March 25, 2025 • 23 mins
In this episode, we dive into one of the most overlooked but deadly hazards in deep powder skiing: snow immersion suffocation (NARSID). Unlike avalanches, snow immersion deaths happen silently—often within feet of a groomed run—when skiers and snowboarders fall into deep snow or tree wells and become trapped. We explore the research behind these incidents, where and how they occur, who is most at risk, and the tragic mechanics of asphyxiation in deep snow. Using studies from Van Tilburg, Baugher, and Cadman, we break down ra eal survival story, discuss prevention strategies, and how both bystanders and professional rescuers should respond. Whether you’re a backcountry adventurer, resort skier, or ski patroller, this episode will change the way you think about deep snow safety. Stay aware, ski with a partner, and stay out of tree wells.
Must Watch: GoPro Awards: Tree Well Rescue
Citations
Baugher, P. (2006). Risk trends at U.S. and British Columbia ski areas: An evaluation of the risk of snow immersion versus avalanche burials. In Proceedings of the 2006 International Snow Science Workshop (pp. 584–591). International Snow Science Workshop.
URL: https://arc.lib.montana.edu/snow-science/item/2076
Cadman, R. (1999). Eight nonavalanche snow-immersion deaths: A 6-year series from British Columbia ski areas. The Physician and Sportsmedicine, 27(13), 31–43.
URL: (No publicly available link found—may be available through institutional access)
Van Tilburg, C. (2010). Non–avalanche-related snow immersion deaths: Tree well and deep snow immersion asphyxiation. Wilderness & Environmental Medicine, 21(3), 257–261.
URL: https://doi.org/10.1016/j.wem.2010.04.004
Van Tilburg, C. S., Grissom, C. K., Zafren, K., McIntosh, S. E., Radwin, M. I., Paal, P., et al. (2017). Wilderness Medical Society practice guidelines for the prevention and management of avalanche and non-avalanche snow burial accidents. Wilderness & Environmental Medicine, 28(1), 23–42.
URL: https://doi.org/10.1016/j.wem.2016.10.001
Chapters
00:00 Introduction: The Hidden Dangers of Snow Immersion
00:37 Understanding Snow Immersion Suffocation
02:58 Historical Context and Research
03:09 Where and How Snow Immersion Happens
04:54 Mechanics of Snow Immersion Traps
06:23 Risk Factors and Victim Profiles
09:27 Prevention and Safety Measures
11:48 Rescue Techniques and Immediate Response
13:34 Professional Rescuer Guidelines
16:12 Advanced Medical Care and Resuscitation
20:11 Conclusion and Final Thoughts
As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.
Connect with us by email at wildernessmedicineupdates@gmail.com.
You can pay us a compliment and share the show with a new listener on any popular platform here.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:05):
Imagine you're skiing orsnowboarding in a beautiful
backcountry glade.
The powder is waist deep.
The trees are towering above,and each turn is effortless.
It's a perfect day, but in asplit second, your world flips.
Literally.
You fall tumbling forward into atree.
Well, that powder you'reenjoying collapses around you
(00:25):
like quicksand.
Your arms are pinned and yourmouth is filling with snow.
You try to yell for help, butthere's no air.
You struggle, but every movementmakes you sink deeper into the
hole.
This is snow immersionsuffocation, one of the least
studied but most lethal hazardsin powder skiing.
(00:46):
Unlike avalanches where thedestructive force is obvious,
this danger lurks silentlybeneath the surface, waiting for
an unsuspecting skier or riderto fall the wrong way.
Welcome back to WildernessMedicine, updates the show for
providers at the edges.
I'm your host, Dr.
Patrick Fink, and today we'regoing to explore the history of
(01:10):
snow immersion research, therealities of how it happens, and
importantly, what you canpotentially do to avoid this
scenario.
And some guidance for careproviders who may manage
patients who are victims of snowimmersion.
So what is snow immersion?
(01:30):
Snow immersion suffocationsometimes called non avalanche
related Snow Immersion death, orN-A-R-S-I-D for not easy, but
short happens when a skier orsnowboarder falls into deep snow
and becomes unable to escapeleading to asphyxiation.
Most often this occurs in atree.
Well, and this is the void thatforms around the base,
(01:53):
particularly of large conifertrees where the snowfall is not
compacted and where there'sperhaps a void of, um, space
where branches along the base ofthe tree create an area where
you can fall in.
But it can also happen alongdeep drifts in gullies or in
other sorts of micro terraintraps.
(02:15):
Unlike avalanches, which get alot of attention, snow immersion
deaths are relatively quiet andare only recognized within the
local community.
I'm bringing this to attentionin the podcast because you know
our community here in Bend,Oregon Mount Bachelor is
actually one of the hotspots, ifyou will, of snow immersion
suffocation.
(02:35):
We with the Cascade Snowpack,which we'll talk about in a
minute.
See a lot of these problems andjust recently suffered another
snow immersion suffocation deathat the ski resort.
These deaths can occur withinfeet of a groom ski trail.
A victim disappears oftenwithout a sound and their fate
is sealed in minutes unlesssomeone sees it happen and acts
(02:56):
immediately.
