I recently took a Remote Area First Aid course with the view it’d come in very useful for all of our backcountry ski and snowboard adventures. Most trips we do tend to have a mix of people of varying abilities and fitness levels, so having some basic First Aid skills training is likely to come in very handy at some point.

Here’s a run down of the main things I took away from the course in relation to backcountry trips:

Trip and contingency planning

• Who’s in your group? I’ve had numerous situations where someone’s tagged along at the last minute with zero background info on what their full name is, emergency contact details, skiing experience, prior medical conditions and general fitness levels. Get this info written down before you go and ideally leave it with someone back home. It’s also worth finding out who in the group has specific skills that may help you in an emergency, such as First Aid training or excellent navigation skills.
• Minimum group size? The official guideline is a minimum 5 people in the event you have one casualty, two to stay with them and two to go for help. In reality, many of us go out with just one other buddy, so the important things in this case are good contingency planning, emergency equipment and communication devices.
• Plan your route based on your group’s minimum capabilities. This sounds like commonsense, but it’s easy to forget someone in the group may have much lower fitness levels and just won’t keep up on an ambitious ski tour. This is the person that the pace of the trip will need to be set to and you need to be prepared to alter or downgrade your trip plan based on what they’re capable of in the field.
• Who’s your home base person and what do they know about your trip? Ideally, you’ve left all the above contact details with someone you trust along with detailed info on the region you’ll be skiing, alternative routes you might take, your likely exit time and any other contingency details if you don’t turn up when you’ve planned to. Details on individuals within the group are also important, such as pre-existing medical conditions, skill levels, even the colour of the jackets and tents they’re using. If you haven’t made contact after an agreed time, this home base person can alert search and rescue to come and find you by calling 000 (Australia) and the Police will take over from there.
• What equipment do you have for an emergency? This obviously includes avalanche and first aid gear, but what happens if someone snaps a pole a helicopter flight away from a repair? Can you fix someone’s bindings or skins? Can you build a shelter with a spare tent, tarp or bivy bag? Do you have enough warm layers to keep someone injured and the rest of the group alive overnight? Do you have enough food and water for a long delay (Minimum 24 hours) while waiting for a rescue? This needs to be the responsibility of the whole group so that you’re not relying on one person to have a good emergency kit.
• Does everyone have a basic First Aid kit and know how to use it? At a minimum, everyone should have a triangular bandage (Slings, binding and bleeds), compression bandage (Sprains), non-stick dressing (Burns), disposable gloves (Bleeds), band aids or tape for blisters (A surefire trip killer) and a tactical tourniquet to stop major arterial bleeding. Anyone with pre-existing conditions (Asthma, diabetes) should have their own medications with them and have told everyone in the group what symptoms to keep an eye out for.
• Does everyone have a paper map and compass? Your iPhone has probably already frozen and you might need multiple navigators if the group splits up for some reason. Note that no less than two people should ever be by themselves in this situation.
• What communication devices do you have in the group? Even close to most ski resorts your mobile phones are likely to be useless, so a Personal Locator Beacon (Available for loan from many National Park stations) is essential in an emergency to call in a professional rescue. If you’re in Australia or NZ, your tax dollars have already paid for a rescue, so don’t be afraid to call one in if it’s absolutely necessary. Note that PLB’s are apparently not legal to use in Japan.
• What’s your agreed plan in an emergency? People are likely to panic if something goes wrong, so make a list of likely scenarios and have a clear escalation plan if one of them occurs. e.g. A broken leg or knee injury is very likely skiing and that person won’t be able to go anywhere without mechanical assistance. If someone argues about what to do in the heat of the moment, your fall back is you’ve already agreed what to do, so you’re sticking to that plan.
• What are the group’s roles in an emergency? Again, in the panic of an emergency there may be too many people trying to help with no training or everyone standing back waiting for someone else to do something. It should be pre-agreed that the uninjured person with the highest level of First Aid training takes charge and delegates responsibilities to the rest of the group. e.g. “You call for help, you get our warm gear ready, you get water.” Having a calm, authoritative leader in these situations is critical to following a well structured process for dealing with an emergency.
• What’s the weather forecast? Many critical emergencies in the backcountry are weather related, so make sure you know if it’s going to be sunny, snowy, windy or rainy on the morning of your trip with the latest forecasts. Also read any avalanche forecasts if they’re relevant to your trip plan and revise your plans accordingly. If you’re intent on pressing ahead with your plans, make sure your equipment is up to it (Weather gear, tents), but don’t be afraid to reschedule or cancel if you have any doubts about ensuring the safety of the whole group.
• Is a professional rescue your only back up plan? In this age of PLB’s and helicopter rescues it’s easy to think you can flick a switch and help will be there in an instant, but this is almost certainly not going to be the case in many backcountry ski areas where weather is very likely to prevent a mechanised rescue. The official first aid advice is to call in a rescue if the patient needs critical care and can’t move under their own steam. However, you might need to move a patient to a safer area (e.g. out of an avalanche zone) and if the weather hinders a rescue you might need to survive in very exposed conditions for more than 24hrs and care for the patient during this time with no external communication. Being recently trained in first aid and having appropriate survival gear in this type of situation becomes critical.

