Search for tag: "skiing"

Interviewer: Dr. Travis Maak is a sports medicine expert and the Head Orthopedic Team Physician for the Utah Jazz. He says a majority of ski injuries happen in the late afternoon, and unfortunately it's during that last run, that one more run. How did you find this out?

Dr. Maak: Part of it was from personal experience, to be honest with you. So I actually was a sort of volunteer ski patroller in my high school days here when I was growing up. It's something that is known to all ski patrollers, that basically . . . ski patrol is in large part about 90% boredom, and that happens from the beginning of the day where you literally just go out and ski yourself because you're so bored, because there's nothing else going on, to about 10% of terror.

That always happens at the end of the day, and sometimes right after lunch. But usually it's from about 3:30 to 5:00 is when everything happens. That's where you basically put your gear on and get ready, because you are going out. It's not an 'if', it's a matter of 'when.'

The reason that happens is it most likely it has to do with two things. One is it's starting to cool down so from a temperature perspective the snow is starting to get a bit harder. It loosened up. It warmed up. It was a little bit softer. During the afternoon it starts to cool down, so it gets a little bit rockier, a little bit skied out, so the terrain itself is more difficult. That's the first thing that is most likely contributing.

But the other contributor is a personal and modifiable factor. You can't change the weather, but you can change yourself. We all want to get in as much as we can, the most bang for our buck. We bought that pass. It may seem a little overpriced, but when you do it, it's fantastic and you want to keep going and get the most out of it.

Basically, it has to do with a muscle fatigue. The ligaments are the structures that hold our joints together. The main injury that we see typically is either a broken bone or a ligament tear. In particular in skiing it's the ACL. The ACL seems to be unfortunately the skier's injury. Generally, the reason it happens is the knee joint has two predominant stabilizers, the muscles, the tendons as one unit, and then the ligaments. Those are separate. The ligaments are literally like ropes. They connect the two bones together.

The muscles are the dynamic stabilizers, so they fire when they're working and you make your knee bend and straighten, and it allows you to do those bumps and do those turns in a perfect fashion. But when muscle fatigue happens, then the muscles aren't working correctly. They aren't firing correctly and they start to get weak and tired. As they get weak and tired, your mind may want them to go, but it's not going to happen because, frankly, you just can't put forth the energy.

So where does that energy go? It doesn't disappear. It goes to the ligaments, and so the ligaments end up taking more energy than they're supposed to and they end up failing and tearing. That's most likely why this happens, because the energy which is dissipated by the muscles can't be because they're tired and fatigued, and so it goes to the next step in the chain.

Interviewer: Do you find that people that are a little bit more muscularly in shape are less likely to have this happen, or at that point in the day is pretty much everybody susceptible?

Dr. Maak: Muscularly in shape is a question that a lot of people take to mean the body builder, giant muscles, and frankly that actually has nothing to do with it. In fact, a lot of people who have those fast-twitch, big muscles end up getting tired quicker. If you look at endurance athletes or athletes that are training for a specific sport, the muscles themselves have become accommodated to a long-term type of energy expenditure.

Skiers, for instance, they train in both strength, the quads, the hams, the lower body strength, but also endurance. Ultimately, that's what we're talking about is endurance. It's the fatigue of the muscle, not the ability to jump really high one time or run a sprint. It's the ability to stay and produce that power and energy over a long period of time, hence the last run of the day.

At the end of the day, it's fatigue. It's training. It's the ability to generate that force required to ski throughout the day. When that ability to generate that force disappears, that's when the injuries happen.

Interviewer: So probably your casual skiers don't have that kind of muscular endurance.

Dr. Maak: They don't. Interestingly, here at the University we've actually produced a skier's program to provide people with sort of an ability to produce that type of power and endurance over a period of time pre-ski season, so that by the time they hit the ski season, they are ready. Their quads are ready. Their hams are ready, and it's a completely different muscle set than happens over the summer when you're out running, you're out doing the type of endurance summer activities, rock climbing, etc. It's totally different for skiing. It's a different muscle group, and if you don't [inaudible] and educate your body to those muscles, you're not going to be able to do it.

