Broken legs - Do US & Canadian patrollers remove pax's boots?

Scary thought.  I'm thinking if I had a tib+fib fracture, my foot would probably come off with the boot.  Do you patrol with a boot-splitter?

Having once been the victim, I can say I'm very glad a former patroller happened by and very quickly got my boot off. Yes, it hurt like a SOB but I know it would've been much, much worse 15 or 30 minutes later when the real pain set in.

It was a spiral tib-fib, Ghost, and yes after seeing the X-rays later I was sure my lower leg would just...I dunno, dangle or something without support. Very creepy feeling, however silly it might've been.

It depends on the  situation.  Generally it's better to splint them on the hill and get them to the aid room where you have tools and help.  You can do a much better job of stabilizing the break when removing the boot if you have extra hands.  We have morphine available, so we can manage the pain if it's bad later on - we can call in to the aid room and have someone set up the line so that it's ready to go as soon as we arrive.  Theoretically, we can also have it administered it on-hill, but that would be such a delay and so difficult that I haven't seen it happen in five seasons.

 

Our mountain isn't that big, so most of the time there isn't that much to gain by removing the boot.   

 

Edit: I have to say that pulling the boot on-hill as standard procedure could pose a risk for further damage to the pt, and lead to a lot of delay in getting them to advanced care especially on a smaller hill, so there should be a good medical reason for pulling it.  I don't think reducing later pain would be a universally good reason.  

Edited by Bob Lee - 11/19/11 at 6:18am

The Candian resort I patrolled did not remove boots as a protocol, but you could if you deemed it neccessary.

 

The American resort, it was part of our protocol, but many didn't do it.

 

We trained in boot removal all the time.  I'd rather have the patrol remove my boot than some hospital orderly who doesn't ski.

I would like the patrol to have the freedom to exercise judgement.  In theory, I'd prefer to have the boot removed by patrol, before swelling makes it much more difficult.  In practice, my boots do not come of until they are warmed up to room temp.  Wouldn't want a patrolman to struggle to remove them.

I patrol at a small mountain and we do not remove boots on the hill. We remove the boot in the aid room which is at most 10 minutes away, usually a lot less. I believe in the US each mountain sets their own protocol. As said above, we are practiced and skilled at boot removal, but in the aid room we have the room and people to do a better job than on the hill.

Interesting question.  Not an orthopod or vascular surgeon (or a patroller....YET) but do have some experience with trauma.  In general I would think that you do want to get the boots off, fairly soon, but not necessarily slope side (especially in a really steep, difficult to access slope side).  ABC's first, the extent of peripheral damage would be better assessed in the aid station, especially if the aid station is only 10 minutes out.  By the time you are ready to be pulling/cutting boots off, I assume that the ABC's are taken care of and they are in the sled and ready to go.  You never know what you might find under the boots.  Judgement calls are the order of the day.  Mabye I'm just scared by a couple of cases I saw during residency/fellowship, but I think I would rather take the boots off at the bottom of the hill where I would be more prepared to deal with what I might find (pain is a given). 

 

You may choose to read the following "cool story bro"... or not

 

Trauma surgery rotation as as a medicine resident.  40 something comes in after a motorcycle vs mountain road/tree.  Mild shock but breathing and mentating ok.  Obvious right hip fx (externally rotated and foreshortened).  Wearing a pair of Pierre the lumberjack knee length lace up leather boots.  I unlace and take off the right one, am rewarded with a quart of clot followed by an arterial squirter than goes at least 15 feet, which appears to be coming from the compound tib/fib fracture with the open wound about 18 cm above the ankle.  Senior trauma resident gives a standard (and reasonable) bark "get pressure on it and if you let off before I say I'll kick your ass."  Held pressure for 40 minutes, through the patient being, intubated, transported, multiple (ok 3),

ct/xrays, and also using up about 15 gauze packs (they just got soaked and I just kept adding them on top).  Patient finally ready for OR and the senior trauma resident says "OK, lets see what youve got there", pulled off the mound of blood soaked gauze and STILL got a squirter.  Eventually had to get a vascular surgeon in on the case, tuns out he had torn the fibular artery well above here I was holding pressure, and was tracking down.