Potential emergency scenarios

You already know you’re going skiing or snowboarding somewhere remote, so you know it’ll be cold (Hypothermia, frostbite), bright (Snow blindness) and dangerous for broken limbs, head injuries and, to a lesser extent, cuts from sharp ski edges and rocks. Prepare your contingency plans and equipment and deal with the following scenarios accordingly:

• Hypothermia: This is caused by the patient’s core temperature dropping below normal and can be brought on by something as simple as sweating too much on the skin up then getting overly cold on the ski down. Prevention is your best cure in this case by ensuring your group are dressed in layers (Jackets off on the skin up if it’s warm), are moving at a pace that prevents excessive sweating and they all have spare dry layers and a decent light puffer jacket to warm up quickly if needed. In the event someone does start getting early stage Hypothermia, they’ll be shivering excessively, irritable and confused. They key is to arrest this ASAP when the first signs are showing, so stop in a safe spot and get them into dry, warm clothes and in some form of shelter. This might be a space blanket or simply out of the wind under a rock, but you should definitely include a layer underneath them to get them off the snow (Backpacks or shell jackets are perfect for this). Day trippers are unlikely to have a sleeping bag, but puffer jackets around the core and legs will suffice without one. Make sure they have a beanie or other warm head gear and dry gloves and socks. If you have a thermos or cooker, small sips of warm (not boiling), ideally sweetened water will start to heat their core. You can also use chemical hand warmers around the neck, armpits and groin over their first layer thermals to prevent excessive heat harming their skin. Shared body heat isn’t advised by the official First Aid guide, but if there’s no other option be sure to share this role amongst the group set set intervals so each person can stay warm. Your goal is to warm their core temperature back up gradually, so don’t bother with lighting fires or warming hands on a camping stove as your method for treating the patient. Bear in mind that other members of the group may get cold when you stop, so they should all rug up while you’re dealing with the patient. Hypothermia may be the principal issue you’re dealing with, or will quickly become a secondary issue if they’ve sprained an ankle and can’t keep going, so deal with the cold as your first priority in most situations. If they recover within 30 minutes you’re likely to be able to keep going or return home under your own steam if they’re up to it. If they don’t show signs of improvement within 30 minutes or show any signs of frostbite on fingers toes and face, start planning for evacuation.
• Broken bones, sprains, dislocations and knee injuries: Most of these situations will require evacuation, so activate your evacuation plan as soon as you’re sure the patient can’t go anywhere under their own steam. You will have zero chance of stretchering or carrying an adult very far in the snow, so treat in place if there’s no immediate danger. Once your evacuation call is underway, it’s then a matter of stabilising the injury with the absolute minimum of moving the patient. e.g. If they’ve broken a leg in an open area, stabilise the leg with whatever is available and keep them warm and comfortable.
• Head & neck injuries: This is most likely to happen if someone’s hit a rock or tree. If they’re mobile, stop the group and monitor the patient for at least 30 minutes to see if their condition deteriorates. Even if they do seem to be OK after 30 mins, keep monitoring them for the next 24hrs. Signs of head injury complications are vomiting, fluid from the ears, slurred speech, impaired motor function and balance, confusion and pupils not dilating normally. If they are deteriorating, activate your evacuation plan, as it could indicate a potentially fatal bleed on the brain. If they end up passing out, put them in the recovery position with their airway clear. For more serious head injuries such as unconsciousness, bleeding from the ears or they say they heard a crack or can’t feel their toes or fingers, keep their helmet on, keep them in the position they fell and activate your evacuation immediately. Have someone brace their head in their hands so their neck doesn’t move and do what you can to make them comfortable without moving them. The only reason you’d ever move someone in this situation is if another life threatening situation is imminent, such as drowning in a creek. Bear in mind that shock and risk of hypothermia will necessitate warming them without moving them unnecessarily.
• Cuts: Most likely to occur in a big fall where their ski edge or tree branch cuts through their clothing and gashes a limb. You may need to remove or cut off their clothing in this instance and do what you can with spare triangular bandages and hand pressure to stem the bleeding. Excessive bleeding may indicate a severed artery, in which case use a tactical tourniquet or other available method to stem the bleeding. If it’s a serious gash that immobilises them you’ll need to evacuate, but for minor cuts you might be able to stabilise and exit under your own steam.