This wasn't always recognized asa major risk in ski areas, and
it took a series of incidentsand dedicated research to expose
just how deadly deep snow couldbe.
So where does deep snowimmersion happen?
For snow immersion to be deadly,you need three things.
First, you need deep andunconsolidated snow, often a
(03:19):
meter or more of fresh powder.
Two, you need some steep or treeterrain areas with tree wells or
terrain traps that can increasethe risk associated with that
snow.
And third, you need a riderfalling headfirst.
Most fatalities occur whensomeone goes into one of these
tree wells upside down.
(03:40):
This combination is most commonin Western North America.
British Columbia, Washington,Oregon, California, and Colorado
are hotspots because they haveheavy snowfall and dense
evergreen forests.
Any studies that I mentionduring this podcast, check'em
out.
Down in the show notes, I have'em listed in order and you can
(04:00):
see these references if youlike.
Studies by Bauer from 2006 andVan Tilburg in 2010 confirm that
the majority of documented snowimmersion deaths have occurred
in the Pacific Northwest and inthe Sierra Nevada.
Unlike avalanche terrain, whichis often remote, high altitude
terrain, snow immersion deathstypically happen in bounds, even
(04:22):
on well-traveled slopes, andthis is probably a fact that
relates to the fact that themajority of skiers are in those
settings.
We would see more of theseevents in the back country if we
had an equal skier populationthere.
There's nothing specific to theski resort that makes this more
likely to happen there.
It's simple exposure, mostlikely.
Indeed Ski patrollers in placeslike Mount Bachelor, Whistler,
(04:46):
and Jackson Hole have reportedmultiple fatalities within sight
of a lift or a groomed run.
Why does that happen?
To understand that we're gonnaneed to look at the mechanics of
how people get trapped.
A skier or snowboarder enters anarea of deep P, often weaving
between trees.
They catch an edge, hit a hiddenstump, or simply lose their
(05:07):
balance, and suddenly they'refalling forward.
Tree wells are the mostdangerous type of trap because a
conifers branches deflect snowaway from their base, forming a
deep soft cavity around thetrunk.
If a rider falls into one headfirst.
That can kind of act like asinkhole.
And the more that that riderstruggles, the deeper they sink
(05:28):
into the hole, and the more thesnow around them falls in around
them and seals them in.
In a 1999 study by Cadman fromBritish Columbia, researchers
simulated falls into tree wells.
They found that even experiencedskiers and snowboarders were
unable to self rescue.
In most cases, the snow wouldlock in around the patient's
(05:51):
body preventing movement, and ina panic, victims thrash
compacting the snow further andworsening their entrapment.
Bower in 2006 had a study thatreinforced these findings.
Over 90% of snow immersionfatalities occur when the
patient is upside down.
Two reasons there.
First, more likely to involvethe airway because you're face
(06:12):
down in the snow.
And second, even a small amountof snow covering the face in
that setting can lead tosuffocation within minutes.
So who's at risk of this?
Snow immersion doesn't justhappen to beginners or reckless
skiers.
It often happens to advanceskiers in deep powder
conditions.
Research shows that about 85% ofvictims are male, and typically
(06:35):
between the ages of 18 to 35,and that comes from Van Berg's
2010 paper.
Most are experienced skiers orsnowboarders riding off piece,
so off the groomed run in deeppowder.
This has gone back and forthbetween studies, but generally
speaking, there are slightlymore snowboarders than skiers
involved in snow immersiondeaths, and that has been
(06:56):
hypothesized to be related tothe difficulty of detaching from
their snowboard while inverted.
But that study where theysimulated tree well immersion
didn't show any benefit to beingable to escape from your skis.
So I suspect that this is morelikely related to how
snowboarders fall.
Namely, if they catch a.
(07:16):
Uh, downhill edge.
They're likely to fall headfirst, where skiers are more
likely to sort of fall in adiagonal manner, but that's just
my hypothesis.
Most victims, however, wereskiing alone or had become
separated from their groove.
So the risk profiles prettyclear.
If you like powder skiing andtree skiing, you need to be
(07:37):
aware of this danger, and youprobably shouldn't ski it alone.
Now, once this happens, how dopeople die from snow immersion?
The cause of death in snowimmersion is asphyxiation, and
that often happens within fiveto 10 minutes of burial, and
there's two mechanisms that areproposed.
The first and the most likely isairway obstruction.
(07:59):
Specifically, you fall headfirstinto a tree.
Well, as a victim, your mouthand nose become packed with
snow, and you can suffocatewithin minutes because you can't
breathe.
The other thing that can happenif a lot of snow packs in around
you is positional asphyxia.
And what that means is that inthis head down position with
compression on your chest, itmay be harder to breathe.
(08:19):
And so you can't actually take abreath because you've been
packed in snow.
Notably, unlike avalancheburials where victims may
survive with an air pocket, snowimmersion leaves almost no
chance for prolonged survival.
In Van Berg's review, alldocumented cases resulted in
death unless rescue occurredwithin 10 minutes.
(08:40):
And that's probably because whenpeople fall in the snowfalls in
around them.
And so the prevalence of an airpocket is very, very low.
Has anyone ever survived?
Yes, but only with immediatehelp.
