Abstract
Debate exists regarding safety and optimal technique for ski patrollers performing cardiopulmonary resuscitation (CPR) on cardiac arrest patients in a moving toboggan during rescue evacuation. Cases of successful outcomes after toboggan-transport (in-sled) manual (hands-on) or mechanical CPR by ski patrollers have not been described in the medical literature. This case series presents 3 adult resort skiers who experienced medical cardiac arrest in Vermont over the years 2024–25, and who received manual CPR in a moving rescue toboggan, leading to return of spontaneous circulation and subsequent neurologically intact hospital discharge. One case displayed signs of cognitive activity only during chest compressions, which suggests that manual CPR in a moving rescue toboggan can create brain perfusion. This study documents that after an initial period of on-scene stationary CPR and defibrillation, manual CPR may be safely continued in the appropriate circumstance by ski patrollers in a moving toboggan and can lead to successful outcomes for medical cardiac arrest. An educational opportunity exists. Practical suggestions and techniques are discussed for the implementation of safe and effective toboggan-transport CPR when indicated.
Introduction
Ski patrollers train to respond to medical emergencies, such as cardiac arrest, that occur in the ski resort environment. Individuals experiencing these emergencies may have better chances of survival on-slope due to this training.1,2 The National Ski Patrol (NSP) mandates that all patrollers maintain professional-level cardiopulmonary resuscitation (CPR) certification. 1 Though many ski patrols have protocols for initial on-scene, high-quality CPR and defibrillation, certain scenarios may require subsequent transport of a patient in cardiac arrest while CPR is ongoing. Thus, several manikin studies have been performed to determine compression quality and positioning to optimize CPR in a moving ski patrol rescue toboggan (in-sled) and mountain environment, using both manual (hands-on) and mechanical compression device techniques.3–10 These studies generally show that manual CPR can be provided in a moving toboggan in certain terrain despite limitations, and that mechanical devices can also assist with quality compressions. Though anecdotal reports of positive outcomes exist, no studies to date have looked at human outcomes or case reports of patients who received CPR by ski patrollers in a moving rescue toboggan. 11 Further, recommendations for the performance of CPR during toboggan transport are not currently included in Outdoor Emergency Care (OEC), the prehospital medical care manual of NSP. 1
The purpose of this case series is to describe the rescue characteristics of 3 medical (nontraumatic) cardiac arrest patients who received manual CPR during toboggan transport by ski patrollers and subsequently experienced return of spontaneous circulation (ROSC) with full neurologic recovery and to provide education to improve future care.
This study was deemed exempt from the Institutional Review Board at the University of Vermont. Patient consent was obtained for each case, and data were extracted from medical records as well as discussions with rescue personnel.
Three Case Reports
In Northern Vermont between January 2024 and April 2025, a total of 3 cases occurred in which CPR was performed on a patient in medical cardiac arrest in a moving rescue toboggan by ski patrollers. Each patient achieved subsequent ROSC and was discharged from the hospital with no reported neurologic deficit. For each case, a description of the patient, resuscitation, and transport characteristics is provided in Table 1. There were no other known cases of skier medical cardiac arrest in Northern Vermont during the 2023–24 or 2024–25 ski seasons for which a patient received CPR by a ski patroller during toboggan transport.
Characteristics of 3 cases of patients receiving manual cardiopulmonary resuscitation by ski patrollers during rescue toboggan transport.
CPR, cardiopulmonary resuscitation; ROSC, return of spontaneous circulation.
Case 1 involved a 72-year-old physically fit male Nordic (cross-country) skier with a prior history of nonischemic cardiomyopathy, who suffered a witnessed collapse from cardiac arrest on a Nordic trail during light activity less than a kilometer from a Nordic ski center. Immediate bystander CPR was performed, and staff on a snowmobile rapidly delivered an automated external defibrillator (AED) to the scene. Responders included a ski patroller who was responding as part of the local mountain rescue service, another mountain rescue professional, and a local emergency medical technician (EMT).
