Another day at the office…Terry at Cloudbreak, Fiji.
While much of our readership has a keen interest in surfing medicine, there are only a handful of us who actually get paid to travel the globe taking care of injured surfers. SMA’s own Terry Farrell, D.O., is one of the lucky few, and SM caught up with him this summer, just as he was waiting for the green light for the big wave contest at Puerto Escondido. What follows is an edited version of an interview we conducted with the Maine emergency physician who has bagged the dream job many of us wish we had. After all, who gets a paid travel to Punta Lobos and hang out with likes of “Twiggy” Baker, Greg Long, Ramon Navarro, and the rest of the big wave chargers? Here we get a physician’s perspective on the thrills, spills, and carnage associated with big wave surfing.
Terry, tell us jealous folks over here at Surfing Medicine how you got this dream job of being a bona fide surfing doctor. It must be rough traveling around the world to epic surf spots and hanging out with the pros.
As with many aspects in life, family connections helped get me started. My brother-in-law, Matt McCabe was involved with the then newly formed WSL. I’m an ER doc, I spent my fair share of time in the military and in wilderness settings and I love to surf so I told him if he ever needed a doctor to supervise events, sign me up. I started by volunteering my time at a number of contests. My first event was Trestles. I got there early and left late every day, I tried to make myself useful. I worked at Pipeline the following two Decembers and met other people in the field like Warren Cramer, MD and Leland Dow, DO. During my second stint at an unruly Pipe, Bede Durbridge hit the reef, suffering an open-book pelvic fracture and Owen Wright took a brutal pounding resulting in an intracranial hemorrhage that would keep him off the tour for a year. At that point, the management of the WSL realized that it needed a full-time emergency physician on tour that could provide ATLS and ACLS level care, and I was hired.
After being on tour for a season, I personally felt the greatest need for a boarded emergency physician was at the big wave contests where chances of a severe injury requiring my expertise was most likely, rescue is a big challenge and advanced medical care is often far away. Currently, I concentrate most of my efforts on the BWT. I love the travel, and I enjoy spending time with some of the most accomplished watermen in the world, I really can’t complain.
Exciting as it is, the logistics can be challenging. The BWT is split into a winter and summer season. We are on yellow alert if it looks like a good swell will be approaching with-in 1 week, and green alert gives us 72 hours to mobilize, and fly out. I still work in my local ER part time and that means I often need to make last-minute schedule swaps to rearrange my shifts. Fortunately, my co-workers and family have been very supportive.
Without getting into specific personal details, tell us about the types of injuries that you’re seeing on the Big Wave Tour. What are the most common types of injuries and what are the most gnarly?
The worst injuries would include a pneumothorax together with a complex ear laceration at Nazarre, and the pelvic fracture and ICH mentioned above. At Puerto Escondido a guy surfaced and started coughing up blood from barotrauma. Other surfers have mentioned that this has also happened to them from pressurized hold-downs. There have also been a number of shoulder dislocations, ACL tears and concussions. Ear drum injuries are pretty common. Unlike smaller wave surfing, it seems like many of these are purely from the force of the wave. A lot of surfers are brought to shore after major wipeouts and are confused and disoriented, without having hit their heads. It seems like the violent shaking alone can cause a concussion.
Walk us through how you do a risk assessment at the various venues. For example, I would imagine the in-water rescues at Nazare are quite different from Puerto Escondido which must be different from Jaws.
As medical director, the first thing I do is think about what are the worst things that could happen and how would we take care of the patient from in the water to in the ICU. I kind of work backwards going from the nearest tertiary care hospital to the nearest hospital or clinic to the ground or air transport to the on-site stabilization which I’d be providing to the retrieval and rescue of the surfer in the impact zone. Each place is different. In Punta de Lobos and Todos Santos the roads are bad and the hospitals are far away. I download the telephone numbers of the ambulance service, the local community hospital and tertiary care hospital on my phone before I leave. On the more remote events we have air medical resources on hand. I talk to local surfers and doctors who have local knowledge about medical resources, communications and travel in the area. I can stabilize the patient on land for that critical “Golden hour” but a big part of my job is coordinating the logistics of the whole medical effort. I can decompress and pneumothorax, I can apply a tourniquet for hemorrhage control from a fin cut, I can provide ventilation with a bag-valve mask, high flow oxygen, and even intubation or cricothyrotomy if needed, but a big part of my job is still getting the critically injured patient to a hospital that can provide definitive care.
A major part of my job is working with Scott Eggers and his team of expert waterman/Paramedics who put themselves in harm’s way at every contest, assisting surfers out of the impact zone after every ride. Without them I could never do it. We regularly go over different scenarios and simulate how we are going to transfer an injured surfer from in the impact zone to me on a boat or on land and then to a hospital setting if need be.
How do they practice surf rescue using skis and sleds? Describe the normal sequence of events that would be involved in rescuing an injured surfer in big waves.