So Van Berger and Bauer, bothdocumented cases where.
Rapid partner rescue savedlives.
(09:01):
For example, one notable exampleinvolved an off-duty ski
patroller who fell into a treewell, but was found by his
partner within several minutes.
CPR was started immediately, andhe was successfully resuscitated
after a few days, stay in thehospital.
But these cases are rare becauseif no one sees the fall, the
chances of survival approachzero.
(09:23):
So knowing that, how can we staysafe?
The answer looks to beprevention.
So snow immersion deaths arecompletely preventable.
Don't go skiing, I'm kidding.
We know that that's not anoption.
So more importantly, ski or ridewith a partner and maintain
(09:43):
visual contact.
So if you lose sight of oneanother, stop and regroup.
And if one of you falls into atree, well the other may see it
and be able to initiate animmediate partner Rescue.
The second is to give trees awide berth.
If you treat a tree well like acliff, then you're less likely
to fall into it.
Assume the tree well isdangerous.
Assume it's an edge that youdon't want to go over.
(10:06):
The third is kind of obvious.
If you can stroke one.
Third, staying on your feet isimportant.
If you feel yourself falling,you want to avoid going
headfirst into a tree, well, sograb the tree fall or roll
towards your side and spread outyour limbs to avoid going in
headfirst.
(10:27):
It is helpful to carry a whistleor a radio somewhere near your
face.
There was a documented case ofsurvival in which a patient was
able to call a friend using aradio when they became headfirst
upside down in a tree.
Well, so having a whistle or aradio some way to call for help
that is near your head and thatyou would be able to reach in a
(10:48):
pinch may be a prudent idea.
It is also a reasonable idea towear an avalanche beacon when
skiing powder in bounds.
Though this isn't standardpractice, there have been plenty
of examples of inboundsavalanches, and I think that
it's a reasonable idea and somevictims have been located more
quickly after tree well burialwhile wearing a beacon.
(11:14):
So these simple steps,particularly not riding alone,
can mean the difference betweenlife and death.
If you need a very, very salientexample of this, take a look
down in the show notes and lookat the GoPro video that shows a
tree well immersion in realtime.
You can see that rescue happenover the course of just a few
(11:36):
minutes and feel the tension andfeel the urgency and understand
why this would not be a goodthing to continue for 20 or 30
minutes.
So.
What happens if you're thatpartner and you need to affect
the rescue?
If your partner goes into atree, well, you should go
(11:56):
directly to where they fell andyou should not leave to go get
help.
Reason being, it may be verydifficult to find that person
from even a short distance away.
Additionally, you may have onlya few minutes to clear their
airway before they die, so youneed to be the rescuer.
It is generally a good idea toapproach from the downhill side
so that you're not kickingadditional snow into that tree
(12:19):
well, and you want to digtowards their face and target
clearing their airway first, andthen continue digging to
extricate their torso and legs.
That patient needs to come outof that hole because we
obviously can't work on them inthe hole.
And once extricated, if they'reunresponsive and don't have
breathing and a pulse, then youshould begin CPR immediately
(12:40):
with a presumed cause of deathof asphyxia.
A small point of fact here isthat if this is a deep powder
scenario, then you're gonna wantto create some sort of little
platform for you to be able toperform effective compressions.
Recently the case at MattBachelor, a bystander began
performing CPR and it wasactually occurring on a
(13:03):
snowboard that they placed underthe patient's torso, which is
genius.
Well done.
Use your snowboard, use yourskis.
Create some kind of platform soyour compressions are actually
being transmitted to thepatient, and make sure to give
rescue breaths.
In this scenario, this is notthe time for compression only
CPR, because with asphyxia weneed some air moving in and out
(13:24):
to resuscitate this patient.
Now, how about professionalrescuers and medical management
of folks after you respond tothem in a professional setting?
So when ski patrollers searchand rescue teams or emergency
medical providers respond to asnow immersion accident, the
approach here is gonna be verydifferent from an avalanche
(13:44):
burial.
While avalanche rescues ofteninvolve transceivers, probes,
and large scale searchoperations, snow immersion
rescues require an immediatefocus.
On location, airway managementand rapid extrication.
So what does the research sayabout how professional rescuers
should handle these cases?
The Wilderness Medicine SocietyGuidelines for Avalanche and Non
(14:07):
Avalanche Snow Burial, also byVan Tilburg, but from 2017
provide evidence-basedrecommendations for professional
rescue teams responding to nonavalanche related snow immersion
deaths.
The NAR Sid we talked aboutearlier.
These guidelines emphasize thata rapid response is critical
because the chances of survivaldrop after that first five to 10
(14:28):
minutes.
So if a skier snowboarder isreported missing in deep snow
conditions, search teams shouldprioritize looking in tree
wells, terrain depressions, andbeginning at an area where the
victim was last seen.
Unlike avalanche burials wherebeacons, recco, reflectors, or
probe lines are effective, mostno immersion victims are found.
(14:50):
With a partially visible pieceof clothing or a board or what
have you.
So that means a visual scan oflikely terrain features should
be the priority, not necessarilya transceiver search, which
should be kind of a secondaryconsideration as more resources
arrive on scene.