The patient received 5 defibrillation shocks on scene during CPR cycles, and the patient remained in cardiac arrest after 21 min; thus, the decision was made to transport the patient to an awaiting ambulance at the Nordic center with CPR in progress. The patient was loaded with head facing forward into a generic metal toboggan approximating the size of a standard ski patrol toboggan. This rescue toboggan was then towed via snowmobile, with chest compressions performed by the ski patroller who was alternating with the other mountain rescue professional. The compressor straddled the patient and faced forward. Another rescuer walked alongside the toboggan intermittently providing ventilations with a bag valve mask (BVM). This transport with CPR in progress occurred over 500 m of relatively flat terrain and lasted approximately 3 minutes, during which one shock was delivered and the compressor was swapped once.
Remarkably, this patient was noted by rescuers to have displayed improved cerebral function in the form of an improved level of alertness and arousal during chest compressions in the moving toboggan. During transport, the patient repeatedly moaned and attempted to push off the arms of the patroller and rescuer performing CPR; however, upon pausing compressions due to the patient awakening, the patient would immediately become unresponsive and pulseless, requiring compressions to resume. This cycle of awakening during chest compressions and subsequent unresponsiveness when compressions were paused occurred multiple times during the 3-minute transport interval.
Several minutes after being loaded into the parked ambulance, the patient developed ROSC and began to mumble words, with a Glasgow Coma Scale score recorded as 12 soon after. In the hospital, the patient received an implanted cardioverter defibrillator and was discharged after 5 days with full neurologic recovery.
Case 2 was a 68-year-old male skier with no known cardiac disease history who collapsed in cardiac arrest while skiing down an intermediate Alpine (downhill) slope. The patient received immediate bystander CPR, and ski patrollers soon arrived with an AED, providing 4 defibrillation shocks and continued CPR. In addition, the patient was given intravenous epinephrine by an advanced-level provider on scene. Remaining pulseless after 22 min, transport was initiated in a Cascade rescue toboggan (Cascade Rescue, Sandpoint, Idaho) driven (“pulled”) by a single patroller using the toboggan's brake chain for speed control, with a thoracic band mechanical compression device (AutoPulse, ZOLL Medical, Chelmsford, Massachusetts) initially providing chest compressions. After 2 minutes of transport, the mechanical device was noted to be malfunctioning due to a broken part, at which time the device was removed, and hands-on chest compressions were resumed by ski patrollers. Three patrollers swapped out 3 times for the 7 minutes of remaining descent, providing continuous chest compressions facing forward and downhill while straddling the patient, who was also oriented head downhill. There was no active ventilation during transport, but oxygen was passively supplied to the patient via mask. The slope angle varied up to 30° (verified by inclinometer), and the total transport distance over 9 min was 1300 m with 300 m of descent.
Shortly after being loaded into the parked ambulance, the patient developed ROSC and non-purposeful movement. In the hospital, the patient was diagnosed with an ST elevation myocardial infarction, underwent stenting of a complete left anterior-descending coronary artery occlusion, and was discharged after 8 days with full neurologic recovery.
Case 3 was a 63-year-old male skier with no known cardiac disease history who had walked up a hill from a parking area to begin skiing at an Alpine ski resort but collapsed in cardiac arrest at the base area. Immediate bystander CPR was initiated, and ski patrol arrived shortly after with an AED and Cascade toboggan towed behind a snowmobile. Three defibrillation shocks were provided on scene (intranasal naloxone was administered due to initial uncertain cause of unresponsiveness), and the pulseless patient was subsequently loaded into the rescue toboggan after 9 minutes of elapsed downtime. During toboggan transport, a ski patroller provided chest compressions for 2 minutes of transport over 200 m of flat terrain across the base area. The patient was oriented with their head to the rear of the toboggan, and the patroller provided chest compressions facing backward in the toboggan and straddling the patient. A second ski patroller rode in the toboggan at the patient's head, facing forward with their boot toes overhanging the rear of the toboggan, and provided rescue breaths by bag valve mask. This toboggan had been modified for a snowmobile hitch and did not include handles or handle locks (“lobster claws”), similar to the toboggan in Case 1. Knee pads were reported to be beneficial by both patrollers to maintain positioning. Shortly after transport, the patient was noted to achieve ROSC and verbal responsiveness in the ski patrol aid clinic while waiting for ambulance arrival. In the hospital, the patient received 3 coronary artery stents and was discharged after 3 days with full neurologic recovery.
