Case Study 18

The Answer


  • Possible local cold injury to the toes

The Plan

  • Immediate warming with skin to skin contact. Immersion in warm water if possible.
  • If frostbitten, decision on warming versus travel.
  • Check every other member of the group.

Anticipated Problems

  • The toes are frostbitten.
  • Inability to walk.


The textbook describes frostbitten digits as cold, white, waxy, and numb. In reality our toes can look like this and just be cold, and look like this and be frostbitten. The white and hard description suggest frostbite, but we may not know know until we warm. 

The trip leader catches this injury early and has to decide to thaw or not to thaw and its impact on evacuation, the group, and the patient. If it’s really frostbitten the tissue can become swollen, painful, and perhaps blistered after warming. This can result, on a practical level, in an unusable injury. Your walking patient with frozen toes becomes a litter case with thawed toes. If it’s thawed, then freezes again, the injury is much more severe. There are tales of people keeping digits frozen in severe cold and even walking with frozen toes, but in this case you anticipate the toes will warm quickly, and that you will be able to keep them warm.

The Tale Continues

This trip leader assesses the toes, thinks they might not be frostbitten. However, he is worried about the big toe. He offers his belly to the student and gasps when the cold toes touch his skin. The student’s eyes well with tears from the pain as his toes warm over 10-15 minutes. 

While the warming is progressing the rest of the group fires up the stoves for hot drinks and makes sure no one else is cold or has a local cold injury.
At the conclusion of the warming the toes are red to their tips. The pain has subsided to a tolerable level. The patient can feel to the end of his toes. The exception is the bottom of the right big toe, which remains pale. Suspicious that this is frostbitten tissue, the trip leader thinks about immersing the toe in warm water. Instead he decides to continue with skin-to-skin warming and places the stubborn cold toe in his armpit. After another 10 minutes it is thawed. The toe is warm, swollen, and very painful.


The ideal treatment for frostbitten tissue is rapid thawing in warm water. The water temperature advised has changed over the years and is currently 99-104°F (37-39°C), or warm bath water. Water that is too cold warms too slowly. Water that is too hot is unnecessarily painful and may damage tissue. In the field skin-to-skin contact is often the practical solution.

In the past we made decisions based on:

1) Is the frostbite only a small area that I can easily thaw?

2) If it’s more extensive, can I keep it frozen and travel to the trailhead, or do I thaw it in the field and create a litter case and an injury I must keep protected and warm? 

The latest treatment modalities include using clot-busting medications normally used to treat heart attacks. Our decision-making needs to include the possibility of quick evacuation to the hospital for use of these medications, especially if frostbite is extensive.

End of the Tale

Due to the lateness of the day the decision is made to camp and keep the patient and his toes warm in the sleeping bag. He takes 600mg of ibuprofen every four hours. The pain eventually subsides. His toe is swollen and red and, after several hours, develops a clear fluid filled blister on the bottom of his toe. This development raises concerns about the patient’s ability to ski back to the road. Also, the temperature continues to drop and is -10F the following morning.

The trip leader alerted his program support last night via cell phone, and they arranged for a snowmachine. In the morning the decision was made to use this tool, and the injured student was evacuated. The toes healed over the next month, and the student was skiing again that winter, hopefully with a better appreciation for the difficulty in deciding when our toes are cold and numb and when we cross the line to injury.