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'Acceptable Risk' vs Danger


Most of us who enjoy sports can recall one or two close brushes with catastrophe. Or at least we can remember an incident that gives us chills when we reflect back on it. I have a few such memories, mostly related to mountaineering and skiing. The most indelible one dates back to a day when I was skiing at high speed down a steep slope in whiteout conditions. Without realizing it I flew off a snowy lip and became airborne, unaware I had rotated upside down. I landed directly on my head and felt a "crack" when my neck flexed forward. After picking myself up, I realized I was all right, but I still shudder when I think how close I came to breaking my neck.

Another time I was climbing an ice field in late spring in the Rocky Mountains, again in whiteout conditions, unable to see more than a few feet ahead. Roped up and in crampons, suddenly I heard a very loud sound like thunder and felt the ground shake beneath me. I assumed a large ice block had broken off above me and believed for a few moments that I was about to die. As it turned out, the sound was from a nearby avalanche that was fortuitously directed away by the slope's contours.

I have also witnessed many traumatic events in sports: death from a head injury on a ski slope; death from a chest injury on a rock face; obstruction of an airway from aspirating a dental bridge. Never did I consider what we were doing really dangerous—a little risky, perhaps.

How do we decide to participate in "dangerous" things? We certainly don't methodically compare the absolute and relative risks of the activity with potential gain, carefully noting all knowns and unknowns. Emotion plays a big part: What risks are we willing to take? What gives us satisfaction? One key factor, though, is the basic understanding that a given activity is dangerous. That alone keeps many of us from participating.

This month's article, "Eight Nonavalanche Snow-Immersion Deaths: A 6-Year Series From British Columbia Ski Areas," page 31, by Robert Cadman, PhD, provides insight into one clearly risky activity. In six of the eight deaths Dr Cadman describes, skiers and snowboarders who took to timbered slopes in deep powder fell headfirst into tree wells and were unable to extricate themselves. They suffocated. (Tree wells form around the bases of conifers where the branches prevent snow from getting close to the trunk. See illustration, page 32.) Given that the victims could have skied or boarded with as much speed and excitement somewhere else, they might have made a different choice had they known the danger. Most likely, though, they were unaware: I was until I read this article, despite having worked as a ski instructor and coach.

In the role of physician-educator, we often assume that sports participants understand and accept the risks of their activities. In fact, though, many don't recognize the dangers, and few thoroughly contemplate the possible consequences. I don't believe this means they are unteachable. After a serious injury, even risk-taking elite athletes are, in my experience, more likely than not to change their behavior. As physicians, we can—once we understand the hazards—educate patients and make the physical lesson unnecessary. This focus on communicating known hazards is particularly important given that high-risk activities are not needed to reap the benefits of exercise and sport.

Our role as physicians is not, of course, to make decisions for our patients—whether the question is where to ski or whether to exercise. But we can often seize a golden moment to teach them.

Gordon O. Matheson, MD, PhD



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