Once a patient is found, therescue priorities are pretty
clear, so we need immediateairway access and clearance
(15:14):
heading for the victim's face,and ensuring the airway is free
of snow.
Before attempting to extricatethe rest of the body while doing
that, we wanna minimize furtherentrapment.
So instead of pulling on limbs,we should dig from the side or
from below to prevent additionalsnow collapsing around that
airway.
And then we need a rapid butcontrolled extrication.
(15:35):
So unlike an avalanche victimwhere spinal injuries are a
concern, snow immersion victimsshould be dug out as quickly as
humanly possible, prioritizingairway and clearing that torso.
And we can be less careful aboutthose spinal precautions.
Obviously, use your judgmenthere because this patient could
have collided with the tree.
So if there's evidence oftrauma, take that into
(15:56):
consideration.
But those traumatic injuriesdon't matter terribly much if
the patient doesn't survivetheir asphyxia.
So these principles mirror theapproach taken in your drowning
accidents, and the goal is torestore breathing as soon as
possible.
When it comes to the advancedmedical care for these patients,
we can consider a few points.
(16:17):
So airway management, patientswho are unconscious but still
breathing should receivesupplemental oxygen and need to
be monitored for things such asaspiration down the line.
If they're not breathing, thenwe just wanna deliver high flow
oxygen and deliver those breathsby whatever means is necessary.
Take a look back at a recentepisode on LMAs.
(16:40):
That's an entirely reasonablething.
Use bag, valve mask, whateveryou have available to you for
pulseless victims.
If there's no pulse present,then chest compressions and
rescue breathing is essentialbecause death is primarily due
to oxygen deprivation.
We need some gas exchange and weneed to circulate that blood.
How about hypothermia?
Well, unlike avalanche burials,deep hypothermia is usually not
(17:03):
a major factor in snow immersioncases because victims suffocate
generally before they can coolsignificantly.
This does in large part mirroravalanche burials in that
hypothermia makes up at most oneto 2% of cases.
So we don't generally need toapply a hypothermic cardiac
arrest protocol, namelyprolonged resuscitative efforts.
(17:28):
To these patients.
What I would say and what I'lltell my teams is if you extract
that patient and they're incardiac arrest, we're gonna
continue resuscitative effortsuntil you can get to a
reasonable place where you feellike you've done a good job
coding that patient.
Probably 20 to 30 minutes of CPRand good respirations, and then
(17:50):
I would prefer to obtain a coretemperature and demonstrate that
they're not severelyhypothermic.
And the chances are they're notgoing to be.
So according to the WMSguidelines, as you're conducting
that resuscitation, if there isan a ED available, we want to
analyze the rhythm.
And if they're in V-fib,consider defibrillating.
(18:14):
However, the majority of thesepatients are gonna present in
asystole because of theirasphyxia.
So the a ED is less likely to behelpful here than in a typical
medical cardiac arrest patient.
According to the WMS guidelines,if a snow immersion victim is
pulseless and has been buriedfor over 60 minutes and has no
signs of life, the likelihood ofsurvival is extremely low.
(18:38):
So long duration, CPR is gonnabe less effective.
But of course, the decision tostop resuscitation should be
made based on downtime, clinicaljudgment, and core temperature
if available.
So takeaways for rescuers.
If you're responding to a snowimmersion incident, you need to
(18:58):
respond quickly and aggressivelywith as many human resources as
possible.
Because we have only a shortperiod of time before asphyxia
results in death, we need all ofthose people to conduct a rapid
visual search beginning wherethe victim was last seen.
Most of these victims arepartially visible, so we're
(19:20):
scanning tree wells and deepsnow depressions before we go to
probes and transceivers as kindof a second line.
Once located, our priority is toclear the airway first.
Don't make it worse bycompressing snow in around the
patient's head and then rapidlyextricate the patient to where
they can be resuscitated ifneeded.
(19:41):
If they're unconscious and notbreathing, don't have a pulse.
We're gonna start CPR andprovide oxygen as soon as
possible.
Hypothermic prolonged CPRprotocols are unlikely to be
helpful, so we're gonna workthem for 20 to 30 minutes with
standard A CLS care.
If someone survives a tree, wellaccident, even if they are awake
(20:02):
and talking, they should betransported for medical
evaluation because they coulddevelop respiratory
complications down the line,such as aspiration pneumonia.
So let's wrap this up.
Snow immersion suffocation isone of the silent but deadly
hazards in the winterenvironment.
(20:22):
The difference between life anddeath in these scenarios often
comes down to minutes and.
To the actions of nearby skiersand rescuers by understanding
how these incidents happen,skiing with a partner and
knowing how to respond.
If we see someone fall into atree, well, if we're responding
to one of these events, can turnthe tide on this killer entity.
(20:46):
So ski safe, stay with apartner.
And treat tree wells like cliffsand be aware that the majority
of these events happen afterseveral feet of fresh snow and
are more prevalent within theWestern us.
Whether you're a backcountryskier, resort skier, ski
(21:07):
patroller, or SA a member, Ihope this episode.
It helps parse the way that youthink about deep snow safety and
how you respond to these events.
So please stay aware, ski with aPartner, and avoid trade wells.
That wraps up this episode ofWilderness Medicine Updates.
