Big Wave Surfing: A physician’s perspective

Credit: T Farrell, DO

Introduction
The sport of big wave surfing has been defined and redefined since the first Polynesian surfer shaped the first board and then rode the first wave. I suspect that from that first wave the allure of riding bigger and more challenging waves had its beginnings.

The history of big wave surfing is extensive with a long list of brave surfers pushing the boundaries and riding waves deemed too big and dangerous by the previous generation. Notable pioneers include Greg Noll (Makaha), Jeff Clark (Mavericks) and Laird Hamilton (Peahi) all connected by a love of the sport and a love of the ocean.

The first organized big wave surfing event was held in memory of legendary big wave surfer and lifeguard Eddy Aikau in 1985 at Sunset Beach, Oahu, and later moved to Waimea bay. A professional Big Wave Tour (BWT) was organized in, 2009 allowing surfers to showcase their talent at select big-wave venues around the world.

I became medical Director for the World Surf League (WSL) BWT in 2015, and the focus of this article will be on the medical experiences and challenges in providing medical support for this extreme sporting event since April of 2015.

Organization of event
Big swells are driven by global weather patterns and as meteorological data improves so too does the ability to accurately predict the ideal timing for big-wave contest a specific venue. The decision to run an event is predicated upon a high probability that the 30-foot minimum wave-height required to run an event will be met and is made by the WSL big-wave commissioner using data provided by Surfline global forecasts. The decision to run an event begins with a “yellow light” five days prior to the proposed event date and then a “green light” 72-hours from the start of the event. This green call results in the mobilization of 24 surfers and 150 members of the production staff and safety team to travel to the venue from all over the globe. Four events are scheduled each year, however in some years events are cancelled due to lack of favorable conditions (i.e. surf > 30 feet). The accommodations and locations have been scouted by the WSL staff and the flights are booked by a travel agent in Australia who deserves an award for her ability to manage the chaos of this challenge.

The Surfers
24 surfers are chosen for each event including the top 10 competitors from the prior season, two invitees from the previous year’s video qualifiers, six regional wild cards and six big wave tour wild cards. These highly-trained athletes remain active year-round by chasing the biggest swells around the globe, and train specifically for the risks associated with this extreme sport. Breath control, water rescue and resuscitation are now a part of each surfer’s preparation. The majority of competitors wear inflation vests which pop full of CO₂ when activated by the surfer via a pull cord, but very few wear helmets.

Much of the training and travel budget for these surfers is dependent on their winnings and is supplemented by sponsors and their own personal savings. As of December 2017, the top earner on the Big Wave Tour Kai Lenny earned $32,000 for the year while half of the BWT surfers made only $2,000 in earnings. Clearly the love and thrill of surfing the biggest waves is the driving force for the majority of surfers on the Tour.

The WSL big wave awards are held at the end of the season and include seven categories: Ride of the year $75,000; Paddle award $30,000; XXL Big wave award $25,000; Tube of the year $10,000; Men’s and Women’s overall performance award $15,000; and Wipeout of the year award $5,000.

The Competition
Twenty-four surfers participate in each event. Each 45-minute heat includes six surfers, with the top surfers advancing to the quarter-finals and semi-finals. The six-man finals are scheduled for one hour. An event can be completed in six to seven hours and depending on the timing of the swell and conditions, most events are completed in one day.

The surfers must paddle themselves into waves. A panel of experienced professional surfers judge the waves and score each ride based on the following criteria: “The surfer exhibiting the most commitment on the largest and most intense waves with emphasis on maneuvers will receive the highest scores.” In other words: It’s not just go big or go home, it’s go big and make it look easy. Jet Ski assistance is only used for rescue and for transfer to a predefined buoy outside the line-up after a wipeout or being caught inside.

Water Safety Team
The water safety team is currently organized by Scott Eggers who has extensive experience in big wave water rescue. He has formed an international team of experienced Jet Ski operators who are extremely competent in large surf and possess added qualifications as Emergency Medical Technicians, Paramedics, and experienced lifeguards. A typical event will require Jet Ski coverage by 10-12 members of the team.

