Technical Rescue Interface: Ski Patrols and Mountaineering Rescue in the Mountainous, Snow, or Glaciated Environment
Michael G. Millin
J. Pearce Beissinger
Jonnathan Busko
The alpine environment offers outdoor and snow enthusiasts almost limitless opportunities for recreation and sport. With those opportunities comes equally limitless opportunities for injury and illness. While the medical and traumatic processes are similar to those encountered in other urban and wilderness environments, ice, snow, and cold temperatures offer unique challenges in patient assessment, care, rescue, and transport. From a wilderness emergency medical services (WEMS) perspective, these environments can be generally divided into those in which WEMS is provided by ski patrols and those in which WEMS is provided by mountain rescue teams. Granting that there is significant potential for overlap between these groups, nonetheless the unique challenges faced in each of these environments make this division useful for planning and training purposes.
Although widely used, the term "ski patroller" has no specific definition in terms of training and scope of practice. Starting as small groups of skiers dedicated to safety at a few resorts, alpine ski patrols are now essentially ubiquitous throughout the ski resort industry. The practice of a ski patroller is influenced by regulatory, administrative, and environmental influences. As frontline WEMS providers in a wide variety of practice settings, ski patrollers are vital links between the general public and front country EMS systems. While the illnesses and injuries they care for match those seen in other WEMS environments, there are significant differences in transport, rescue, and evacuation techniques used by ski patrollers versus other WEMS disciplines.
Also note that in terms of training and scope of practice we use an expanded definition of "physician medical oversight" in this chapter. We use it here to represent the requisite oversight any EMS system must have for non-clinicians. Consistent with most state laws, published consensus of wilderness medicine and EMS educators, regulators, and clinicians, and with the National EMS Scope of Practice Model, physician medical oversight and collaboration must be present in the organizational structure.19,33 However, a physician may defer certain portions of that medical oversight to other qualified clinicians (like APRNs or PAs). Throughout this chapter, "physician medical oversight" also includes such arrangements with collaborative providers who reinforce and supplement that required physician oversight.
Defining the role of a mountain rescue unit (MRU) is a unique challenge that may present as much variability as the terrain in which these groups operate. With the formation of the Mountain Rescue Association (MRA) in 1959 (see Chapter 1), many MRUs have pursued technical accreditation validating their unique skillset in technical terrain. This association of professional rescuers, comprised of volunteer and paid resources, typically performs its work within the National Incident Management System (NIMS; see Chapter 3) where they have the opportunity to share in the role of patient care with other WEMS personnel.
SKI PATROL-SERVICED ENVIRONMENTS
While the term "ski patrol" often brings to mind images of lodges and lift-serviced terrain, ski patrols in fact provide WEMS care in a number of terrain types and across many snow sport disciplines. The vast majority of ski patrolling is carried out in lift-serviced terrain but patrollers also operate in Nordic (cross-country) and backcountry environments. Organized ski patrols evolved in large part from the advocacy efforts of the National Ski Patrol (NSP), a training, education, and consulting member-based organization established in 1938 to consolidate and standardize ski patrol practice.1 The newly formed NSP played a significant role in the development of the U.S. Army's 10th Mountain Division; consequently, when its veterans returned into the civilian ski and alpine community immediately following World War II, ski resorts embraced them and took on greater responsibility in providing emergency medical care to sick and injured outdoor enthusiasts.2 See Chapter 1 for further discussion of this history.
The exact incidence of injuries and deaths in ski areas in the United States is unknown. The National Ski Areas Association, an U.S. industry trade group, estimates 2.5 injuries per 1,000 skier days with 40 catastrophic injuries and 50 fatalities per year.3 However, this number is felt by some to underrepresent the scope of the problem.3 Regardless, considering that a large resort may be visited by several thousand skiers per day on busy days, it is clear that ski patrols provide an important service to ski area patrons on a daily basis.
A ski patroller's practice is shaped by a number of regulatory, managerial, and environmental factors. It is the combination of these various factors that create the medical and geographic scope of practice of a ski patroller. The following overview should help the reader to understand the general principles but before practicing at a specific site, any patroller must understand local regulations and practice.