I hope you enjoy the show.
(21:28):
If you want to get in touch, asalways, you can reach out at
Wilderness Medicineupdates@gmail.com.
I appreciate all the questionsthat I get there and have some
really interesting things comingdown the pipeline because of
connections that have been madethrough that outlet.
So not yet on any social mediaplatforms, prefer to meet
(21:50):
one-on-one with folks.
No question is a stupidquestion.
'cause if you have the question,then somebody else does and I
love to hear from you all.
Even if you just wanna shout outand say, hey.
If you like the show and want tohelp support me, the best way
that you can do that is twothings.
The first is give me a five starreview on Apple Podcasts on
(22:10):
Spotify, wherever you listen.
'cause that helps get that outto more people.
And then the second thing thatyou can do is you can share this
episode or an episode that youlike with someone like you,
whether that's a ski patroller,a backcountry skier.
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(22:33):
think will appreciate this,share it with one person today
and help this show grow andreach more people.
I thank you for doing that.
It's the best way and each oneof these episodes we're seeing a
little bit more traction.
Get more traction, and I lovethat because.
I wanna bring good informationto more people, more people just
like you.
(22:53):
So I hope that you enjoyed thisepisode.
I'm your host, Patrick Fink, anduntil next time, stay fit, stay
focused, and have fun.
Imagine you're skiing orsnowboarding in a beautiful
backcountry glade.
The powder is waist deep.
The trees are towering above,and each turn is effortless.
It's a perfect day, but in asplit second, your world flips.
Literally.
You fall tumbling forward into atree.
Well, that powder you'reenjoying collapses around you
(00:25):
like quicksand.
Your arms are pinned and yourmouth is filling with snow.
You try to yell for help, butthere's no air.
You struggle, but every movementmakes you sink deeper into the
hole.
This is snow immersionsuffocation, one of the least
studied but most lethal hazardsin powder skiing.
(00:46):
Unlike avalanches where thedestructive force is obvious,
this danger lurks silentlybeneath the surface, waiting for
an unsuspecting skier or riderto fall the wrong way.
Welcome back to WildernessMedicine, updates the show for
providers at the edges.
I'm your host, Dr.
Patrick Fink, and today we'regoing to explore the history of
(01:10):
snow immersion research, therealities of how it happens, and
importantly, what you canpotentially do to avoid this
scenario.
And some guidance for careproviders who may manage
patients who are victims of snowimmersion.
So what is snow immersion?
(01:30):
Snow immersion suffocationsometimes called non avalanche
related Snow Immersion death, orN-A-R-S-I-D for not easy, but
short happens when a skier orsnowboarder falls into deep snow
and becomes unable to escapeleading to asphyxiation.
Most often this occurs in atree.
Well, and this is the void thatforms around the base,
(01:53):
particularly of large conifertrees where the snowfall is not
compacted and where there'sperhaps a void of, um, space
where branches along the base ofthe tree create an area where
you can fall in.
But it can also happen alongdeep drifts in gullies or in
other sorts of micro terraintraps.
(02:15):
Unlike avalanches, which get alot of attention, snow immersion
deaths are relatively quiet andare only recognized within the
local community.
I'm bringing this to attentionin the podcast because you know
our community here in Bend,Oregon Mount Bachelor is
actually one of the hotspots, ifyou will, of snow immersion
suffocation.
(02:35):
We with the Cascade Snowpack,which we'll talk about in a
minute.
See a lot of these problems andjust recently suffered another
snow immersion suffocation deathat the ski resort.
These deaths can occur withinfeet of a groom ski trail.
A victim disappears oftenwithout a sound and their fate
is sealed in minutes unlesssomeone sees it happen and acts
(02:56):
immediately.
This wasn't always recognized asa major risk in ski areas, and
it took a series of incidentsand dedicated research to expose
just how deadly deep snow couldbe.
So where does deep snowimmersion happen?
For snow immersion to be deadly,you need three things.
First, you need deep andunconsolidated snow, often a
(03:19):
meter or more of fresh powder.
Two, you need some steep or treeterrain areas with tree wells or
terrain traps that can increasethe risk associated with that
snow.
And third, you need a riderfalling headfirst.
Most fatalities occur whensomeone goes into one of these
tree wells upside down.
(03:40):
This combination is most commonin Western North America.
British Columbia, Washington,Oregon, California, and Colorado
are hotspots because they haveheavy snowfall and dense
evergreen forests.
Any studies that I mentionduring this podcast, check'em
out.
Down in the show notes, I have'em listed in order and you can
(04:00):
see these references if youlike.
Studies by Bauer from 2006 andVan Tilburg in 2010 confirm that
the majority of documented snowimmersion deaths have occurred
in the Pacific Northwest and inthe Sierra Nevada.
Unlike avalanche terrain, whichis often remote, high altitude
terrain, snow immersion deathstypically happen in bounds, even
(04:22):
on well-traveled slopes, andthis is probably a fact that
relates to the fact that themajority of skiers are in those
settings.
We would see more of theseevents in the back country if we
had an equal skier populationthere.
There's nothing specific to theski resort that makes this more
likely to happen there.
It's simple exposure, mostlikely.