Team members are organized to provide water rescue based on zones specific to each event site. A land-based spotter calls out the number and locations of surfers in need of Jet Ski assist via radio. Two-man teams cover each zone allowing for a back-up rescuer if the first man misses the pick-up. This system prevents multiple skis from entering the impact zone and potentially striking a surfer in the white water or interfering with a successful pick-up. There is also a designated medical Jet Ski with a paramedic operator who is involved in every medical rescue. He is responsible for life saving measures such as CPR, hemorrhage management or spinal immobilization prior to transfer to the medical boat or beach-based medical team. He is in direct radio communication with the entire water safety team as well as the team physician. This communication allows early coordination of medical support before the injured surfer is delivered to the medical team.

The Medical Team
The medical team is led by a board-certified Emergency physician in conjunction with a group of highly trained paramedics sourced from the local EMS system. Area physicians are often included on the team to provide local knowledge of the medical system in the event that an injury requires hospital transfer. This local sourcing also helps with language barriers that often result from the international locations of these events.

The goal of the medical team is to provide acute medical care and advanced life support for the critically injured surfer and streamline the process of transfer to a higher level of care if indicated. Each event has a dedicated ambulance on-site as well as a plan for air-ambulance if the injury and the setting require this.

The medical kit used at the event was designed to include equipment for intubation and airway management, cricothyrotomy, hemorrhage control, ACLS medications, long bone and pelvic fractures, defibrillation, spinal immobilization, management of pneumothorax, and includes a portable ultrasound to assist in trauma exams. The primary focus of the medical team is to provide a high level of acute medical support as soon as possible after an injury. The water-safety team trains yearly to develop the skills needed to reach this goal. There is a strong emphasis placed on preparation for worst-case scenarios in an often uncontrolled and unpredictable setting. Video footage and individual performance from the prior contest are reviewed to facilitate pre and post event team training and discussions to improve safety performance.

BWT Injuries

Discussion:
The BWT injuries managed by the medical team are limited to those reported to the medical team. The underreporting of injuries is likely on the day of the competition due to the hectic nature of a one-day event, as well as the tendency of the extreme athlete to minimize injury complaints. In my experience, the nature of the injuries seen in big wave surfing differ from those I have seen on the World Championship tour (WCT).

• The larger the swells seen on the BWT break in deeper water, making it less likely that the surfer will contact the reef or ocean bottom. The larger waves result in falls from greater height with deeper penetration after impact. This penetration results in a greater likelihood of barotrauma to the lung and ear.
• The knee injuries seen in big wave surfing more commonly involve the leashed rear leg due to the tremendous forces created by the drag of a large surfboard in enormous surf. Knee injuries seen this year were secondary to strikes from behind by a the crashing lip and the forces created by a 10-foot board pulling the leg to extension after a fall in a 30-foot wave. This pattern differs from the WCT where the knee and ankle injuries are more commonly due to the rotational forces and valgus stress associated with turns and aerial maneuvers.
• The incidence of concussion in big wave surfing may be under reported as well. The Nazare 2016 event was notable for three head injuries with three different mechanisms of injury. One surfer was struck by a board, the second by a Jet Ski and the third by the wave itself. The fall from a 30-40 foot wave onto a non-compressible surface (water) followed by the pressure of submersion to 15-20 feet by the force of the wave and the period of hypoxia associated with a big wave hold-down may result in a more magnified concussive response. This is clearly an area for future research and will be part of the medical team pre and post event protocol for 2018.
• There is a significant risk of drowning in a BWT event however the use of self-activated C02 inflation vests by the majority of surfers adds a level of safety. The skill and competence of the Jet Ski operators on the water safety team reduces risk by quickly extracting the surfer from the dangerous impact zone.

Conclusion:
The incidence of injury on the BWT remains low for the 9 events I have attended. Preliminary data suggests that there is less than a 2% injury rate for that period. The average wave height during these events is on the thirty to fifty-foot range and the events are held in five different locations with variable weather and water conditions. The incidence of life-threatening injuries has been extremely low and speaks to the training and resilience of the big wave surfers as well as the quality of the water safety team in its role to minimize injury and prevent drowning.

Credit: T Farrell, DO

Terrance Farrell, D.O.
Medical Director, WSL Big Wave Tour