State regulators take a number of approaches to ski patrols. These may include no regulation, in which case managerial and environmental factors primarily define the patrollers' scope of practice. Other states have rules that define a minimum training requirement for medical providers at ski area operations. Since most states codify American National Standards Institute Standard B77.1 "Ski Chair Lift Safety" into law and the U.S. Forest Service requires compliance with the most current version of ANSI B77.1 for any lifts operated on National Forest Lands, this standard sets a minimum for essentially all ski areas in the United States.4 ANSI B77.1-2011 states, "One or more persons must be trained to provide first aid/emergency care at the BLS level including cardiopulmonary resuscitation (CPR). Basic Life Support is defined as medically accepted non-invasive procedures used to sustain life".5
Beyond ANSI B77.1, there are few states that specifically regulate ski patrols. Maryland has recognized the NSP's OEC Technician certification as an EMS licensure level if the patroller is also affiliated with the local fire department, formally embracing ski patrols within the EMS system. Nevada has used a hybrid approach to insert EMS licensees into the ski patrols. Other states such as Idaho6 and Maine7 explicitly exempt ski patrols from EMS System oversight. The Maine Code Title 32: Professions and Occupations, Chapter 2-B: Maine Emergency Medical Services Act of 1982 §82. Requirements for License, subsection 2 License Not Required defines those not requiring medical licensure:
E. A person serving as an industrial nurse or safety officer, a school or youth camp nurse, a life guard, a member of a ski patrol, a nurse or technician in a hospital or a physician's office, or other similar occupation in which the person provides on-site emergency treatment at a single facility to the patrons or employees of that facility.
As the only reference to Ski Patrols in Title 32, this places ski patrols outside of regulation of the Maine Office of EMS. Idaho goes so far as to define the medical care delivered at ski resorts by ski patrollers with OEC Technician certification as completely first aid, exempting it from other regulated practices of medicine and from the need for further license or medical oversight.17 Unless specifically excluded by state law, ski patrols do appear to meet all criteria in the published definition of EMS.8
Since there is limited statutory regulation of ski patrols, often the decisions regarding training and certification requirements for patrollers and patrollers' scope of practice are made by the ski area management. When there are state regulations requiring a certain level of training or licensure, then the ski area must at a minimum abide by those rules. Otherwise, management has a number of options including requiring basic first aid and CPR training only, accepting other health care licenses (eg, RN, MD, DO, PA)9 or emergency medical technician (EMT) certifications that have additional training in ski rescue,1 requiring another standardized certification, or some combination thereof. For many ski area operators, this decision is made based on insurance requirements. Insurance companies recognize the NSP's Outdoor Emergency Care (OEC) training program and certification as valid training and therefore many ski areas elect to require OEC certification.9 While OEC is typically not required by insurers and an area could choose to accept another brand of WEMS certification, it is commonly used due to its wide recognition and acceptance.
Many patrols have patrollers that hold additional EMS or medical licensure and patrols may elect to formally take advantage of the scopes of practice of those licensed EMS providers. This is typically done in one of three ways:
1. The ski area contracts with a medical director for the patrol who defines a scope of practice and protocols for patrollers with various EMS licenses. In states in which patrols are unregulated, this essentially becomes a form of delegated practice.
2. Patrollers with EMS licenses affiliate with the primary EMS agency that responds to the resort. When such a patroller
encounters a patient with medical needs that exceed his scope of practice as a patroller, the patroller "switches" to being an EMS provider for the responding service and therefore falls under all EMS rules and regulations, including documentation standards and medical oversight.
3. The ski patrol registers with the state as a licensed EMS agency and all patrollers are required to hold some level of EMS license and affiliate with the EMS agency.
The environment of practice also influences the scope of practice of the ski patroller. At the broadest level, this class of winter sports can be divided into lift-serviced downhill (aka alpine), Nordic (aka cross-country, on established and typically groomed trail systems), and backcountry (off-piste, non-lift-serviced touring without formally established/groomed trail systems and alpine/downhill riding). The types of equipment and styles used in these disciplines vary tremendously (see Figure 31.1 and Table 31.1). The three disciplines have different implications for ski patrollers as WEMS providers. Patrollers may work in alpine resorts with typical transport times from the scene to the aid room of under 15 minutes, a situation akin to an urban EMS system. In these cases, patrollers need a scope of practice that allows them to address ABC life threats (Airway, Breathing, and Circulation) but do not necessarily need a broader scope of practice. By the same token, many larger alpine resorts may have trails from which transport to the aid room may take over 45 minutes. Similarly, Nordic ski resorts will often have prolonged transport times since trails may lead miles from the lodge and aid room. In these situations, practice is akin to rural EMS in that beyond immediate life threats, patrollers may be forced to deal with the natural history of the disease process as it evolves over periods of an hour or more. Therefore, a more extensive scope of practice may be necessary to adequately meet the needs of patients. Finally, for Nordic patrols with a backcountry responsibility or dedicated backcountry ski patrols, the scope of responsibility (and therefore the scope of practice) is similar to that of a WEMS search and rescue (SAR) team. Response to an incident may be prolonged and treatment and transport may be extended to hours or even days.
