Field Notes: 50 CC of Pampering for the Skier-Stump, Stat!

May 2, 2004
Outside Magazine
Outside magazine, April 1998

Field Notes: 50 CC of Pampering for the Skier-Stump, Stat!

A peek under the rug of Aspen's ER, where Very Important Ligaments come to be healed
By Florence Williams

You want Chris Martinez to be your doctor. A youthful, bespectacled, 40-year-old specialist in emergency medicine at Aspen Valley Hospital, he invariably projects the sincere belief that your malady is the most interesting, most affecting thing he's ever seen. Greeting you in the ER, he shakes your hand and sits down so his face is level with, or beneath, your face. He tightens his brow and hunches closer as you tell him what ails you. He listens for as long as you talk, and when you're done, he asks for more. If you're upset — if, say, you're a 37-year-old male skier who collapsed in seizures during your last run of the day — he'll touch your arm as he tells you he's very concerned.

Martinez, a Louisiana native, has a voice reminiscent of what Tom Wolfe once wrote about the hillbilly inflection of test pilot Chuck Yeager: It possesses "a particular drawl, a particular folksiness, a particular down-home calmness that is so exaggerated it begins to parody itself (nevertheless! — it's reassuring)." This is a doctor who hates pets, but who once let himself be talked into doing CPR on an iguana. The reptile belonged to a man in a long fur coat who was beside himself that a local vet could not be found. "It died," Martinez says, shrugging.

I've arranged to spend the weekend between Christmas and New Year's Day in Aspen Valley's ER, when I figure the action, along with the number of visitors to Aspen and their average wealth, will spike sharply upward. At any time of year, treating the medical problems of Aspenites can be a rigorous exercise in "interpersonal relations," as Martinez puts it. I see what he means when an entire family arrives in the ER late on Friday night wearing identical outfits: creaseless black leather jackets, black fuzzy sweaters, black pants, and black boots. The 15-year-old son has thrown up a chili dog and passed out in a hotel elevator. Martinez wants to start an IV, but the kid's dad, a shrink, thinks it's a bad idea. Martinez — smiling grimly — manages to win the battle. "Doctors are the worst," he grumbles. As another ER doc puts it, "By and large, our patients are bosses in their own world. They're used to dealing with people vertically, not horizontally. A rich jerk has a greater capacity to make your life miserable than a poor jerk." Martinez's strategy for coping is to give his patients something they're used to: undivided attention. "You have to make them think they're getting what they want but also give them what they need," he tells me.

If diplomacy matters, so does discretion. An emergency room like the one at Aspen Valley is a resort's back alley, an inconspicuous place where the consequences of bad luck and trauma are tidied up, and a place the chamber of commerce and the destination's marketing people prefer that you don't notice. Especially in the weeks surrounding Christmas and spring break, ski-resort hospitals witness the numerous small and occasionally enormous heartaches of a good time gone sour. Here are the bar-fight bruises, the skiing dings and disasters, the expensive dinner in a vomit bucket.

One administrator tried to dampen my expectations before I arrived. "It's not like TV," he said. "It's really mundane. There are long stretches of boredom interrupted by rare spurts of panic — lots of knees and shoulders, followed by someone who hit a tree." He was right, of course, but if I had tried to visit five days later he would have probably barred my access to the ER, given the raging media frenzy that ensued. For on New Year's Eve, Michael Kennedy would crash into a tree while playing football on skis at the Copper Bowl run and would be pronounced dead in that same ER.

Kennedy was brought into the Aspen Valley ER at 4:51 P.M. Until then, it had been a day pretty much like the others I spent there that week — a few cases of the flu and a hectic succession of sprained thumbs, blown-out knees, separated shoulders. Late afternoon is the busiest time of day; one doc refers to it as "the testosterone hours," when muscle fatigue, hangovers, and icing slopes compound the already troubled formula of kinetic energy: Skiers fall down, and skiers moving fast fall down hard.

Half an hour earlier, a 16-year veteran of the Aspen Ski Patrol named Michael Ferrara had taken the call from the dispatcher: unconscious male at phone 312. Within four minutes, Ferrara and his team arrived at the scene and began treating the victim, a man in his late thirties who had sustained a severe head injury. After Ferrara had cleared Kennedy's airway, stabilized his neck, and administered oxygen, he attempted to boost his weak heartbeat with IV-injected cardiac drugs and hooked up an EKG. (Such an intensive life-support protocol is fairly uncommon in the ski-patrol world; most resorts do not require their staff to be paramedics.) During the toboggan run down the mountain, Kennedy's heart stopped. Standing with his right leg in Kennedy's sled and his left leg in the support sled, Ferrara inserted a second IV and started advanced cardiac resuscitation. At the bottom, a county ambulance was waiting. Ferrara still did not know the victim's name. A few miles away, a surgical team headed by Dr. William Rodman, a trauma specialist, had already assembled at Aspen Valley Hospital. Soon after Kennedy was brought into the ER, scans and X rays showed cranial damage and a severed spinal cord. Doctors spent an hour vainly attempting to save him before they gave up.