Interviewer: So what's your final advice? I mean, you've laid it out that the injuries are happening in the late afternoon. Do you just not do that last run? Do you just slow it down a little bit? What would you tell a skier?

Dr. Maak: At the end of the day there's always one last run. That's unavoidable. So the message that we try to get out here is make that one last run a fun one, and not a potentially serious or a safety issue run. The way to do that, let your body be your guide. You can do all of the things that we've talked about already, which is prepare yourself for the run. Prepare yourself for skiing. Get yourself in tip-top shape as best you can. But also listen to your body.

After lunch, you're going to be a little fatigued. You let things set in. You may slow down the runs. Don't go hit the double black run right after lunch. Instead, maybe start on blues, ramp it back up a little bit. But once 2:30, 3:00 starts setting in, look at your watch, listen to your legs, listen to your body, and instead of going and hitting the double black as the last run, maybe take a groomer. Take a nice, little, smooth one down. Enjoy yourself. You don't have to be a hero at the end of the day. At the end of the day, if you do it that way, you'll be able to come back the day after.

updated: December 14, 2022
originally published: February 17, 2016

Interviewer: You come back from the slopes, and your thumb is hurting really, really badly. Is it something you should worry about or not? We'll find out next on The Scope.

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Interviewer: Dr. David Rothberg is an orthopedic surgeon at the University of Utah Hospital. We're going to talk about something called "skier's thumb" right now. So you go for a day of skiing, you come back, your thumb hurts. Do you have skier's thumb or not? How do you even know? First of all, what is skier's thumb?

Dr. Rothberg: Skier's thumb is a relatively common injury of the upper extremity suffered when someone falls on a pole. So the most common scenario is with a grip-fitted poles, you fall, and the pole is forced into the palm as you place your hand down to slow your fall.

People know when they have it because the actual ligament that's hurt is your ulnar collateral ligament on your thumb, and it supports your thumb as a post. So when you pinch with your forefinger and your thumb . . .

Interviewer: Kind of making the "OK" symbol except for against the side of your thumb . . .

Dr. Rothberg:That's putting pressure on that collateral ligament.

Interviewer: Okay.

Dr. Rothberg: If you think about all the daily tasks we do with grip strength and manipulating objects with your hand, it's really common that we use your thumb as a post. So the quickest and dirtiest way to figure this out is to use your thumb as a post. Press your forefinger against the side of your thumb and see if it hurts at the large knuckle at the base of your palm, or your MCP joint.

Interviewer: So it refers pain down, because you're touching at the very top part of the thumb, and it's kind of coming down, the base of the nail almost, off to the side.

Dr. Rothberg: Right, and you're going to feel that.

Interviewer: Okay. And if you feel that, is it for sure that you've got skier's thumb?

Dr. Rothberg: It may not be for sure, because like all ligament injuries, it can really come with a grade of injury, from a sprain, which the vast majorities will be, to complete tears, to fractures of the insertion of the ligament.

Interviewer: So if you're feeling pain, should you go see somebody right away? Is it important that you see somebody or should you just kind of wait and see if it goes away?

Dr. Rothberg: I think, in the very beginning, if this is something that gets better very quickly, then you're probably safe. But if you have a persistent pain lasting more than a day or two, and it's causing dysfunction, it's worthwhile to get checked out by an orthopedic hand surgeon.

They're most commonly going to take an X-ray to rule out that scenario where there may be fracture associated with it. The reason that you want to take care of this is it can lead to a chronic instability of that joint, meaning that you're no longer able to fully use your thumb as a post because of non-healing of the ligament.

So the typical course of treatment is in a non-operative setting, which is the vast majority, is a brace. That brace is going to hold your thumb in a position that protects it from being used as a post or really straining or stressing that ligament as it attaches at the MCP joint.

Interviewer: So it sounds like kind of a big deal, because it could hinder your usage of that for the rest of your life if you don't have something done to it, and it's simple. It's a brace.