Table 31.1 List (not exhaustive but covers the major classes of equipment) of Commonly Used Snow Sports (skiing and boarding) Equipment
Two skis with fixed heel bindings and rigid boots. Typically used in lift-serviced downhill terrain
Two skis with free heel bindings, boots range from moderate stiffness to rigid. Typically used in downhill disciplines
Two skis with free heel bindings, boots are soft to moderately stiff. Used for cross-country (skating or classic techniques) or backcountry touring
Alpine terrain/AT/Randonee
Two skis with bindings designed to fix the heel in place during descent but to be free heel and pivot at the toe for ascent and touring. Boots vary in stiffness and modern boots typically designed to be able to double as mountaineering boots. Used in backcountry touring and non-lift-serviced descents, this configuration is also popular with many lift-serviced terrain ski patrollers due to the ability to climb hills and efficiently traverse flat areas
Single wider ski with two fixed heel bindings oriented with the pelvis facing downhill and the feet fixed side by side
Snowboard including split boards
Wide board with fixed bindings set with a leading foot and a trailing foot. The setting of the bindings rotates the pelvis to an orientation more parallel to the angle of the descent than with skis. Typically used in lift-serviced terrain, but split boards designed to break in half are used in Nordic style for touring and ascent in backcountry pursuits, and backcountry snowboarders may carry their boards in a pack using short "approach skis" or snowshoes to reach descents
FIGURE 31.1. Different Snow Sports Disciplines Require Different Equipment. From left to right, alpine skis, telemark skis, Nordic (cross-country) skis, alpine terrain (AT or randonee), and a snowboard. Courtesy of Jonnathan Busko.
National Ski Patrol Outdoor Emergency Care Technician Training
Since the majority of active ski patrollers in the United States are trained through the NSP's OEC Technician class, it is important to understand the scope of this training so that one can define the skill set and scope of practice of ski patrollers who practice based on this certification. Broadly speaking, the OEC Technician training exceeds that of the Emergency Medical Responder (EMR) but does not include all of the elements of an EMT curriculum.10 Additionally, there is a heavy emphasis in the OEC Technician curriculum on cold environment and winter sports emergencies, for obvious reasons. The National Highway Traffic Safety Administration (NHTSA) National Emergency Medical Services Education Standards for EMR include airway management (manual maneuvers, suctioning, application of supplemental oxygen, use of pocket masks, oropharyngeal airways, and bag-valve-mask ventilation), acquisition of vital signs manually, manual CPR and use of an automated external defibrillator, assistance of normal childbirth, manual stabilization of the cervical spine or extremity injuries (but not the use of splints), hemorrhage control including use of a tourniquet, emergency moves, and eye irrigation. The OEC Technician curriculum adds to those skills the following11: moving, lifting, and transporting patients, use of nasopharyngeal airways, assisting with a metered dose inhaler, administration of an auto-injector, stabilization of impaled objects, splinting of injured joints and extremities, reduction of a posterior sternoclavicular dislocation, traction splinting, spinal cord protection (SCP) including SCP techniques and use of adjunctive splints, helmet removal, stabilization of ocular impalements, management of open chest wounds, stabilization of pelvic injuries, patient restraint, documentation, and administration of nerve agent antidotes.
It should be clear from this scope of practice that ski patrollers do not practice "first aid" in the generally used sense of the term by the American Red Cross,12 Occupational Health And Safety Administration,13 or ANSI.14 Rather, ski patrollers have a sophisticated medical practice involving complex decision making with the risk of causing harm if errors are made.