Indeed Ski patrollers in placeslike Mount Bachelor, Whistler,
(04:46):
and Jackson Hole have reportedmultiple fatalities within sight
of a lift or a groomed run.
Why does that happen?
To understand that we're gonnaneed to look at the mechanics of
how people get trapped.
A skier or snowboarder enters anarea of deep P, often weaving
between trees.
They catch an edge, hit a hiddenstump, or simply lose their
(05:07):
balance, and suddenly they'refalling forward.
Tree wells are the mostdangerous type of trap because a
conifers branches deflect snowaway from their base, forming a
deep soft cavity around thetrunk.
If a rider falls into one headfirst.
That can kind of act like asinkhole.
And the more that that riderstruggles, the deeper they sink
(05:28):
into the hole, and the more thesnow around them falls in around
them and seals them in.
In a 1999 study by Cadman fromBritish Columbia, researchers
simulated falls into tree wells.
They found that even experiencedskiers and snowboarders were
unable to self rescue.
In most cases, the snow wouldlock in around the patient's
(05:51):
body preventing movement, and ina panic, victims thrash
compacting the snow further andworsening their entrapment.
Bower in 2006 had a study thatreinforced these findings.
Over 90% of snow immersionfatalities occur when the
patient is upside down.
Two reasons there.
First, more likely to involvethe airway because you're face
(06:12):
down in the snow.
And second, even a small amountof snow covering the face in
that setting can lead tosuffocation within minutes.
So who's at risk of this?
Snow immersion doesn't justhappen to beginners or reckless
skiers.
It often happens to advanceskiers in deep powder
conditions.
Research shows that about 85% ofvictims are male, and typically
(06:35):
between the ages of 18 to 35,and that comes from Van Berg's
2010 paper.
Most are experienced skiers orsnowboarders riding off piece,
so off the groomed run in deeppowder.
This has gone back and forthbetween studies, but generally
speaking, there are slightlymore snowboarders than skiers
involved in snow immersiondeaths, and that has been
(06:56):
hypothesized to be related tothe difficulty of detaching from
their snowboard while inverted.
But that study where theysimulated tree well immersion
didn't show any benefit to beingable to escape from your skis.
So I suspect that this is morelikely related to how
snowboarders fall.
Namely, if they catch a.
(07:16):
Uh, downhill edge.
They're likely to fall headfirst, where skiers are more
likely to sort of fall in adiagonal manner, but that's just
my hypothesis.
Most victims, however, wereskiing alone or had become
separated from their groove.
So the risk profiles prettyclear.
If you like powder skiing andtree skiing, you need to be
(07:37):
aware of this danger, and youprobably shouldn't ski it alone.
Now, once this happens, how dopeople die from snow immersion?
The cause of death in snowimmersion is asphyxiation, and
that often happens within fiveto 10 minutes of burial, and
there's two mechanisms that areproposed.
The first and the most likely isairway obstruction.
(07:59):
Specifically, you fall headfirstinto a tree.
Well, as a victim, your mouthand nose become packed with
snow, and you can suffocatewithin minutes because you can't
breathe.
The other thing that can happenif a lot of snow packs in around
you is positional asphyxia.
And what that means is that inthis head down position with
compression on your chest, itmay be harder to breathe.
(08:19):
And so you can't actually take abreath because you've been
packed in snow.
Notably, unlike avalancheburials where victims may
survive with an air pocket, snowimmersion leaves almost no
chance for prolonged survival.
In Van Berg's review, alldocumented cases resulted in
death unless rescue occurredwithin 10 minutes.
(08:40):
And that's probably because whenpeople fall in the snowfalls in
around them.
And so the prevalence of an airpocket is very, very low.
Has anyone ever survived?
Yes, but only with immediatehelp.
So Van Berger and Bauer, bothdocumented cases where.
Rapid partner rescue savedlives.
(09:01):
For example, one notable exampleinvolved an off-duty ski
patroller who fell into a treewell, but was found by his
partner within several minutes.
CPR was started immediately, andhe was successfully resuscitated
after a few days, stay in thehospital.
But these cases are rare becauseif no one sees the fall, the
chances of survival approachzero.
(09:23):
So knowing that, how can we staysafe?
The answer looks to beprevention.
So snow immersion deaths arecompletely preventable.
Don't go skiing, I'm kidding.
We know that that's not anoption.
So more importantly, ski or ridewith a partner and maintain
(09:43):
visual contact.
So if you lose sight of oneanother, stop and regroup.
And if one of you falls into atree, well the other may see it
and be able to initiate animmediate partner Rescue.
The second is to give trees awide berth.
If you treat a tree well like acliff, then you're less likely
to fall into it.
Assume the tree well isdangerous.
Assume it's an edge that youdon't want to go over.
(10:06):
The third is kind of obvious.
If you can stroke one.
Third, staying on your feet isimportant.
If you feel yourself falling,you want to avoid going
headfirst into a tree, well, sograb the tree fall or roll
towards your side and spread outyour limbs to avoid going in
headfirst.
(10:27):
It is helpful to carry a whistleor a radio somewhere near your
face.
There was a documented case ofsurvival in which a patient was
able to call a friend using aradio when they became headfirst
upside down in a tree.