Kennedy's accident was what medical professionals call a "skier versus tree," sometimes shortened to "skier-tree." Aspen sees about a half-dozen skier-trees a year that result in major head trauma, and another dozen from skier-rocks, skier-chairlift pylons, skier-snow, and skier-skiers. One or two die from such collisions at Aspen each year, a typical figure for major ski areas. On average, 32 people die annually in the United States in skiing accidents (a number that does not include deaths resulting from heart attacks, asthma, strokes, and other medical causes).

Like Sonny Bono, who hit a tree at South Lake Tahoe a week later, Kennedy was statistically on the older side for a trauma fatality. (Most are between the ages of 18 and 26.) Apart from that, and the odd coincidence that both victims were celebrities, their deaths were textbook ordinary. To quote from one 1996 study: A typical skier death involves "an experienced male running into a tree off the edge of an intermediate skill level slope at a high rate of speed, resulting in massive head or neck injury." Bingo.

Actually, Aspen is a great place to get seriously hurt, although the tourist brochures are not about to tell you this. ("Your catastrophic-injury needs can be handled at our fine emergency room...") Not only will you be treated to the unfailing hospitality of someone like Dr. Martinez, you will experience the kind of sophisticated, high-tech care you might expect at a much larger hospital, and unlike almost everywhere else in Aspen, you'll be charged a fair, standard price. In a town where you can buy a $14,750 singing Christmas tree and where the median home price is now $2 million, and in a county whose property values exceed the gross domestic products of Nicaragua, Honduras, and Suriname combined, the civic authorities aren't about to let a cost-cutting mentality dictate policy. Corporate consolidation and managed-care efficiencies may hold sway in other places, but Aspen Valley Hospital has remained an independent, community-owned institution, run by an elected board and generously funded by property taxes and private foundations as well as by patient fees.

Dr. Bud Glismann, the director of Aspen Valley's Emergency Department, is not just stating the obvious when he tells me that "this is not your typical inner-city hospital." Except for the mishaps that befall them while they're out having strenuous fun, people who occupy Aspen's peculiar demographic niche tend to be unusually healthy and peace-loving. The last homicide in Aspen occurred in 1985, and there are few stab or gunshot wounds or drug-related medical emergencies, few overweight or diabetic patients, and few elderly or Medicaid patients, the staple crop of most ERs around the country. "The average person in this town could buy and sell this hospital ten times over," Glismann says. All of this translates into a unique focus on bones and ligaments and the ailments of rich folks, and a highly trained staff of specialists, including six orthopedic surgeons, two neurologists, and the only endocrinologist between Denver and Grand Junction. "Very simply," Glismann says, "this is the finest 35-bed hospital on the planet."

On a busy day, 30 to 50 Aspen skiers will go to the ER. "Your average person doesn't know how dangerous this sport is," says one doctor. "Maybe that's a good thing."

The waiting room and hallways of Aspen Valley's ER do not look particularly impressive — nothing, for example, like the posh decor at the new 77,000-square-foot Aspen Club spa, where patrons spend up to $415 per day to work out, detoxify, hydro-massage, herbal-wrap, deep-cleanse, and coif themselves, or perhaps take skiing or snowboarding lessons indoors on an inclined carpeted treadmill. In fact, Aspen Valley looks the same as countless other small-town public hospitals, with its 1970s corn-chowder-yellow walls, its avocado Formica nurses' station, and its pallid, chipped linoleum floors. The difference becomes clear behind the closed doors, where you find the multimillion-dollar CT and MRI scanners, the telenetworked computers, and numerous monitors, each showing a different slice of someone's brain.

Two days after Christmas, snow on the mountain is thin and firm; by early afternoon, fallen skiers and snowboarders suffering various degree of contusion, concussion, fracture, and exsanguination are strewn around the ER like wreckage left in the wake of a carnival. Just past the suture room is the X-ray light box, where Martinez and the orthopedists on call examine a quick succession of breaks and dislocations (more upper-body films for snowboarders, lower-body ones for skiers). At 2:10, I follow Martinez into an exam room where a Swedish teenager with a separated shoulder waits with a friend.

"How long have y'all been in town?" Martinez asks.

Neither boy speaks much English, so Martinez retrieves a rubber skeleton. He presses a rubber bone and then points to the corresponding place on the boy's shoulder. Speaking slowly, he tells his patient, "You'll need to wear a sling. A sling." The teenagers nod gravely and Martinez moves on.