Ski Patrol Medical Direction and Oversight
From the discussion thus far, it is clear that ski patrols are an integral component of EMS systems of care. The NSP in particular has made this a center point of the current (5th edition) Outdoor Emergency Care Technician certification, asserting that ongoing medical oversight, the hallmark of EMS practice of medicine, is also "the hallmark of quality health care and is the best method of ensuring that the treatment rendered by ski patrollers meets or exceeds both customers' expectations and the national education standards for emergency medical personnel"12 (medical oversight in WEMS operations is discussed in further detail in Chapter 4). NSP's magazine, Ski Patrol Magazine, has also published assertions that "nationwide, ski patrols are known as an integral part of the EMS system."15
Despite this affirmation from the largest member organization for ski patrollers, many patrols position themselves as outside of not just the EMS system but of medicine itself. While reasonable arguments can be made about whether current state EMS structures can adequately accommodate the specific skill set and scope of practice of the OEC Technician,9 it is difficult to argue against using the traditional medical quality assurance tools of oversight, review, and credentialing to assure that the public is receiving the highest quality care from ski patrollers. As identified in the Institute of Medicine (IOM) report "To Err is Human," it is expected that health care providers, even when well intentioned, have the potential to cause medical errors.16 Yet, when an error occurs, there should be a process to review the error, and develop training programs to correct the error. The process of patient care review falls within the purview of indirect medical oversight (see Chapter 4 for a more complete discussion of indirect medical oversight). This process should be clinician-led and should be about education and improvement of patient care. The focus should be on the patient and the system and not on the provider. For these reasons, among others, all ski patrols should aspire to have medical oversight from a licensed clinician-level provider.9,17,18
With the understanding that EMS is a practice of medicine, as discussed previously in this text, ski patrollers have a defined scope of practice that is established by four pillars—education, certification of the education, licensure, and credentialing.19 Ideally, in order to be allowed to provide care to the public at a level above first aid, the patroller needs to be recognized by the state EMS regulatory authority through licensure, and credentialed by a local EMS medical director. Ski patrollers that do not have an established scope of practice, as established by the four pillars described above that necessarily include physician oversight for non-clinicians, risk practicing medicine without a license. If an appropriate regulatory structure can be put into place that is sensitive to the specific contextual practice of ski patrols, is driven by patrollers and ski patrol medical directors with an EMS background, and does not produce excessively burdensome fees for participation or requirements for compliance, recognition from and oversight by a state's EMS regulatory authority carries many potential benefits to ski patrol. These may include civil and criminal liability protection, access to grants and special funding, and a professional track for career development. For this reason, we support intelligent, thoughtful, and effective integration of ski patrols into state regulatory structures, specifically under EMS. That being said, even in states such as Idaho and Maine that exempt patrollers from EMS regulatory oversight, participation in the field of medicine itself ethically mandates participation in quality assurance and oversight practices.
It is important to note that while few patrols may have a formal arrangement for medical direction, there are many
mechanisms for participating in a quality management system. For example, in the 13 active NSP-affiliated alpine patrols in Maine, medical oversight is achieved in several through the following mechanisms: formal medical director contracts, designation of medical director duties as part of patroller responsibilities (with physician-specific liability coverage provided), and as NSP "Medical Associates," a designation for physicians who provide professional medical expertise to the education and oversight of the patrols. In the case of the patrol with the formally contracted medical director, this contract is with a physician to provide EMS-style oversight, protocols, and medical control. That ski area's management pursued such an arrangement and therefore patrollers at that patrol use protocols that mirror the Maine EMS protocols with additional training that affords them an operationally specific scope of practice including the use of blind insertion airway devices, assisted and primary medication administration, and evidence-based guidelines for orthopedic injury management and disposition. Although unusual, this arrangement is consistent with recently published consensus guidelines for WEMS development.33
Technical Rescue Interface: High and Low Angle Rescue
Technical Rescue Interface: Cave Rescue
Wilderness EMS Research
Management of Cold Injuries
Management of Heat Illnesses
Management of Lightning Injuries and Severe Storms
Technical Rescue Interface: Search and Rescue in the Non-Snow/Glacier/Mountaineering Environment
Wilderness EMS Equipment
Tags: Wilderness EMS
Oct 16, 2018 | Posted by drzezo in EMERGENCY MEDICINE | Comments Off on Technical Rescue Interface: Ski Patrols and Mountaineering Rescue in the Mountainous, Snow, or Glaciated Environment