Scott and his international water-patrol team have as many as 11 jet skis at a given contest. They divide the area into different zones of the surf break. Zone-one is the impact zone and there are usually two skis dedicated to that area, two more to the middle zone others in the outer zone. There is a spotter with a VHF Radio who oversees and coordinates the rescue from the judging stands or a cliff above. After each successful ride or wipeout, the surfer is picked up by the water patrol guys. Uninjured surfers get a ride back to the line-up. We have different protocols for injured conscious and injured unconscious.
When a surfer goes down in the impact zone, a zone-one ski goes in for the pick-up followed closely by the second ski. If the first ski missed the pick-up, hopefully the second ski makes the grab. If neither of those skis is successful, two skis from the adjacent zone will swoop in. If the surfer is incapacitated and unable to help themselves, a water patrol guy will get in the water and lift an arm of the victim so they can be grabbed by ski and pulled onto the sled. We practice simulated scenarios, for example how do move an injured surfer on a back board from a sled up into a boat. This came in handy in Tavarua when we had a potential spine injury at Cloudbreak. We practice this stuff every year in San Diego, and I can’t emphasize enough that these guys from Hawaii, Australia, and South America are among the best of the best watermen- paramedics in the world. See training video.
What kind of protective gear do you see the riders wearing these days? Tell us about the use of helmets, floatation vests and any supplemental air devices that people are routinely using and when they’re using them.
Almost everyone wears a floatation vest. Most have a CO2 cartridges that will inflate the vest when a deployment cord is pulled. Although an inflated vest usually keeps the surfer’s head out of the water, it also prevents any attempt at diving under an approaching wall of white water. Once inflated, surfers still take a ton of punishment because they tend to get pushed shoreward for longer distances. During the huge and windy conditions we saw during the 2015 Peahi (Jaws) contest, the surfers were actually pulling their ripcords as they were falling down the face of a wave. This makes the job of the water patrol challenging because a surfer can end up 100’s of yards shoreward of where they fell in.
Surfers have considered helmets, both as a form of protection and as a way to enhance in-water communication, but so far, no one uses them routinely. The counterarguments are that they interfere with the sensory cues that aid balance. They also effectively increase the size of the head which makes swimming underwater more difficult. No-one uses any supplemental “spare-air” devices. I think it would be near impossible to connect to a mouthpiece when getting rag-dolled underwater.
What would your recommendations be for a physician who is volunteering to provide medical backup at a surf contest? What preparations need to be made beforehand and what Materials would you suggest bringing to the event site.
Again, it depends on the venue. Think about what is the worst-case scenario: drowning, c-spine injury, head injury, major bleeding and try to be prepared for those. Know how you will contact emergency services, how the patient will get out of the water and into an ambulance and what hospital they are going to go to. Make sure you have all of the local phone numbers you might need. Bring your own equipment and supplies and carry the life saving portion to the waterline to meet the surfer. I personally pack a tourniquet, a bag valve mask or a pocket mask, hemostatic sponges such as quick clot and a C-Collar in a backpack and carry it on my shoulder. The venue usually has supplies such as Oxygen and back board which are sourced locally. For the more common minor injuries I bring a laceration kit that includes a skin stapler, dermabond, antibiotic ointment gauzes and bandages. I carry non-narcotic pain medication. For orthopedic care, I usually have a sling, knee immobilizer, Sam extremity splints and a Sam pelvic splint. I bring a couple of space blankets for hypothermia. When I’m in remote settings we also have oxygen, nasal cannula and a pulse oximeter, and I bring a laryngoscope and endotracheal tubes for intubation. I also carry a mini-chest tube which I almost used at Nazarre. I carry the stuff in a backpack that is with me at all times. Another thing to think about is back-up liability insurance if the contest is in a state or country in which you don’t have a medical license.
No one has objectively studied the risks associated with big wave surfing. I understand that you are interested in conducting some research on this subject.
I’ve noticed that a lot of guys – when they come in after a major wipeout – will be foggy-headed, confused, and wobbly on their feet. While they haven’t hit their heads on anything, I think the violent shaking that they sustain may be causing concussions – what I like to call “shaken surfer syndrome”. I’m designing a study right where we are going to measure pre and post-contest concussion scores using a King-Devick test – the same test used on the sideline for football players. The test is well validated, is administered on an iPad and only takes about 2 minutes. It measures eye movement, language, attention and pattern recognition using the touch screen. It seems to me that a lot of the big wave surfers are suffering from the shaken surfer syndrome, and I’d like to look at this more objectively. Another interesting thing I’ve been thinking about is putting an accelerometer and pressure gauge into a helmet to look at the forces and pressures involved when you wipeout at say – Jaws or Puerto.
Lastly, I know you are a “Maine-iac”, do you yourself get much surfing in when you’re the medical officer at these contests? I imagine particularly on the big wave tour that it’s very important that you be near a radio and out of harm’s way so you are always prepared to take care of the surfers.
During lay-days, if it’s not too big, I’ll get some water time in. In Fiji I had a couple of fun days at Restaurants during high tide. I get plenty of coaching from the pro’s, and they usually let me get my share of waves. I’m still rehabbing my shoulder from a wipeout I took at my home break in Maine in small-ish surf – it was only double overhead.