Patients in the ER rotate like the heavens: early Saturday evening, the skiers start to give way to the black eyes, chest pains, and acute intoxications. (Of 139 patients who came to the ER during the 48 hours of my visit, only half had been injured on the mountain.) Other patients have bad colds, some have been in car wrecks (locals call the icy highway to Aspen "Killer 82"), some have fallen in the street or on condo stairs. Two patients come in with high-altitude pulmonary edema, which is rare at 7,500 feet. Then there is the snowmaking mechanic who limps in at two in the morning. He's one of many furtive elves who work all night so skiers can wake up and imagine it's snowed, but tonight his snowmobile slid and flipped, mauling the guy's face before it tumbled a third of the way down the mountain. Other service-industry casualties trickle in over the weekend: the goateed sushi chef who sliced his finger making crab roll, the Mexican maid whose baby has a chronic ear infection, the Australian nanny who went snowmobiling on her day off and ran into a branch, the lift operator who threw out his back while trying to save a skier from getting swiped by a chair. Twenty minutes after this last poor fellow was discharged, he got into a car wreck and was wheeled back in on a stretcher.

Sunday morning starts out quiet, and the ER staff ebbs and flows near the nurses' station. Between ambulance runs, ski patroller Ferrara tells us about his recent bout of acute mountain sickness while attempting to climb a 7,000-meter peak in Nepal. A young first-year physician, Scott Gallagher, walks over to describe what seems to have been yesterday's biggest headache: He was on duty when a man came in with an index finger that had been mangled in an electric gate, severing the top of the digit. Not content with the prognosis, the man immediately arranged to be flown off in his Lear jet to consult his physician in Beverly Hills. "I trained in Oakland," Gallagher says, "where a lot of the problems that bring people to the ER are life-threatening. Here, people just act like they are."

Talk turns to the holiday crowds, to the need for caffeine, and inevitably to recent patients with the most gruesome stories and wildest etiologies. A skier-stump arrived the other day with six broken ribs and a collapsed lung. Another skier-stump shattered her knee, and then there was the guy who was just airlifted to Grand Junction.

"Was that a skier-skier?" one of nurses asks.

"No," someone replies, "that was a skier-snow."

Just how dangerous are skiing and snowboarding? Ask a ski company executive, and you're unlikely to find out. Denver Post writer Mark Obmascik tried for a year to get the Colorado ski industry and then the U.S. Forest Service, which leases ski acreage to resorts, to cough up injury statistics. They wouldn't budge. "It's a basic consumer issue," Obmascik argues. "We ought to have access to safety records."

"The skiing company is a business, and they're a private business, so they're not required to release any information," says Tom Walsh, an Aspen paramedic and county coroner. When I spoke to one Vail Mountain official, she said, "I'd love to tell you our statistics, but I can't. I've been told it's a huge liability risk."

But injury studies do exist, and they point to two clear truths: Skier and snowboarder fatalities are quite rare, but skier and snowboarder injuries are disturbingly common. On average, only three to four skiers per million will die — 0.69 deaths per million "skier visits," as it is commonly quantified. "Skiing is at least three times safer than bicycling in terms of fatalities," says Carl Ettlinger, director of a public-interest group called Vermont Safety Research and a leading authority on ski-injury stats. "But there is an epidemic of serious knee sprains in this country," he adds. Indeed, an estimated 24,000 skiers this year will blow out their anterior cruciate ligaments. While broken legs have decreased by 88 percent in the last 20 years, knee sprains, such as ACL tears, have increased by 240 percent, thanks to an evolution toward taller, stiffer boots, which transfer torsional energy up the leg.

These statistics seem borne out on Sunday afternoon, when Martinez does four ACL exams in a row. "Did you hear a pop when you fell?" he asks a very tan woman from California. She nods. He places one hand behind her calf and another supporting her thigh, and then tugs forward. Her lower leg just keeps sliding out from the knee like an opening drawer. Martinez release his hold and sits down to tell her he recommends surgery.

The Aspen ER sees about a thousand ACL ruptures per season, and the hospital will surgically repair about half of them. On hardpack days, people are more likely to actually fracture something, and a steady stream of broken wrists and tibias comes through the glass doors from the ambulance bay. In general, women are more likely to suffer ACL injuries; men, more likely to bang up their shoulders and ribs.

"Your average person, they don't realize how dangerous this sport is," Martinez remarks, "and maybe it's good that they don't." Characteristically, he hastens to add, "What I like people to know is I'm here to take care of them."

The studies and the statistics summon up a disquieting thought. Next time you're on the slopes, look around. On a busy day, Aspen's ski patrols will send between 30 and 50 of your fleece-clad fellows to the ER. As Ferrara tells me during some downtime in the radio room, that injury rate is comparable to the national average of about two per 1,000 skier/snowboarder days. (These figures, however, don't include the estimated thick-headed 30 percent of us who will limp off the hill by ourselves.)