 

So yeah... I might want to take the boots off where I have more control, but could be just scared

 

Wow! Cool story.  (to be a good patroller you have to be a trauma junky or avy junky).  The mountain where the protocall was to remove boots was to check the circulation.  Nothing like looking for a dorsalis pedis pulse on a cold day with layers of gloves and socks involved.  I would usually ask if their toes were numb.  If yes, I'd ask them if they were not numb before the accident.  If yes, the protocol was to remove the boot and make one attempt to straighten things out and get a pulse.  I never had to do that one, but a friend turned a backwards foot around and did restore circulation.

 

Just so we're perfectly clear, where I work we pretty much always take off the boot in the aid room, because you need to expose the injury to assess it, and for the reasons stated above.  When the ambulance comes, they are usually pretty glad that the boot is off.  

 

I thought this discussion was basically about whether to remove the boot on-hill.  

 

I wonder if the ER mentioned above had a saw to cut casts with that they could have used to cut the boot off.  

 

on our Smaller Eastern Ski area the standard practice is quick splint with the boot on the hill, remove the boot in the Aid room.   You absolutely can do a better job of splinting, properly evaluate the injury zone (CMS, etc),.  I think that Boot and Helmet removal is a fundamental patroller skill

Oddly enough, our protocol says to leave the boot on.  Even more oddly, every time the ambulance technicians arrive, they ask us to take them off, as they don't touch them.  Basically it is patient's call or the ambulance tech's call.  If the boot has to come off, they we'll do it.  (one guy holds the leg, one guy opens the boot, and one guy pulls the back of the boot to remove)  I've helped take off quite a few, never had a single complaint or scream!  BTW, we are not allowed to administer drugs of any kind.

Well,

 

Every area can establish their own protocols on something like this.  It's not 'wrong' to remove the boot on the hill, and I think we can all conceive of some unusual sitations where on-hill boot removal might be very desirable.

 

But, for all the reasons already posted above, I think "boot on for transport, boot off in the patrol room"  makes the most sense.  

 

Liam

Madmas it sounds as if your friend was transported pretty immediately to an E/R (just guessing) with little time spent in the aid room.

 

In our area we will not remove on the hill, too cold and no point unless there is uncontrollable bleeding.

 

Our local ambulance/FD is staffed by former patrollers or patrollers who are also working for the FD. They usually reach our aid room about the time the sled does, sometimes sooner. They can administer pain meds (we do not) and then if the decision is made to remove the boot prior to transport it is a team effort.

 

I prefer to get the boot off in the aid room myself, but there are times when immediate transport trumps preference. Most of the FD guys are EMT-Ps so I will defer to their higher level of training.

 

Every area/situation is different.

On the hill we splint with boot on in all cases. In first aid room the boot is removed very carefully by 3 patrollers with 6 hands before sending patient to the hospital. One patroller stabilizes the lower leg with hands in the boot as far as possible.  The other two patroller than spread the boot far apart and then roll the boot very carefully off the foot.  There is no pulling on the leg.  We practice this every year with many different kinds of boots.  Most hospitals would not have the skill or training to remove boots. 

 

Our ski patrol is in  NY state where Hospital with an Medical Doctor and Orthopedic surgeon  is 40 minutes away by ambulance.  

 

If a ski area has an emergency room with Orthopedic surgeon less than 10 minutes away from the base,  it may be best to keep the boot on. 

Half way down a slalom course I was late on a gate and rather than skiing on off the course I tried turning hard. I thought I'd hit a little bump but when I put my foot down I found out there wasn't a ski on that foot. It was like stepping out of a moving car at 60 mph. When I finally quit sliding down the black slope, I could wiggle everything but that one leg. So, I got a sled ride into the ski patrol first aid station.