Discussion
This study represents the first case report or series documenting that manual (hands-on) toboggan-transport (in-sled) CPR by ski patrollers straddling a patient in a standard-width moving rescue toboggan can contribute to a successful resuscitation of adult medical cardiac arrest. Further, this study is the first to document signs of human cerebral perfusion occurring during manual chest compressions during toboggan transport, as evidenced by the patient in Case 1, who repeatedly displayed arousal and waved off rescuers during toboggan-transport compressions only to become entirely unresponsive and pulseless when compressions were paused. This phenomenon of CPR-related cognitive activity can be challenging for rescuers but has been associated with increased survival. 12 Cases 1 and 2 show that ROSC with full neurologic recovery can occur in skiers with cardiac arrest for which over 30 min of CPR may be required, necessitating consideration of toboggan transport of these patients after an initial trial of substantial on-scene CPR. Each case displayed that despite any potential safety concerns for patrollers performing manual CPR while kneeling during toboggan transport and straddling a patient, no injury occurred to the patroller or the patient. Finally, despite possible limitations of compression quality during manual toboggan-transport CPR, positive outcomes can occur.
Based on this case series and incorporating current available medical literature, the following practical lessons can be summarized for future use by ski patrollers and rescuers.
First, early defibrillation with high-performance CPR, maximizing chest compressions, saves lives and should not be underemphasized. 13 To maximize survival chances and determine if CPR during transport is even necessary, protocols may include an initial period of high-quality, on-scene CPR, minimizing pauses prior to transport. The optimal on-scene time is not well-defined in the existing medical literature. This study supports 3–5 CPR cycles with defibrillation attempts, approximating 10 to 20 min of on-scene time, prior to transport for medical cardiac arrest.
Second, based on this case series, there are cases in which rescue toboggan transport with ongoing CPR is deemed necessary to reach a higher level of care. Intermittent CPR (stopping CPR briefly during transport) in the non-hypothermic medical cardiac arrest patient would not maximize the fraction of time performing chest compressions, a core element of high-performance CPR. Thus, continuous CPR during slow, controlled toboggan transport would be superior to intermittent CPR for medical cardiac arrest if it minimizes interruptions in chest compressions. 13 There will likely also continue to be circumstances of cardiac arrest in which a mechanical CPR device is not available or functional. Therefore, in select cases, manual CPR in a moving rescue toboggan appears to be an effective option on appropriate terrain when it can be safely administered and can contribute to a positive outcome.
Third, patient positioning with head uphill and toward the rear of the standard-width toboggan, with the patroller performing chest compressions straddling the patient facing uphill and backward, appears to be the orientation best supported by medical literature and rescuer stability. Manikin studies generally involve this toboggan-transport CPR orientation.3,4,6,7,9,10 The 3 ski patrollers in Case 2 who took turns providing chest compressions while riding facing downhill, straddling the patient, at slope angles up to 30° (after mechanical device failure) reported feeling unsteady and commented that the reverse orientation would have been more stable. CPR with head elevation is a debated topic for which one prehospital study found improved outcomes when bundled with other CPR initiatives. 14 Though cerebral perfusion may be improved by a reduction in intracranial pressure with head elevation, this position lacks evidence for widespread standard CPR use. 15 Porcine CPR models have shown improved cerebral and coronary perfusion with the body tilted head up to 30° and worsened with the body tilted head down. 16 Outcomes for prehospital CPR with head lowered have not been studied in humans. As no harm has been attributed to head elevation CPR, and considering the importance of patroller stability and safety, head-up transport during CPR can be a reasonable position to use in a moving ski patrol rescue toboggan.