Well, so having a whistle or aradio some way to call for help
that is near your head and thatyou would be able to reach in a
(10:48):
pinch may be a prudent idea.
It is also a reasonable idea towear an avalanche beacon when
skiing powder in bounds.
Though this isn't standardpractice, there have been plenty
of examples of inboundsavalanches, and I think that
it's a reasonable idea and somevictims have been located more
quickly after tree well burialwhile wearing a beacon.
(11:14):
So these simple steps,particularly not riding alone,
can mean the difference betweenlife and death.
If you need a very, very salientexample of this, take a look
down in the show notes and lookat the GoPro video that shows a
tree well immersion in realtime.
You can see that rescue happenover the course of just a few
(11:36):
minutes and feel the tension andfeel the urgency and understand
why this would not be a goodthing to continue for 20 or 30
minutes.
So.
What happens if you're thatpartner and you need to affect
the rescue?
If your partner goes into atree, well, you should go
(11:56):
directly to where they fell andyou should not leave to go get
help.
Reason being, it may be verydifficult to find that person
from even a short distance away.
Additionally, you may have onlya few minutes to clear their
airway before they die, so youneed to be the rescuer.
It is generally a good idea toapproach from the downhill side
so that you're not kickingadditional snow into that tree
(12:19):
well, and you want to digtowards their face and target
clearing their airway first, andthen continue digging to
extricate their torso and legs.
That patient needs to come outof that hole because we
obviously can't work on them inthe hole.
And once extricated, if they'reunresponsive and don't have
breathing and a pulse, then youshould begin CPR immediately
(12:40):
with a presumed cause of deathof asphyxia.
A small point of fact here isthat if this is a deep powder
scenario, then you're gonna wantto create some sort of little
platform for you to be able toperform effective compressions.
Recently the case at MattBachelor, a bystander began
performing CPR and it wasactually occurring on a
(13:03):
snowboard that they placed underthe patient's torso, which is
genius.
Well done.
Use your snowboard, use yourskis.
Create some kind of platform soyour compressions are actually
being transmitted to thepatient, and make sure to give
rescue breaths.
In this scenario, this is notthe time for compression only
CPR, because with asphyxia weneed some air moving in and out
(13:24):
to resuscitate this patient.
Now, how about professionalrescuers and medical management
of folks after you respond tothem in a professional setting?
So when ski patrollers searchand rescue teams or emergency
medical providers respond to asnow immersion accident, the
approach here is gonna be verydifferent from an avalanche
(13:44):
burial.
While avalanche rescues ofteninvolve transceivers, probes,
and large scale searchoperations, snow immersion
rescues require an immediatefocus.
On location, airway managementand rapid extrication.
So what does the research sayabout how professional rescuers
should handle these cases?
The Wilderness Medicine SocietyGuidelines for Avalanche and Non
(14:07):
Avalanche Snow Burial, also byVan Tilburg, but from 2017
provide evidence-basedrecommendations for professional
rescue teams responding to nonavalanche related snow immersion
deaths.
The NAR Sid we talked aboutearlier.
These guidelines emphasize thata rapid response is critical
because the chances of survivaldrop after that first five to 10
(14:28):
minutes.
So if a skier snowboarder isreported missing in deep snow
conditions, search teams shouldprioritize looking in tree
wells, terrain depressions, andbeginning at an area where the
victim was last seen.
Unlike avalanche burials wherebeacons, recco, reflectors, or
probe lines are effective, mostno immersion victims are found.
(14:50):
With a partially visible pieceof clothing or a board or what
have you.
So that means a visual scan oflikely terrain features should
be the priority, not necessarilya transceiver search, which
should be kind of a secondaryconsideration as more resources
arrive on scene.
Once a patient is found, therescue priorities are pretty
clear, so we need immediateairway access and clearance
(15:14):
heading for the victim's face,and ensuring the airway is free
of snow.
Before attempting to extricatethe rest of the body while doing
that, we wanna minimize furtherentrapment.
So instead of pulling on limbs,we should dig from the side or
from below to prevent additionalsnow collapsing around that
airway.
And then we need a rapid butcontrolled extrication.
(15:35):
So unlike an avalanche victimwhere spinal injuries are a
concern, snow immersion victimsshould be dug out as quickly as
humanly possible, prioritizingairway and clearing that torso.
And we can be less careful aboutthose spinal precautions.
Obviously, use your judgmenthere because this patient could
have collided with the tree.
So if there's evidence oftrauma, take that into
(15:56):
consideration.
But those traumatic injuriesdon't matter terribly much if
the patient doesn't survivetheir asphyxia.
So these principles mirror theapproach taken in your drowning
accidents, and the goal is torestore breathing as soon as
possible.
When it comes to the advancedmedical care for these patients,
we can consider a few points.
(16:17):
So airway management, patientswho are unconscious but still
breathing should receivesupplemental oxygen and need to
be monitored for things such asaspiration down the line.
If they're not breathing, thenwe just wanna deliver high flow
oxygen and deliver those breathsby whatever means is necessary.
Take a look back at a recentepisode on LMAs.
(16:40):
That's an entirely reasonablething.
Use bag, valve mask, whateveryou have available to you for
pulseless victims.
