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Case Study

Winter Solstice Skier Case Study Part 1

It is winter solstice. You and three friends are settling into your backcountry hut after a short, but unbelievable day of backcountry skiing and snowboarding in Alberta (elevation: 1430m/ 4690’). The weather has been clear and cold enough (-12C/ 10F) for a few days now, making for great powder and conditions all around.

As folks hang gear to dry and get out supplies for hot drinks, you hear boots stepping on the porch- your group is here, so this must be other folks using the hut. You wonder if you already put your sleeping bag on the bunk you wanted to grab, and then the door opens. A concerned woman peeks in and says, “I need help for my friend. She’s cold and she isn’t making sense anymore. She could only ski to the trees over there before she sat down. Can someone come help her, please?”

Your friends agree to help and immediately nominate you as the field medical provider, based on your training. You ask about the situation as you ski out. You learn that the friend, Dara, had a rough day cross-country skiing. “She just kept losing her balance,” and “she said she just couldn’t get going or get warm.” She denied any high-velocity or concerning falls. “Mostly she just kept leaning out of the tracks.” You ask about medications, allergies, medical history, or anything else that might help you treat her, but the friend says, “I don’t think there’s anything, really. I know she’s been watching what she eats to try and lose weight, but that’s about it. She ate a protein bar this morning. Maybe she has to take a pill for thyroid, I think.”

Just a ten-minute ski away from the hut, you find the person- about 50 years old, dressed in ski clothes and sitting in the snow, shivering vigorously. She slowly looks up at you as you approach, but doesn’t really say anything.

Your scene size-up so far:

Risk: cold weather, impending darkness, safe to approach the patient

MOI: medical and environmental seem the most likely, but you are open to any findings that might suggest trauma

Numbers: 1 patient, 5 rescuers, 1 hut nearby

You introduce yourself and ask Dara for permission to help her, and she nods. You can see that she is breathing quickly, but with adequate depth. You ask her if she had any big falls and she mumbles “no, not big.” You ask her if you can check for bleeding, and she nods.

Your primary assessment so far:

Airway, breathing: no concerns

Pulse, severe bleeding: no concerns

AVPU, spine: awake but speech is mumbled, and patient is slow to respond; spine- no concerns

You start thinking about STOPEATS as causes for altered mental status.

For the secondary assessment, you decide to start with a brief physical exam. Dara denies pain, but mumbles “my hands don’t work. My feet don’t feel.” Her speech is slurred and difficult to understand. You attempt to perform a BE FAST stroke exam, but it is difficult to get a reliable assessment with the shivering and difficulty following commands. You find Dara’s hydration pack and ask if she can take sips of water if you help her, which she can do. One of your friends has an energy gel packet, and you patiently support Dara while she swallows most of it. Dara’s pulse is 92, respirations seem to be 18, and skin is cool and sweaty. You realize you haven’t asked Dara her SAMPLE history directly yet. You relay the information from the friend, and Dara nods in agreement. “Anything else?” you ask her, and she mumbles “no.”

You decide to use the team gear sled to get Dara to the hut. One friend goes ahead to get hot drinks ready – “something with lots of sugar!” you request, and two friends ski her to the hut and help her stumble inside.

Once inside, you notice that Dara’s layers were wetter than you realized, and you get a sleeping bag for her while her friend helps her out of the wet layers. Dara continues to shiver profoundly, and you ask the friend to help her slowly sip lukewarm sugary apple cider. As you think about next steps, you notice that Dara’s fingers are grey and waxy-appearing. You are still concerned about all the potential STOPEATS:

Sugar: she probably has low blood sugar

Temperature: she has mild hypothermia

Oxygen: you don’t think low oxygen was a factor, but you cannot perform a full BE FAST exam yet for stroke. While watching her take sips of cider, you notice that she lifts both hands to reach for the mug, which is reassuring.

Pressure: ^ ICP cannot be ruled out

Electricity: no history of seizures or report of seizure-like activity

Altitude: not a factor

Toxins: unknown, friend denies anything

Salts: hyponatremia is not likely

Someone hands you a satellite device and asks if you want to use it to call for help.

What do you think? Is this serious or not serious? Drop your thoughts in the comments section of this Case Study on our Facebook or Instagram. Stay tuned on those platforms for the next part of the assessment and follow-up discussion!