 

Several patrol folks gathered around and they started gently pulling the boot sides and tounge apart so they could slip it off. Meanwhile the pain was excruciating and while walking on clinched butt cheeks I couldn't help myself and started yelling "JUST F'N DO IT !!!". So, they slipped it off right quick and instantly my foot uncontrollably flopped over on its side. And in a moment of great understatement they said "We're not supposed to make diagnoses. However, were pretty confident you have a broken leg". No shite Sherlock, It was a classic boot top double bone break and only attached by meat, no bones. The compressive force of stepping out of the binding caused both bones to break and side slip past each other about 4". I had a couple of spots where the bones tried to penetrate the meat sack but the boots prevented that from happening all the way.

 

I'm glad they didn't remove my boot on the hill. That would have really sucked. Thanks to the great care I received at the resort and hospitals one year later to the day I was skiing at the same resort and I took the ski patrol a great big basket of cheese, chips, crackers and dips as a thank you.

 

^ I wish I could unsee that.  

 

Vibes and all that.

Usually in the Aid Room for us too. Most of our patients asked us to remove the boot when we told them ER at Christchurch would probably cut the boot off. Boot removal was a big part of the training program, hands to steady the leg, and strong hands to open the boot and extra hands if available to hold the boot tongue away from the leg.Boot then rolled off. We also had a good ex army medic/trainer to run part of our training courses which allowed us to target the material accurately, as we found the classic St Johns or Red Cross first aid courses not really ideal. This was in the mid eighties at Canterbury (NZ) club fields. Since then NZQA has put together a NZ Cert. for Ski Patrol and lot of the original material came from CSP

 

 

As a rule, I see no reason not to remove the boot in the aid room?

Distal pulse to the injury needs to be assessed. (prior and post splinting)

Sensation distal to injury needs to be assessed. (prior and post splinting)

Possible realignment necessary to achieve the above conditions maybe necessary (post splinting).

 

However this being said, there maybe circumstances that prevent boot removal - these should be noted and passed on to next level of care.

 

Just my thoughts - but always willing to learn

 

 

 

having this just happen to me, this was pretty much the protocol. they splinted me up on the sled- put a bag of snow on my leg but left the boot on until they could better evaluate. Once at the base traige, they chose not to remove the boot but did unbuckle and loosen booster strap. Since I had considerable knee and lower leg pain (turned out to be a sprained ankle in addition to ACL tear) they wanted to let the folks in the ER assess.  Once at the ER, the carefully removed boots (although new technician was not proficient and thankfully did not remove the boot on my injured foot :) )
 

 

Dawg, that is making me feel nauseous   This is the closest imodicon to puking.... 

When I broke my leg I went to the hospital in a friend's car with the boot still on. It was about 2 hours before the casualty staff took it off. We went in the car because it was going to be a long wait for an ambulance, better just to get going. They wanted to cut the boot off but it was quite a new boot so i wouldn't let them. Yes it hurt like hell to get it off, but it wasn't mission impossible. i had a tibial plateau fracture so the site of the injury was not that close to tbe boot, but I'm not sure that made much difference. But since it was clear from tbe beginning that I had a knee injury we decided that that it didn't really matter when the boot came off. There are different sorts of broken legs....

All i was wearing was a speed suit (i crashed in race training) and it was at least -10C and windy. I was really, really cold before the snow patrol arrived on a snowmobile even though it was not that long a wait. The idea of taking my boot off on the hill instead of getting me quickly down to safety in the warm is quite ridiculous. Field first aid requires you to prioritise depending on the situation and in this case there was a clear risk of hypothermia and/or frostbite which is a much higher priority to deal with.

This

I remember our orthopod advisor saying there are only two good times to remove a boot:  when the person is shot full of adrenaline (as in right after the accident), or shot full of morphine.