Dr. Rothberg: That's exactly right. When chronically injured, then it becomes something kind of interesting historically. It's called a "gamekeeper's thumb," and that referred to when people who farmed chickens they would break the neck of the chicken over their thumb, and it could lead to repetitive stress on the ligament, that then loosened it and then caused chronic disability.

So that's the worry when you don't take care of this skier's thumb is that it becomes a chronic instability that causes pain and dysfunction.

Interviewer: How long does it take for this to recover at this point, after you get the brace?

Dr. Rothberg: Typically, people are in the brace from four to six weeks, and then depending on the range of motion and tasks that they have in their daily life, they may start some hand therapy. Motion tends to help with the healing process. All in all, people can be back to activities around the six week mark.

Interviewer: So just for perspective, not something to be taken lightly. Not to go, "Aw, it's just my thumb. I won't worry about it."

Dr. Rothberg: That's very true, and I think it's a real common one that people get and take lightly, and then are presenting to us later with problems.

Interviewer: Then it's too late. Is it too late at that point? I guess that's a good question. What if three years down the road, I come in? Is it too late to fix that problem?

Dr. Rothberg: It isn't necessarily too late, depending on whether you've developed any arthritis in the joint because of instability. Certainly, there are late reconstructions, where we can reconstruct the ligament to give you stability. In most people, this tends to be something they pick up and don't really miss, because it does cause quite a bit of dysfunction. But getting it looked at sooner is always better than later.

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Scot: Avalanche danger super high across the entire state of Utah. Unfortunately a couple people have already died because of avalanches. We're with Dr. Troy Madsen, Emergency Medicine at Utah Hospital. Have you ever seen avalanche victims come into the ER?

Dr. Madsen: I have. I have seen avalanche victims come into the ER. Sometimes these are patients who have been transported. In some cases-I haven't cared for them personally-but I've heard of cases where they have just been basically had no heartbeat but they continue to work on them to try and get them back, and brought them to the ER, transporting them from the mountains. I've seen patients who have come in who have had multiple injuries those types of things. So kind of the full range of avalanche victims have come into the emergency department.

Scot: So I would have thought if somebody had died because of an avalanche they'd just say well, "They're dead," but they bring them to the ER.

Dr. Madsen: They will, and the reason they'll work on them, and continue to try and treat them for longer than, say, a victim of a motor vehicle accident is because if you're in an avalanche you're often under the snow for a prolonged period of time. If they don't have a pulse on that person that person is also hypothermic, their body is very cold, and being very cold can preserve the brain function, and sometimes help us get that person back, where if the average person had had a heart attack and was down for 30 minutes, the likelihood of getting that person back, and having any kind of a good outcome is very low.
So avalanche victims it's a little bit different in that sense where they may have been very cold and that can kind of preserve things so they may continue to work on those patients longer than we would otherwise.

Scot: Really? So there's a better chance you could resuscitate them?

Dr. Madsen: Yeah, potentially. Yeah.

Scot: And have a good recovery?

Dr. Madsen: Yeah. It's kind of like drowning in cold water, we think of it the same way. Being in that just really cold temperature, that's kind of like preserving meat in a freezer in a sense.

Scot: Sure. I guess that makes sense, but I never realized that was actually fact. That's interesting.

Dr. Madsen: It really does work, and you know it's interesting too if we do CPR on a patient and we get them back, we cool their body down at that point to try and preserve them and kind of preserve their brain function, and we've shown it helps them to have a better outcome.

Scot: Interesting. All right. So let's talk about avalanche danger in general. What are some of the things people should be aware of?

Dr. Madsen: Yeah. I think the number one thing to be aware of right now is the avalanche danger is extremely high, and I'll preface this by saying I'm not an avalanche exper.t I'm an ER doctor who's cared for the consequences of avalanches, and I would kind of casually like to go in the outdoors, and in the back country. But keep in mind the danger is extremely high, and we're not talking about people going up you know high in the back country, on back country skis. We're talking about people snowshoeing next to the road. This person who died, American Fort Canyon, from what I can tell was pretty close to the road in what may seem a very tame area.

