Case Study 17

The Answer


  • Possible spine injury. 

The Plan

  • Patient has lower back pain and is not a candidate for a focused spine assessment.  
  • Immobilize the patient to the ground.
  • Protect the patient from the cold.
  • Continue to monitor.
  • Send two skiers back on the trail to a ridge where we should have cell phone service and call for assistance.

Anticipated Problems

  • Hypothermia and frostbite.  We have minimal insulating gear and no sleeping bag.
  • Shock from an internal injury.

The Tale Continues

Both you and the patient wish he could stand and ski, but you’re worried about the spine and the patient’s back pain worsens over time. The equipment inventory lacks those sleeping bags and plastic sheets you had on your WFR course. You’re able to log roll the patient again and dress him with his down jacket and an extra layer of pile. You also pull a set of over-pants onto him, loosen his boots, and change his socks to a dry pair. A spare scarf insulates and serves as a c-collar. Your packs immobilize his head. The rest of you don your spare layers. It’s becoming cold. You’re not moving. The sun is low on the horizon and you’re now in the shade.

The patient reports that he was skiing with a companion who went down the slope before him.  As you’re preparing to wait in the cold, the friend returns, sweating from an uphill slog, learns what had happened, volunteers a bunch of candy bars, and two heat packs, which you place in the patient’s boots. He decides to stay and help his friend.

You determine our coordinates from your GPS and double check them against your topo map. Two of the group organize to ski back along the trail and take off shortly. You’re all worried about your ability to stay warm. You build a fire, more for emotional comfort than real heat, but you do curl up close and spoon with the patient to keep him warm.

You remember listening to the tale of Tom Hornbein and Willi Unsoeld on the first ascent of the West Ridge of Everest in 1963. Unable to descend in the dark, they bivouacked high on the mountain. In the words of Dr. Hornbein: "our survival hinged on the fact that the wind did not blow." You decide not to share this memory.

The patient’s low back pain persists and even worsens, but CSM’s stay intact. His vital signs don’t worsen. The heart rate remains higher than normal, which is worrisome; his skin remains pale, warm and dry; he remains A+Ox4; and he has a radial pulse. The patient urinates once, facilitated by log rolling him onto his side and having him pee dark yellow urine onto the snow. The absence of obvious blood in the urine is heartening. Everyone is shivering occasionally as the sun sets.

End of the Tale

After the eternity of two hours your two companions return. The good news is that they made contact with local SAR, who are responding with snowmachines and sleds. The bad news is that it might be a few more hours before they arrive. The skiers become the spooners and the spooners welcome the chance to move and get warm. The fire is built to an impressive size. A metal water bottle is used to melt snow into a warm drink. 

It’s an hour before the first welcome whine of the snow machines and another half hour before they arrive. The travel in the groomed conditions has been hard. The rescue sled stays while the others return to the chore of packing the trail. These guys are prepared and have sleeping bags, a litter, numerous hot packs, and several thermoses of hot drinks.  They complement your bivouac and fire and appreciate that you can help them package and load the patient onto a sled in the care of an EMT. They head to the trailhead. You gather your gear and begin the weary ski out, suddenly feeling exhausted by your work.


This is based on an actual event. We pack our packs in the warmth of our homes where it is hard to imagine the reality of 4:00AM on a winter’s night. These WFRs and WFAs did a fine job assessing the patient, protecting his spine, organizing a plan to gain assistance, and staying warm. They had enough to get by, but it would have been a long night if the SAR unit had not arrived. The patient had several spine fractures, but no spinal cord injury.