When Ferarra's beeper goes off, he rushes away, pausing for a moment to introduce me to Dr. William Rodman. Rodman is the hospital's trauma surgeon (he will be called in to run the show when Michael Kennedy is brought to Aspen Valley's ER three days hence), and he was the doctor responsible for making the hospital a certified Level 3 trauma center, the only resort facility in Colorado with such a high rating. (Level 1 and 2 trauma centers can provide even more advanced care, such as the services of on-call or on-duty neurosurgeons. Most rural hospitals don't have trauma-center certification.)

Rodman, who bears an uncanny resemblance to Garrison Keillor, takes Ferrara's seat in the radio room and hands me a stack of material on head injuries. It turns out he's on a crusade to make us all wear helmets, and he hastens to explain why.

Rodman describes your brain this way: Picture a head of cauliflower, wrapped in cellophane and then bagged in brown paper. Most head injuries involve minor concussions, a rough jostling of the cauliflower; but sometimes contusions (bruises) occur in the cauliflower itself or near the brown bag, causing swelling and bleeding. If it's bad enough, you'll need to be essentially deflated by a neurosurgeon, which involves a helicopter trip to Denver or Grand Junction. But if it's really bad, if the bleeding causes even greater pressure in the enclosed space inside your skull, your brain could be squeezed so hard that it starts to push down into your neck, suffocating your brain stem and your body's vital control center. That's when cardiac arrest occurs, among other things, and less than 1 percent of you will survive. None of you will survive as the cauliflower you once were.

A snowboarder himself, Rodman tells me he always wears a helmet. His wife and two kids also snowboard, and they wear helmets, too. "We saw 137 serious head injuries in here last year," he says. "For every other gravity sport you can tick off — mountain biking, hang gliding, parasailing, rock climbing — you wear helmets. It's common sense."

Within 72 hours, of course, powerful evidence supporting Rodman's mild-mannered argument will arrive in the form of Michael Kennedy's fatal injury.

When a skier hits a tree, the ER professionals call it a "skier-tree." Other mishaps include skier-rocks, skier-chairlift pylons, snowboarder-snow, and skier-skiers.

My last afternoon in the ER, a snowboarder-snow comes in on a stretcher. Mike Still, a local 17-year-old, passed out after banging his head during a jump in the snowboarding park. When he came to a few minutes later, he couldn't remember what had happened or what day it was.

Martinez handles the case. After examining Still and checking his X rays, Martinez pulls up a stool to have a heart-to-heart with Mike. "Well, looks like you're OK," he says soothingly. "But some new studies have just come out showing that concussions are cumulative. That means each one takes a bit more to recover from. I want you to wear a helmet from now on."

Mike nods, still a bit dazed. I wonder how much of this conversation he'll remember, and a few weeks later, I call him up and ask him.

Mike tells me that he feels great, that he never even got a bump, and that he's been back on the jumps course for weeks.

"So are you wearing a helmet now?" I ask, already knowing the answer.

"Nah," he chuckles awkwardly. "They're too sweaty."

Martinez should probably have figured as much, even as he was dispensing his advice. After all, Martinez told me he didn't wear a helmet when he snowboards or climbs. In fact, my informal weekend survey seemed to indicate that the population most likely to require emergency medical care in Aspen are the emergency doctors themselves. Dr. Steve Ayers was visibly limping after recently breaking his toe in a fall; last year, he suffered a serious concussion while in-line skating. Martinez broke his foot last year too — a rock-climbing accident. Glismann, who races motorcycles, skis fervently, and travels with the U.S. Ski Team as one of its physicians, recently fractured his back, pelvis, and ribs falling through the second floor of a house he's building.

At three in the morning, when there is a lull between a flu case and a woman whose infected fingernail needs to be pulled off, Martinez takes a break in his cubicle office and gulps down a sandwich while regaling me with the story of how rock climbing changed his life: It made him realize he didn't want be a doctor in private practice. "Those guys have no life," he says. "I want to have a good time." Martinez doesn't want a pet; he doesn't want kids. Attachments would keep him off the rocks and off the slopes.

Besides, he says, such pursuits serve him well, for he likens the rigors of extreme sports to emergency medicine. They provide a model of both alertness and doggedness that will serve him well throughout the craziness of the coming week and throughout the remainder of a long icy season. Tomorrow, once again, there will be 20,000 people up on the slopes, traveling downhill at 30 miles per hour on skis and snowboards. Inevitably, those with bad luck or bad judgment will be making a visit to the ER, and Martinez, with his world-class bedside manner, will be there to soften the blow.

Florence Williams wrote about Greenpeace in the November 1997 issue of Outside.

Illustration by Anastasia Vasilakis

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