Scot: Wow. Because my wife and I joke about that, we snow shoe and we're like, "Oh, the avalanche, that's not going to affect us."

Dr. Madsen: And that was my thought too. You know you think, "I'm in my neighborhood. I'm just in the foothills," or, "I'm just up in the mountains, I'm not high up at 10,000 feet." This was not at 10,000 feet. Avalanches can happen on any slope, but classically they say 30 degrees or more. And it's always tough for us to tell what's exactly is 30 degrees. But we're talking about a decent slope there but not a real steep slope. So you could be anywhere in the backcountry, hiking, snow shoeing, just getting out, certainly snowmobiling, these sorts of things.
It is just an incredibly high risk right now, and if there's any advice I would give it would be to always go to the Utah Avalanche website, UtahAvalanche.org. They're going to have all of the ratings for the risk, and right now it's approaching extreme. It's very high right now, and if that's the case it's just best to avoid the backcountry because of the risk there.

Scot: All right. Let's talk about somebody does go out into the backcountry. An avalanche happens, I'm not buried but somebody that I'm with is. What do I do at that point?

Dr. Madsen: Well, first of all, at that point it's you're in a tough situation. I think that's the bottom line. The teaching I've had, and learned . . . and there's a great book if you ever go in the backcountry. You should read it. It's called Surviving an Avalanche Training is the title of it, I think. But it talks about how the best thing to avoid is certainly being in an avalanche in the first place. Because when you're in an avalanche, 25% of the time you're going to get killed just by the trauma, just by rocks, boulders, that sort of thing.
So then there's a 75% chance you're going to be buried under the snow. If you're under the snow you're not going to be able to dig yourself out. It's like being encased in concrete. You can't move; you're stuck there. So if you're with someone where that happens, hopefully, first of all, you're wearing a beacon, and beacons are something you can get. They're a little expensive; you're looking at like a $150.00, but it's something where basically it's going to allow another person with a beacon to detect where you are.

Ideally, before you're in the backcountry you've used these things, you know how they work, but you're going to use your beacon to try to find where this person is. Again, trying to find a person that doesn't have a beacon on is extremely difficult. We're not talking about a small pile of snow this person's under. We're talking often times about a slope that's a 100, 200 feet wide, that has slid for 400 feet, and is covering someone somewhere underneath it.

Tom: Ski helmets: are you really safer when you put one on? What you hear might surprise you, next on Scope Radio.

Announcer: Medical News and Research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Tom: I'm here with William Couldwell, who is the chair of the University of Utah's Department of Neurosurgery. Bill is nationally recognized leader and researcher in complex cranial surgery and is the current President of the American Association of Neurological Surgeons.
Bill, a New York Times article came out on New Year's Eve, and it led off with Michael Schumacher's traumatic brain injury. Now, Schumacher, I guess, is the winningest Formula One racecar driver in history. And it seems ironic that he was not injured on the racetrack but he was injured while skiing. And he was wearing a helmet. That seems doubly ironic to me. What do you think about that? Do you think ski helmets help?

William: Well, I think there's two ways to look at this, Tom. I think they do help in that if you do have an injury, they reduce some of the impact to the brain. The problem with ski helmets is that it also may give you a false sense of security. And I think what's happening is that the culture of skiing and snowboarding is increasing the risks and the height and the speed and the rotational injuries. The other thing that helmets don't do is they do not prevent the brain from rotating within the skull. And so they don't prevent that mechanism of injury as well, which is an important one.

Tom: Do you think that's the primary reason that people have traumatic brain injuries in . . .

William: I think it's a combination of the magnitude of the injury, the speed, the torque and also the twisting.

Tom: Well, here we are watching the Sochi Olympics and we're seeing these young athletes just taking great heights and great speeds. And they've always done that. But it seems like it's even accentuated now. And ski resorts are building train parks. And they're supporting events that get in to jumping and going faster.

William: Yeah, I think also the culture is faster, higher. The superpipes now are much bigger than they used to be. Even, you saw Shaun White actually stepped out of the Olympics on the slope style event because he felt that the jumps were to big and it was unsafe.