Fourth, this study, in combination with the aforementioned manikin studies, suggests that passive ventilation (with continuous supplemental high-flow oxygen via mask) and compression-only CPR during transport is an appropriate choice on an Alpine slope.3,4,6,9,10 However, with flat terrain on a toboggan towed by a snowmobile, active ventilation by a rescuer using BVM or other advanced airway may be another feasible option. 7 Note that the available length for rescuers inside a toboggan rigged for a snowmobile hitch does not generally differ markedly from one configured for skiing with handle locks engaged. A wider (81 cm) toboggan is currently marketed for the performance of 2-rescuer CPR, with an optional seat for the airway-dedicated rescuer over the head of the patient in the head-first/downhill position (Trauma One Toboggan, Cascade Rescue, Sandpoint, Idaho). However, these larger toboggans are not as commonly available and have also been tested with compression-only CPR on Alpine slopes.9,10 Thus, compression-only CPR appears to be reasonable on the Alpine slope during toboggan transport, and utilization of an airway-dedicated rescuer remains challenging though possible in certain flat terrain circumstances.
Fifth, to maintain high-quality chest compressions in a moving rescue toboggan, ski patrollers should be aware that studies have shown certain limitations with manual toboggan-transport CPR and that the following should be observed to avoid pitfalls: maintain adequate compression depth of 5–6 cm, maintain hands over the lower sternum and avoid sliding from that location, maintain shoulders over the lower sternum and avoid sliding toward the feet of the patient, maintain proper compression rate not faster than 120 compressions per minute, allow adequate chest recoil by not leaning on the patient's chest, and avoid compression pauses.3,4,6,7,10 Patrollers performing compressions should be rotated approximately every 2 minutes to avoid fatigue, at which time AED analysis can also reoccur (AED can remain on the patient during transport). It has been proposed that BVM ventilation could additionally be delivered by another team member if available during these rotations. 10 A strap under the boot soles (or over the boots) of the patroller providing compressions has been suggested to improve stability and minimize sliding of the patroller toward the patient’s feet.3,10 Knee padding appears to be important for positioning and stability. Patroller and team practice can help to learn and maintain proper technique and positioning, and CPR simulation has been associated with improved patient neurologic outcomes. 17
Sixth, while mechanical devices may improve rescuer safety or compression quality in certain circumstances, both manual and mechanical techniques can be considered for toboggan-transport CPR, and neither has evidence of superior outcomes.6–8,18 Study authors do not therefore advocate one technique over another but suggest that each technique may have its appropriate circumstance, such as mechanical on steeper terrain or for longer transport. Additionally, study authors do not advocate any single device over another but note that a thoracic band compression device exhibited a problem in Case 2 and that a recent study demonstrated success with ski patrollers using a piston-type mechanical compression device. 6
Finally, the goal of this study is to highlight real-world cases of toboggan-transport CPR and provide practical advice that is both reasonable and useful. Educational highlights are summarized in Figures 1 and 2. Though flat terrain and snowmobile assistance in 2 of 3 cases may not represent the most difficult circumstances that a ski patroller may encounter, these cases contribute to a foundation for initial recommendations that can continue to develop for the benefit of patients. Also, study authors recognize that individual patrols may have successful protocols that vary. Further, although 2 of the study authors are volunteer medical advisors in the Eastern Division of NSP, this study does not represent the policy or opinions of NSP. This study includes findings and a discussion that can be incorporated into future education for ski patrollers and rescuers to improve patient care in medical cardiac arrest in the ski resort or mountain environment.
Key points for chest compression in ski patroller toboggan-transport (in-sled) cardiopulmonary resuscitation. See text for references to manikin studies.
Take-home messages for ski patroller toboggan-transport (in-sled) cardiopulmonary resuscitation (CPR) for medical cardiac arrest.
Footnotes
Acknowledgments
The authors thank the ski patrollers, rescuers, and staff who provided information for this study and outstanding patient care, as well as the patients for their consent to publish their experiences to advance future care. The authors further thank Dr Charles Allen, NSP national medical advisor; Dr David Johe, former NSP national medical advisor and OEC sixth edition medical editor; and Richard Hamlin, NSP national historian, for their review of the manuscript.
Author Contribution(s)
Consent for Publication
Consent was obtained from each study participant.
Consent to Participate
Consent was obtained from each study participant.
Data Availability
Data were made available to the authors only.
Declaration of Conflicting Interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Considerations
The study was determined to be exempt from Institutional Review Board review at the University of Vermont.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
