors.
Uniformly, victims from this group also survived only in the presence of
an air pocket.

This is the second point to be learned from the European data: if you are buried
longer than 15 minutes you will probably suffocate but, if somehow you are able
to wiggle enough, or have the presence of mind to create an air pocket, you
have a slightly better chance of survival. This is key when considering the
new technology and advances potentially offered by the Avalung (if it proves
to work). The Avalung effectively creates a huge air pocket and will hopefully
prevent the formation of any ice mask.

There is an anecdotal report of an avalanche victim in the Utah backcountry
that illustrates both points from the European study. There was a girl riding
a snowmobile (with a helmet) when caught in a slide a few years ago. She was
buried, and the immediate rescuers were clueless. Needless to say, her recovery
was not as slick as some and the down time was extended. When recovered she
was cyanotic; however, she spontaneously awoke and walked from the scene. Rescuers
noted that a) she was wearing a helmet (avoiding associated trauma) and b) the
face shield on the helmet created an effective air pocket in front of her face
likely preventing asphyxia during the time of burial. The girl was clueless
about avalanche safety. None of her party had beacons/shovels and she was in
bad terrain. But she happened to have a face shield which increased her surface
area for gas exchange and they pulled her out “just in time.” She was unconscious
(probably from CO2 retention), but she had available
oxygen from the air pocket and she was breathing spontaneously (which often
does not happen when you get hit on the head). The Avalung and our new beacons
will most certainly help – maybe.

My concern is that for creatures that have supposedly evolved to this point
we are quick to abandon common sense in exchange for new technology. This year
I foresee the following conversation:

“Dude, this thing (the Avalung) rocks. I’ll go down this chute first and
if I’m buried, you dig me out.”

“Dude,” with a tone of concern about the sick line.

“Dude, you can breathe with this thing. Some guy did research and shit.”

The last couple of years have been banner years for avalanche technology. The
new beacons, in theory, as well as in several “research tests and shit” allow
for quicker more precise rescue. In theory, new beacons, as well as the Avalung,
could enhance survival.

But in a slide it is imperative to have your faculties about you. If you can’t
think, you can’t wiggle/swim/ditch gear/make an air pocket or sometimes even
breathe. You have to be able to swim/remove gear/retain your Avalung device
in your mouth. The point is, you can’t afford a second of unconsciousness. Very
few of us use helmets as part of our standard avalanche gear. We all wear them
biking (slower speeds), we all spend hundreds on avalanche gear but may be neglecting
a necessary item.

Victims of a 1938 avalanche are laid out in an Austrian mortuary

All last year as the mortality in the Wasatch increased on a slow, steady basis,
I could not get the /images of the brain dead skiers that donated their organs
out of my mind. I was also unable to rid myself thoughts of that day up at Alta:
no snow, an avalanche, minimal burial, lots of rocks, and a death.

So, I went to the medical examiners office and spent time reviewing case/scene
reports of avalanche victims in Utah over the past seven years. There were twenty-seven
deaths from avalanche. As expected, most had asphyxia listed as the primary
cause of death. Associated trauma was present in the expected numbers – the
medical texts say 30% of avalanche victims will have associated blunt trauma,
and in Utah 28% of victims had associated injuries. Associated trauma in medical
texts is listed as long bone fractures, pelvic fractures, liver/abdominal injuries,
or chest injuries. In medicine, blunt head trauma is often classified as general
blunt trauma. But from a mechanistic and avalanche safety standpoint, a distinction
needs to be made because helmets are not used currently in avalanche safety.

In the group of Utah victims, one was wearing a helmet (an ice climber) which
was designed to deflect ice fall, not a human fall (which is what happened when
he was swept off-route by the avalanche). As I reviewed the ME’s reports, I
realized that head injuries were listed as incidental findings to the cause
of death – a kind of footnote to asphyxia. Most head injuries were documented
with notes of lacerations, contusions or abrasions, but from a physiologic viewpoint
they were not cause of death. From the perspective of the medical examiner the
cause of death was asphyxia. Associated traumas, head injuries included, were
dutifully noted.

I dug through the grim reports of all twenty-seven deaths as well as the scene
reports and data from the Utah Avalanche Forecast Center (when available – many
of these were in the files of the M.E. – there was also newspaper data, and
many scene reports are posted on the Internet). I found the Examiner’s report
on the kid that died in November. When I reviewed the report, I saw some interesting
notes. The cause of death was listed as asphyxia. Incidental findings included
multiple abrasions, lacerations, and contusions, several of these were on the
head/scalp. Of the 27 victims, over twenty percent had evidence (on a physical
exam basis) of moderate to major head trauma. That’s one of every five victims
with some degree of head injury. Another important note: of the victims with
associated head trauma in Utah, many were found under a minimal amount of snow.
I can’t say that they would have been able to escape had they been conscious.
But, it makes more sense that their bodies were often found head downhill, face
down, and gear still on, without an air pocket. I think the chances of swimming
to the side of a slide, removing gear, inserting your fancy new breathing device,
or jabbing a fist to the surface at the last second is unlikely if you hit your
head. Of the victims found to have major head trauma, many were found relatively
close to the surface, and were found by other members of the party within the
fifteen-minute window of “survival.” These victims often had no “ice mask,”
and none was noted to have created an “air pocket” at the time of burial. I
would argue that from the perspective of avalanche safety, head injury and consequent
unconsciousness might preempt asphyxia as the cause of death. Think about it.

I found what I believe was troubling me about that kid’s death in November.
It seems that a significant number of avalanche deaths are associated with some
degree of closed head injury. Helmet use is currently not routine in our avalanche
safety. I can’t say that using a helmet would have prevented death. Whether
the injuries were sufficient to render the kid unconscious cannot be known given
the outcome. But the findings at autopsy, the associated head lesions, and the
fact that he was not buried deeply coupled with the observation that he did
not have an associated air pocket or ice mask makes me think that he was likely
knocked unconscious. I think it can be said after looking at all the autopsy/scene
reports is that head injuries likely constitute a real/significant injury in
avalanche victims, which may contribute to burial and asphyxiation.

The point is, current survival strategies involve specific maneuvers by the
avalanche victim. Maneuvers such as swimming to the side, the release of gear,
a last effort to gain an air pocket, and even the attempt to keep the snorkel
from your fancy new Avalung all assume one thing: your brain works.

As “extreme” practices become local events, they are beginning to disrupt my
ability to distinguish tragedy from a bad idea. But I’m sure that this year
will have great advances. Everyone and their dog (literally, I suspect) will
have new beacons and a shiny new Avalung. So this year when we pass each other
in the backcountry, please note that just because we are headed to the same
general area does not mean I will cut you off on that first decent you have
been contemplating. No one is filming me and my partner refuses to carry a camera.
We won’t step on your cornice or spoil your chute. We’ll be the ones that will
step to the side, let you take the freshies down the sick line. Just don’t ask,
“Dude, what’s the helmet for?” – some guy did research.