We Need More: Avalanche Rescue Education isn’t Enough.

A north facing slope in Central Oregon with recent slide activity.

You’ve put in the time to take an avalanche rescue course, maybe two. You practice each year with your beacon, and the dutiful among you might even attend your annual Snow and Avalanche Workshop to continue to learn all that you can about how to avoid an avalanche. Then, one day, you find yourself in the terrible position of digging out your buried partner. You succeed in pulling them to the surface, but they’re not moving or breathing. Have you trained for this?

This year, avalanche accidents in Oregon, Idaho, Montana, and Utah have highlighted the reality that avalanche rescue doesn’t end when the skier is located and extracted. In each of these cases, CPR was required, and in the Oregon and Montana cases, trauma care was needed as well. While dissecting accident reports can be informative and can help us to understand the circumstances and decisions that can get us into trouble, they’re also useful as a sounding board for our own preparation. Do we know what to do after digging out our partner? Do we know how to perform good CPR or deliver basic high-yield trauma care? If we have these skills, are we confident that we would be able to access and apply them during moments of critical stress?

Collectively, we’ve come a long way from the days of the avalanche cord as a risk mitigator. The field of avalanche science has shifted its education attention from shear stresses, fracture planes, and crystal types to an emphasis on terrain choice, decision making, heuristic traps, and group dynamics. Technology has followed suit, producing user-friendly beacons and airbag backpacks. Pivoting to focus on the factors that truly improve human survival in avalanche terrain has, on the whole, been a highly successful endeavor, with annual avalanche fatalities remaining essentially level as backcountry ridership has exploded. Lack of medical knowledge remains a gaping hole in avalanche education and may represent the next chance to improve survival after an avalanche.

Think back to the last avalanche rescue course that you attended. The rescue practice probably culminated with a simulated multiple-burial scenario, and you responded with your group to locate, probe, and excavate multiple buried “victims.” Pulling those backpacks to the surface one-by-one you might have learned some valuable lessons about managing multiple signals, working as a team, digging strategically, and summoning additional resources. Ultimately, all backpacks on the surface, you turn off the beacons, high-five, and head for the debrief. But why does the scenario stop there? If this was a real avalanche, these backpacks would be real people who were possibly not breathing, without a pulse, hypothermic, or suffering significant injuries.

Case series studies of avalanche victims who are critically buried (head under the snow) repeatedly show strong evidence that 1) rapid extrication is crucial to survival and; 2) CPR is an effective intervention that is necessary in many avalanche burials and an intervention that can lead to survival with a good neurological outcome (e.g. Moroder et. al. 2015, Resuscitation). This is because the principal cause of death in critical burials is asphyxia, or lack of oxygen, and CPR is an effective intervention to quickly salvage that problem. Still, it is a skill that cannot be learned from watching ER reruns, and the nuances of applying it to avalanche victims are several.

So why don’t avalanche centers and avalanche education groups like the American Avalanche Institute, American Avalanche Association, and AIARE teach any medical skills? My guess is they don’t deem this domain of knowledge as a comfortable area of specialty. Medical education is also fraught with its own certifications and burdens. They may also think of rescue skills as primary, which is fair, as you can’t do CPR while someone is still buried. Still, I assert that your extremely professional beacon search is only a body recovery if you don’t have the skills to continue caring for an avalanche victim after the dig. Twenty years ago, I imagine that group management and discussion of heuristics and other cognitive traps was probably considered to be outside of the wheelhouse of avalanche science, but their value has won out with time.

Avalanche education of the future should include and integrate basic medical care of the buried avalanche victim so that these equally critical skills become engrained in the same way that rescue skills are.

To address this gap in avalanche education, I propose the following changes to avalanche rescue courses:

1. Require current CPR certification as a prerequisite for the course. This ensures that all participants have a baseline understanding of this critical skill.
2. Dedicate classroom time to discussing the medical aspects of avalanche rescue, including the pathophysiology of asphyxia, hypothermia, and trauma, and the appropriate interventions for each.
3. Provide students with a medical rescue algorithm card for reference during and after the course.
4. Use mannequins with head and torso during rescue practice to simulate the need for proper patient access and positioning for medical care.
5. Incorporate medical scenarios into rescue practice, providing students with information about the patient’s condition and requiring them to verbalize appropriate care and rationale.

Imagine again that end-of-course multiple-burial scenario. Instead of backpacks, students rescue human shapes from the snow and position them onto flat areas where they can be assessed and cared for. They are forced to use manpower to perform CPR on excavated victims instead of all moving to the next beacon. They are forced to practice thinking their way through the necessary medical care with a heart rate thumping away from their aggressive digging. The instructor prompts them to make difficult decisions about whether to continue CPR or go help rescue other buried victims. At the end of the scenario, perhaps the students are left with the feeling that they don’t know enough, that they might have to go take a WFR course or practice other scenarios. Instead of high-fiving halfway through the rescue, they’re asked to think about how they could care for injured partners and facilitate their evacuation. Integrating medical decision-making might not lend itself to as neat and tidy a finale, but it will certainly produce a backcountry partner who is better-prepared for the realities of an avalanche burial.

There are organizations in their infancy that are beginning to address the issue of avalanche resuscitation education, and I applaud their efforts. Mountain Medical Academy and After the Avalanche are two such organizations. However, more is needed. If members of this community have contacts in the American Avalanche Association, AIARE, or other such curriculum-driving organizations who would want to partner on development of a rescue curriculum, please put us in touch. And if you find yourself reading this and realizing that you aren’t confident in performing CPR, please consider taking an AHA Basic Life Support course. Together, we can work towards a future where every backcountry enthusiast is prepared to be a competent rescuer and a skilled medical provider.