Tom: It's interesting. I mean, the article, the Times article reported a 250% increase in brain injuries among youths and teenagers between 1996 and 2010 even though the helmet use has increased in that period of time. Which means to me that, I mean, obviously they're doing things that are more intense than they were doing before.

William: I think the bigger issue here is the culture behind it. We've seen over the last few years that NASCAR has done a good job. They've improved equipment and the safety level of their cars and their helmets and to reduce the neck injuries. I think the NFL, right now, is under scrutiny and will be looking at the whole concussion issue. And in the helmets, we're actually putting monitors to measure torque and pressure within the helmet to get an idea of the kind of stresses that these players are seeing during the individual games.

Tom: And there's nothing yet like that in skiing.

William: No, in fact, Kevin Pierce and I are talking about doing that within snowboard helmets now.

Tom: Great.

William: A study with torque monitors.

Tom: So, finally, to our listeners, what advice would you have for the weekend warrior skier, or the teenage athlete, in terms of reducing their risk for traumatic brain injury?

William: Well, I think the important thing is to remember that these injuries can be life changing. I think that we need to deliver that message stronger. I think we need to be . . . if I was a parent who had children of this age now, I'd have them wearing the best helmet, the best sanctioned helmet that you could buy for them.

Tom: But that, there was another question I had. Are there differences between helmets?

William: There are different types of helmets. And certainly a motorcycle helmet is much bigger and bulkier than a snowboarding helmet. The trouble is that with the snowboarding they want a light helmet with good visibility, but it doesn't give them the optimal protection.

Tom: Exactly.

William: Like a football helmet would. Or a motorcycle helmet.

Tom: Or a motorcycle helmet with a chin guard on it, yeah.

William: Exactly. And so that's the problem. So, you're fighting this compromise all the time.

Tom: So, I'm sorry, I think your last piece of advice . . .

William: Yeah, so I think we should buy the best equipment for our children. And we should encourage them to wear it. I think the other issue that we didn't discuss is the neck injury issue, and the spinal cord injury.

Tom: Clearly. I mean, these helmets don't prevent against neck injury.

William: Every year here we see significant spinal cord injuries. . .

Tom: That's great to know that.

William: . . . especially from these train parks. And the twisting and the falling and the torqueing of the neck can be just as much of an injury to the spinal cord. And that can have a huge impact on life as well. And so I think it's a combination of the head injury plus the neck injury that I'm concerned about. We have a greater responsibility as parents and business leaders. And I don't think that we should push the limits, understanding that they're not going to have the judgment to deal with that.

Male: We're your daily dose of science, conversation and medicine. This is The Scope, University of Utah Health Sciences Radio.

Interviewer: Make this year an injury-free year, whether you ski or snowboard. That's coming up next on The Scope.

Announcer: Medical news and research University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: The ski season opening up, the snowboarding season opening up and Jackson Hole, just like Salt Lake City, we've got some great opportunities to do those types of things. We're with Dr. Jeffrey Greenbaum from St. John's Medical Center in Jackson Hole. Let's talk about preparing for the season; first of all, if you're a skier or snowboarder, we want to do it without getting hurt. What are some thoughts that you have?

Dr. Greenbaum: Well, of course, as far as preparation is concerned, it's the same as with any athletic endeavor and, you want to be in condition. So it's probably wise to go out and take some kind of fitness class, and here in Jackson Hole, and I'm certain in Salt Lake City, we have specific ski fitness classes that focus on getting your legs and core prepared for the season.

Interviewer: So how far in advance should somebody start getting in shape for the season or snowboarding?

Dr. Greenbaum: Of course, you could always stay in shape, but probably the most typical is about a month or six weeks before the ski season to begin a fitness course.

Interviewer: What about stretching? Like, are there two or three stretches you would absolutely recommend somebody do?

Dr. Greenbaum: You need to stretch the areas which you consider to be important, whether they be your hamstrings, or your low back, or it might even be your shoulders.

