Bringing ALS to the Mountain

Nothing is more frustrating than knowing what a patient needs and not being able to provide it. This has driven progress in many EMS systems, and it certainly was the reason for developing an ALS system at the Mt. Rose Ski Resort in Nevada.

Located on the mountain ridge between Reno and Lake Tahoe, Mt. Rose Ski Resort has a base elevation of more than 8,000 feet. In good weather, it can take a ground ALS ambulance more than 20 minutes to wind its way up the steep access road. Poor weather can double or triple response times. Even with the rapid response of an ambulance, it can take 15–20 minutes just to get a patient to one of the resort’s two base lodges. Helicopter air ambulances are available in the area, but if the weather is poor, they can’t fly to the mountain.

An unusual set of circumstances and a group of committed individuals allowed the creation of an ALS system at the ski resort using the professional ski patrol staff. One of the ski patrollers, Charlie Tabano, put together the proposal to bring ALS to the resort. Many of the ski patrol staff also serve as paramedics with the North Lake Tahoe Fire Protection District (NLTFPD) and Washoe County’s Regional EMS Authority (REMSA). In addition, both of these agencies have the same physician medical director. But developing an ALS system would take the cooperation and coordination of many more people and organizations.

The operational, administrative and legal departments of REMSA, NLTFPD, the Mt. Rose Ski Resort, the Mt. Rose Ski Patrol and Nevada state EMS office had to sign off on the program. Protocols had to be developed, along with a QA/QI program. There was essentially no money budgeted for the program, so donations had to be solicited from various agencies and vendors.

Leaders launched a pilot study during the 2008–09 ski season. Once the program began, patrol management tried to schedule a minimum of one designated paramedic every day; however, since the paramedics were part-time employees of the resort, this was not always possible. Any possible ALS calls missed when paramedics were not on duty were documented.

The goal was to provide specific ALS care on the ski runs for life-threatening illnesses such as cardiac, respiratory and altered-LOC problems. Today’s Baby Boomers may be aging, but they are still participating in outdoor sports like skiing. When patients with histories of heart, lung and other serious conditions venture into the mountains, altitude and exertion can cause acute illness. Another goal was to be able to provide pain management for trauma cases before moving them down the mountain for ambulance transport.

First aid stations at Mt. Rose’s two lodges were equipped with donated Philips HeartStart MRx 12-lead-capable monitor-defibrillators, as well as ALS kits with medications, advanced airway equipment and other diagnostic gear. Two ALS kits were located in ski patrol shacks on the mountain. These kits had basic medications, a donated Cardiac Science AED able to display a single-lead ECG, a nitrous oxide kit, King airways and IV equipment. Paramedics began carrying controlled drugs (morphine, fentanyl, Versed) in padded kits on their bodies.

Using the nitrous oxide and intranasal fentanyl, the medics could administer pain meds to stable patients without the need to immediately start IVs. Considering the environmental conditions and the amount of clothing worn by patients, this would represent a quick and efficient way to manage pain. We implemented an agreement for restocking of narcotics from incoming units as well as full control and security of controlled medications.

For quality control, all ALS charts were sent to REMSA or NLTFPD medical control for review. In addition, at the end of the season, all charts were reviewed and broken down for analysis of call types and treatments. This helped fine-tune the program and gauge its effectiveness, and helped leaders address future equipment and care issues.

After the first season, all the agencies were pleased with the results. They decided to make the program permanent beginning with the 2009–10 ski season.

Some of the EMT-B-qualified ski patrol members were initially not enthusiastic about the program. They thought they would no longer be assessing and treating patients. However, their attitudes changed once they discovered they would still be doing initial assessments and treatments until paramedics arrived. In addition, they were getting feedback on their care and training on assisting with ALS patients.

Another benefit was more appropriate use of responding resources. The Mt. Rose Ski Patrol had developed specific criteria for the automatic dispatch of a helicopter ambulance. With an ALS team available to do more thorough assessment and treatment, many automatic responses could be cancelled. Air ambulance responses were reduced by approximately 60% from non-ALS years at the resort.

During the last full ski season, 2010–11, around 10% of the approximately 1,000 patients seen by the ski patrol received an ALS assessment and/or treatment. The Mt. Rose ALS program is considered a success and will continue for the foreseeable future. The participants are continuing to refine and better the program with each season. They would like to obtain some sort of automatic CPR device so they can continue CPR on the sled down the mountain. However, the program still depends on donations for major equipment.

A project like this, with so many agencies involved, takes much work and patience. However, the outcome has been better patient care and more efficient use of EMS resources.

Barry D. Smith is ground CQI coordinator for the Regional Emergency Medical Services Authority (REMSA) in Reno, NV. Contact him at bsmith@remsa-cf.com.