If there's no pulse present,then chest compressions and
rescue breathing is essentialbecause death is primarily due
to oxygen deprivation.
We need some gas exchange and weneed to circulate that blood.
How about hypothermia?
Well, unlike avalanche burials,deep hypothermia is usually not
(17:03):
a major factor in snow immersioncases because victims suffocate
generally before they can coolsignificantly.
This does in large part mirroravalanche burials in that
hypothermia makes up at most oneto 2% of cases.
So we don't generally need toapply a hypothermic cardiac
arrest protocol, namelyprolonged resuscitative efforts.
(17:28):
To these patients.
What I would say and what I'lltell my teams is if you extract
that patient and they're incardiac arrest, we're gonna
continue resuscitative effortsuntil you can get to a
reasonable place where you feellike you've done a good job
coding that patient.
Probably 20 to 30 minutes of CPRand good respirations, and then
(17:50):
I would prefer to obtain a coretemperature and demonstrate that
they're not severelyhypothermic.
And the chances are they're notgoing to be.
So according to the WMSguidelines, as you're conducting
that resuscitation, if there isan a ED available, we want to
analyze the rhythm.
And if they're in V-fib,consider defibrillating.
(18:14):
However, the majority of thesepatients are gonna present in
asystole because of theirasphyxia.
So the a ED is less likely to behelpful here than in a typical
medical cardiac arrest patient.
According to the WMS guidelines,if a snow immersion victim is
pulseless and has been buriedfor over 60 minutes and has no
signs of life, the likelihood ofsurvival is extremely low.
(18:38):
So long duration, CPR is gonnabe less effective.
But of course, the decision tostop resuscitation should be
made based on downtime, clinicaljudgment, and core temperature
if available.
So takeaways for rescuers.
If you're responding to a snowimmersion incident, you need to
(18:58):
respond quickly and aggressivelywith as many human resources as
possible.
Because we have only a shortperiod of time before asphyxia
results in death, we need all ofthose people to conduct a rapid
visual search beginning wherethe victim was last seen.
Most of these victims arepartially visible, so we're
(19:20):
scanning tree wells and deepsnow depressions before we go to
probes and transceivers as kindof a second line.
Once located, our priority is toclear the airway first.
Don't make it worse bycompressing snow in around the
patient's head and then rapidlyextricate the patient to where
they can be resuscitated ifneeded.
(19:41):
If they're unconscious and notbreathing, don't have a pulse.
We're gonna start CPR andprovide oxygen as soon as
possible.
Hypothermic prolonged CPRprotocols are unlikely to be
helpful, so we're gonna workthem for 20 to 30 minutes with
standard A CLS care.
If someone survives a tree, wellaccident, even if they are awake
(20:02):
and talking, they should betransported for medical
evaluation because they coulddevelop respiratory
complications down the line,such as aspiration pneumonia.
So let's wrap this up.
Snow immersion suffocation isone of the silent but deadly
hazards in the winterenvironment.
(20:22):
The difference between life anddeath in these scenarios often
comes down to minutes and.
To the actions of nearby skiersand rescuers by understanding
how these incidents happen,skiing with a partner and
knowing how to respond.
If we see someone fall into atree, well, if we're responding
to one of these events, can turnthe tide on this killer entity.
(20:46):
So ski safe, stay with apartner.
And treat tree wells like cliffsand be aware that the majority
of these events happen afterseveral feet of fresh snow and
are more prevalent within theWestern us.
Whether you're a backcountryskier, resort skier, ski
(21:07):
patroller, or SA a member, Ihope this episode.
It helps parse the way that youthink about deep snow safety and
how you respond to these events.
So please stay aware, ski with aPartner, and avoid trade wells.
That wraps up this episode ofWilderness Medicine Updates.
I hope you enjoy the show.
(21:28):
If you want to get in touch, asalways, you can reach out at
Wilderness Medicineupdates@gmail.com.
I appreciate all the questionsthat I get there and have some
really interesting things comingdown the pipeline because of
connections that have been madethrough that outlet.
So not yet on any social mediaplatforms, prefer to meet
(21:50):
one-on-one with folks.
No question is a stupidquestion.
'cause if you have the question,then somebody else does and I
love to hear from you all.
Even if you just wanna shout outand say, hey.
If you like the show and want tohelp support me, the best way
that you can do that is twothings.
The first is give me a five starreview on Apple Podcasts on
(22:10):
Spotify, wherever you listen.
'cause that helps get that outto more people.
And then the second thing thatyou can do is you can share this
episode or an episode that youlike with someone like you,
whether that's a ski patroller,a backcountry skier.
Someone in your wilderness firstaid class, an EMT, A doc, a
nurse, a flight medic, member ofyour military crew, whomever you
(22:33):
think will appreciate this,share it with one person today
and help this show grow andreach more people.
I thank you for doing that.
It's the best way and each oneof these episodes we're seeing a
little bit more traction.
Get more traction, and I lovethat because.
I wanna bring good informationto more people, more people just
like you.
(22:53):
So I hope that you enjoyed thisepisode.
I'm your host, Patrick Fink, anduntil next time, stay fit, stay
focused, and have fun.
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