Interviewer: Gotcha. What do you stretch before you hit the slopes?

Dr. Greenbaum: Definitely hamstrings and definitely back.

Interviewer: Are you a skier or a snowboarder?

Dr. Greenbaum: I'm a skier.

Interviewer: Are there different potential injuries between the two?

Dr. Greenbaum: Oh, absolutely.

Interviewer: All right. So let's talk about skiing injuries. What are some of the more common things you want to watch out for?

Dr. Greenbaum: Well, every skier wants to watch out for knee injuries. Probably the most concerning knee injuries are the ACL tear or the fracture of the upper tibia, the tibial plateau. Generally, these types of injuries are caused by twisting and tumbling falls when your ski binding does not release.

Interviewer: Oh. So how can you avoid that then?

Dr. Greenbaum: Make sure that your gear is properly adjusted.

Interviewer: Yeah.

Dr. Greenbaum: Make sure that your boots fit you correctly. Make sure that your bindings are not antiquated or obsolete, and that the person who adjusted them is actually a certified technician.

Interviewer: So that equipment really makes a big difference, it sounds like.

Dr. Greenbaum: Well, it's the equipment actually which results in the injury because you're locked into the ski.

Interviewer: What about snowboarders? What are they looking at?

Dr. Greenbaum: Snowboarders have a lot of injuries to their shoulders and wrists.

Interviewer: They're, again, from falls.

Dr. Greenbaum: Yes.

Interviewer: Is there anything you can do?

Dr. Greenbaum: Well, for beginner snowboarders, it's very wise to wear pads and wrist guards.

Interviewer: Okay. Any other types of things you'd want to do?

Dr. Greenbaum: As far as snowboarding is concerned?

Interviewer: Yeah, to prevent injury.

Dr. Greenbaum: Take a lesson.

Interviewer: Probably true for skiing or snowboarding.

Dr. Greenbaum: It is true.

Interviewer: You really need to have some sort of sense of control if you need to maneuver quickly, I'd imagine.

Dr. Greenbaum: Yes, and, of course, with a lot of mountain sports there's a sense from some individuals that they can simply pick up the equipment and go at it without having a lesson. That's usually a mistake.

Interviewer: Yeah. What about head injuries? You see more and more people finally wearing helmets. I suppose helmets are finally becoming accepted.

Dr. Greenbaum: Helmets are much more popular these days.

Interviewer: Yeah.

Dr. Greenbaum: I think the popularity of helmets originated with snowboarders who have a blind spot that skiers never had.

Interviewer: Oh, okay.

Dr. Greenbaum: And snowboarders really did bring the helmets to the scene and skiers have followed suit.

Interviewer: That's good. That must make you fee pretty good.

Dr. Greenbaum: Well, we're definitely seeing a lot less of the minor head injuries that we used to see.

Interviewer: All right. So if somebody falls on the snow, it's soft. What's happening there exactly?

Dr. Greenbaum: No, it's not always soft.

Interviewer: Okay.

Dr. Greenbaum: A lot of the snow is firm, particularly when it's paced down, particularly when you've gone through a thaw and freeze cycle.

Interviewer: And how much of a bonk to the head does it take to cause some injury? Probably less that one might think?

Dr. Greenbaum: Oh, a slow speed falls definitely can result in head injuries.

Interviewer: Mm-hmm.

Dr. Greenbaum: They're usually mild to moderate head injuries but they can be severe.

Interviewer: All right.

Dr. Greenbaum: Again, it's not so much how fast you fall it's what you hit. You can be going only 5 miles an hour and hit your head against a tree and I'm certain that would not bode well for you.

Interviewer: So it sounds like equipment is the answer, being in shape, maybe doing some stretching, but equipment. Checking your equipment, wearing some wrist guards, wearing some helmets. Any other thoughts on avoiding injuries this year?

Dr. Greenbaum: Be prepared before you come out skiing or snowboarding. Make sure you have the proper equipment and that you are physically and mentally prepared. People show up for vacation and it's very stressful and intense just getting here. The next day, they hit the slopes and maybe they haven't prepared, such as eating a proper breakfast. You really want to be careful.

