Running for more than 15 years, the BMC Frostbite Advisory service has helped countless skiers, snowboarders and mountaineers deal with their injuries. We spoke to 2 members of the team, David Hillebrandt and Chris Imray, about their work...
Thanks David and Chris for answering our questions. Can you tell us how the BMC Frostbite Advisory Service came about?
DH: I was contacted through the BMC by a father of a 22 year old who suffered frostbite whilst descending from the summit of Aconcagua (6962m). The mountaineer had managed to walk out on frozen feet and reached the hospital in Mendoza where they'd dressed his toes. Once back in Buenos Aires a local surgeon suggested surgery to remove the dead flesh and follow up with a skin graft from the groin. It was at this point that he started to have doubts and contacted his father. Within 6 hours of the initial phone call, I was able to share photos of his injuries and discuss his case with Chris. We were able to advise him against surgery and return home as quickly as possible. We helped arrange a business class flight so that he could elevate his leg and sufficient champagne to dilate his injured blood vessels! He went on to make a full recovery and ran the London Marathon 3 months later dressed as a fairy! Surgery was not needed.
We later wrote it up for the BMJ - The article can be found here.
With so many people getting in touch has a common pattern of injury emerged?
DH: I think a lot of people put on new clean socks for summit day and they are too tight. Lacing boots too tight is another cause. Talking about common patterns of injury it's worth looking at our write up of Kite Skier's Toe. What do you think Chris?
CI: Sadly the majority of injuries have avoidable or preventable features. Getting the basics right significantly reduces the incidence of frostbite.
Further information on the prevention of frostbite can be found here.
At what point are you normally contacted? What treatment do you recommend?
DH: All 3 of us can be contacted by satellite phone or email. With 3 members of our team someone is normally available. We prefer to be contacted from the field to get early photos and ensure that thawing is carried out correctly. The next priority is an iloprost infusion which is when a rapid return to UK may be important. However this is now available in Nepal and other locations. As GP's Paul and I can provide advice in the field. Generally, we believe that surgery is not required in the days after injury. Once back in the UK this is where Chris comes in with his vascular surgery knowledge. We then liase with other medical teams near the patient's home.
An excellent article on the treatment of frostbite can be found here.
Do you advise using supplemental oxygen in those frostbite cases that occur at high altitude?
CI: Yes. There is emerging evidence that hypoxia causes vasoconstriction and cooling of the extremities. We took a group of 10 healthy volunteers and exposed them to a range of simulated altitudes. Measuring the surface temperature of their hands we found a cooling effect as the hypoxic exposure was increased. Details of the study can be found here.
Thermographic images of hands exposed to simulated altitudes of 300m, 1600m, 3000m, 3900m and 300m oxygen. The study took place in a hypoxic chamber and an ambient temperature of 20 degrees C was maintained throughout.
Have you had successes with iloprost?
DH: Yes, several in recent years!
CI: Yes. We have been advocating it's use for some time. Whilst the early studies only advocated it's use in the first 24 hours after injury we believe that this time limit is arbitrary and patients can still benefit from iloprost days later.
A fascinating series of 5 frostbite cases treated with iloprost can be found here.
At what point do patients undergo surgery?
DH: As late as possible. Let nature do most of the work!
Is it possible to predict the need for surgery? Does Cauchy's Frostbite Classification help?
DH: For most cases why does one need to predict? Time and nature will tell you. (very hippy!).
CI: Yes. Not always perfectly, but its the best we have at the moment.
Technetium scanning is not widely available and one does wonder about alternative imaging modalities.
Early frostbite pioneers recommended the use of oral vasodilators such as buflomedil. Do you recommend their use?
DH: Not now.
CI: At present there is no strong evidence to support the use of these drugs.
What analgesia do you recommend in the initial stages of frostbite?
DH: The strongest you have got to control the pain!
Do you recommend the use of NSAID's such as ibuprofen in field management?
CI: Yes, there is reasonable evidence to support this. A good review of the wider uses of ibuprofen can be found here.
Do you follow your patients up? What's your advice to those who've suffered frostbite and want to get back to the mountains?
DH: No, most climbers just want to get back to climbing. Initial control of that urge is important. Beyond that? No smoking. 8000m boots for 6000m peaks. Double boots for Scottish winter. Good fitting boots. Care with rock boots. Lots of good gloves and mitts.
What is the worst case you've encountered?
DH: It's worth taking a look at this case study to really get an idea of how damaging frostbite can be and the long recovery that lies ahead.
Thanks David and Chris!
Congratulations on establishing the BMC Frostbite Advisory Service. Here's to the next 15 years!
Dr David Hildebrandt is a GP and the Honorary Medical Advisor to the British Mountaineering Council and the British (IFMGA) Mountain Guides.
Prof Chris Imray is a Consultant Vascular and Renal Transplant Surgeon at University Hospitals of Coventry and Warwickshire (UHCW). He is currently President of the Vascular Society of Great Britain and Ireland.