• Burns: Likely if you’re boiling up lunch on a camping stove, so if you can get the patient to a stream or have a good supply of cool water, run the burn under this for at least 20 minutes. Snow is not advised by the official First Aid guide, as it may end up causing frost bite, so if you can only use snow, wrap it in something where there’s no direct skin contact (Like a spare t-shirt or storage bag). If the burn is blistering or bleeding, ensure it’s clean and cover with a non-stick dressing. A clean, slippery surface like the inside lining of a waterproof bag, glad wrap or tin foil may suffice if no one has a non-stick dressing. Most of these style burns will be non life-threatening, but evacuate if a burn has run around an entire limb or trunk of the body or if the patient won’t be able to ski or skin out by themselves. You may also need to treat the patient for shock, which is largely similar to treating Hypothermia.
• Asthma: Always a risk for someone with a prior history on a big hike or in cold weather. If they can’t self medicate, give 4 puffs of a puffer like Ventolin (Grey/blue canister) every 4 minutes until symptoms subside, using a spacer if one’s available for best effect. Evacuate if there’s no improvement after 20-30 minutes as they’ll likely need serious medical attention. 
• Snow Blindness: This will be caused on bright sunny days if the patient hasn’t been wearing proper eye protection (Sunglasses or goggles). Note that general fashion sunglasses are usually inadequate for the snow, so try and wear proper glacier glasses with very dark lenses and side coverings. Treatment for severe snow blindness is to keep the patient in-doors, so you may need to evacuate if the patient still has symptoms that prevent them from returning under their own steam.
• Avalanche: This post doesn’t attempt to address avalanche safety or rescue, but bear in mind that someone who’s been buried or swept by an avalanche will probably have very serious injuries such as internal organ damage, broken bones, head and neck injuries or even be in cardiac arrest. Activate your evacuation plan as soon as you know someone has been buried or isn’t moving and then address their injuries once you reach them. You’ll need to keep them stable until help arrives.
• Preparing for a rescue: As detailed already, if your patient is immobile and in need of critical care you’ll need to initiate a rescue. This will be done by either activating a PLB, contacting 000 if you have a mobile signal or relying on your home base person to do so when you haven’t called in at a pre-agreed time. The group should stay together unless it’s absolutely critical for no less than two members of the group to go for help and no less than one person stay with the patient. Otherwise, sit tight and make sure everyone is warm, comfortable and you have adequate shelter for a potentially long wait, taking turns to monitor and reassure the patient. If you’re in a forested area, locate an open space where a helicopter may be able to land and mark this with obvious objects (Skis, backpacks, space blankets etc) to be seen from the air. This area should be as flat as possible, at least 30m in diameter and be free of obstacles like large rocks or fallen trees. If you have the ability to send the GPS or map coordinates of this spot to emergency services, do so. If you think there’s more likelihood of being found by a ground search team due to terrain or adverse weather conditions, establish clear markers of your position that might be seen by an approaching party. Establish a roster so that there’s always someone awake to alert a rescue party if you hear them approaching. Headlamps are an excellent way to alert rescuers in low light conditions.
• Monitoring and hand over: In all serious situations where you’ve activated your evacuation plan, continue to monitor the patient’s heart rate and breathing and any other symptoms at 10 minute intervals, recording the results on paper. If they’re conscious also record any allergies they have (e.g. Penicillin), their last food and drink or anything you give them whilst keeping them reassured and comfortable. The “I MIST AMBO” format is excellent for this: Introduction (you and patient) / Mechanism of injury, Injuries, Signs/Symptoms, Treatments / Allergies, Medications, Background (medical history), Other. You can then pass this information to the paramedic or other rescuer when they arrive so that the hospital the doctors have a clear record of their condition before they arrived.

These are the main considerations we can currently think of for planning your ski or snowboard tour and the common scenarios you might need to deal with. This is based on Australian standards for First Aid and rescue, so may differ in other countries. We welcome any ideas or advice that may improve the tips provided here.

Just remember that good planning and prevention are the best cures and that professional evacuation is often going to be your best contingency in the event of something serious happening!

Resources:

• Red Cross Australia: Remote Area First Aid
• Snow Safety Australia: Alpine First Aid & Avalanche Skills Training
• Alpine Access Australia: Avalanche Skills Training
• Mountain Sports Collective: Backcountry Conditions Bulletin
• NSW SES Alpine Search & Rescue Unit: Alpine Alerts
• Alpine Search & Rescue Victoria: Alpine Alerts