Interviewer: And that stuff really makes a difference, in your opinion?

Dr. Greenbaum: I really do think so. A lot of our visitors are injured in their first few runs and others are certainly injured on their last runs of the day, when they're worn out.

Interviewer: If I get an injury, how do I know if I need to come to the hospital?

Dr. Greenbaum: This is always a difficult question and that's asked of my friends frequently. I think that as far as coming to the emergency department, or to the clinic at the base of the ski area, come there if you have an injury which is so severe that you think that you're going to need to take a strong pain medication for it, or certainly if you're incapable of using that body part. In other words, if your knee doesn't work or wrist does not work, it's time to have it checked.

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Interviewer: My name is Vivian Lee. I'm the senior vice president for health sciences at the University of Utah, and today we're going to talk about the cold. This can mean dangerous medical problems for people that are exposed to the cold for long periods of time and even short periods of time. Joining me today is Dr. Amalia Cochran, assistant professor of medicine at the University of Utah's department of surgery. She's also an attending surgeon in the university hospital's burn unit and a leading expert on frostbite. Welcome to the show.

Dr. Amalia Cochran: Thank you very much.

Interviewer: We had an experience that made me have to go online and look up frostbite and I realized there wasn't as much information as I would hope. My daughter came back. She was fine after a whole day of skiing, and then she got into the bathtub and she started screaming because she said her feet were really painful and then the tips of her toes were dark red, almost bluish. At that point in time you can imagine I just panicked and tried to look online. I thought, here you are, the expert, let me ask you, what was happening with her? How could I have prevented that?

Dr. Amalia Cochran: It honestly sounds to me like she probably had a case of frost nip. When you're out skiing you've got a prolonged exposure, as does anyone who's outdoors during this weather. The fact that prior to that exposure to the warm water bath she hadn't really had any significant complaints and you hadn't really noticed anything different . . .

Interviewer: No, and is that because you have numbness so you don't even realize what's happening?

Dr. Amalia Cochran: Precisely. There is numbness with frost nip and you see very few changes in the skin if someone has a case of frost nip.

Interviewer: Frost nip is different from frost bite?

Dr. Amalia Cochran: Frost nip is the extremely mild form of frost bite. The way that we tend to differentiate between them is that frost bite involves tissue changes where the skin will actually blister up versus frost nip where there is some of that damage to the skin and the soft tissue but not to the level where it blisters.

Interviewer: Is it blistering because the tissue is actually freezing? What's actually happening there in the skin?

Dr. Amalia Cochran: There are really two different things that occur in the skin with a frost bite or a frost nip injury. One of those is the direct cold injury from the temperature. That impacts the tissues. They do freeze. Little crystals form in them. The other phenomenon that occurs in association with that is ischemia where there is poor blood flow to the cold effected areas. Initially, when the outdoor temperature drops or when we're exposed to lower temperatures somewhere in the neighborhood of 50 degrees fahrenheit, there's a cold induced phase of dilation that occurs.

Interviewer: Blood vessels expand. All of a sudden this blood rushes back in, and then what happens?

Dr. Amalia Cochran: Right. But then after that they constrict. They narrow back down and so the blood flow diminishes.

Interviewer: One of the things about this that worries me is that because of the numbness the kids don't even seem to know that it's happening, so how do we know that that damage is occurring?

Dr. Amalia Cochran: Cold checks are what are recommended in the Alpine mountaineering literature. I think they apply to those of us that are recreational outdoor in the winter as well. The concept of cold checks is that you get yourself to a relatively sheltered location, and I phrase it that way since this is from the Alpine mountaineering literature because there would be a relative shelter if you're skiing, you can say, hey, let's take a hot chocolate break after an hour and a half, and go in and check fingers, check toes.

Interviewer: We do them every half hour sometimes.

Dr. Amalia Cochran: Some days that's really appropriate. You can check everyone's fingers, check everyone's toes. If you notice that the fingertips or the toes are looking particularly pale, if they start getting a little bit woody in terms of how they feel, if they're not as soft as they normally feel, any of those sort of characteristics, that would make you concerned that you may have the early phases of a cold injury occurring.

Interviewer: How can we prevent it?

Dr. Amalia Cochran: Preventing it is a little bit tough if you have a love for winter sports. One of the things is that if you are someone who knows that you have circulatory challenges finding ways to keep your fingers and toes warm.

Interviewer: So even when it's not that cold our fingers and toes get kind of cold. We're particularly sensitive to developing it.

Dr. Amalia Cochran: Absolutely. Be mindful. I tell people I have something known as Raynaud's phenomenon, which means that when I get cold my blood vessels in my fingers and my toes clamp down. So I not only very easily get cold fingers and toes but I'm at higher risk for cold injury. So when I ski I have heaters in my boots and my mittens.

Interviewer: Those hand warmer, toe warmer type things?

Dr. Amalia Cochran: They're actually battery packs.

Interviewer: Oh, I didn't know they made that.

Dr. Amalia Cochran: Yeah, they're a little spendy but they're worth it. I whine a lot less and I have to take fewer breaks.

Interviewer: But short of that, you recommend the hand warmers and toe warmers?

Dr. Amalia Cochran: They're definitely helpful.

Interviewer: Dr. Cochran, you're not only an expert in frostbite but you're also a leader in burn injuries. I noticed we recently had an avalanche victim who had frostbite and was cared for in our burn unit. Maybe you can explain to us this relationship. Why are the frostbite patients and the burn patients all cared for by the same people?

Dr. Amalia Cochran: That surprises people and I know our avalanche victim was a little confused when I showed up and introduced myself and said I was a burn surgeon. She gave me this puzzled look. I said, "Trust me. This is going to be okay." There are a couple of reasons that frost bite victims end up in the care of the burn unit, and one of those is because the mechanism of injury, the way that the body works to generate the frostbite injury or the cold injury is actually very similar to what ends up happening if people have a burn injury. The underlying pathophysiology, to use the big fancy word for it, of what causes the tissue damage is very similar. The other part of it is that with more major cases of frostbite when people have blisters or if they don't get treatment in a timely fashion they can even have gangrene where the tissues die, we are experts in managing soft tissue loss and getting areas of soft tissue loss closed or covered because of the fact that that's what we do with burns. So it ends up making our frostbite practice a very logical extension of what we're already doing.

Interviewer: One of the things I read online when I was reading about this was that you're not supposed to rub the tissues. Why not?

Dr. Amalia Cochran: That's an old wives tale. Historically, people were advised to remove their gloves and their boots and rub the area with snow even to help with cold injury if they thought they were getting cold injury. The problem with doing that is you extend the damage in the soft tissues with the friction. So it's actually not helpful to do that

Interviewer: So the tissue is already pretty fragile and if you're rubbing it you're just making the damage worse.

Dr. Amalia Cochran: Right. So the recommendation for rewarming now is a 40 degree centigrade, which is around 100 degree fahrenheit, warm water bath.

Interviewer: Is 100 degrees about a normal temperature bath?

Dr. Amalia Cochran: It would be a warm bath.

Interviewer: A warm bath.

Dr. Amalia Cochran: Yes.

Interviewer: I was always told that you need to keep your central body really, really warm and if you kept your trunk warm your extremities would sort of take care of themselves. But you're sort of saying, no, those hand warmers are important too.

Dr. Amalia Cochran: Yes, it's both. You need to keep your core warm because of the risk of hypothermia, but when you're looking at a risk for frostbite you need to look at keeping your extremity areas, your fingers, your toes, even your nose is an area that's at risk for lower blood flow when you get really cold.

Interviewer: So those face warmers too.

Dr. Amalia Cochran: Yes.

Interviewer: Well, Dr. Amalia Cochran, thank you so much for being my guest today.

Dr. Amalia Cochran: Thank you, Dr. Lee.

Announcer: We're your daily dose of science, conversation, medicine. This is The Scope. University of Utah Health Sciences Radio.