Surfer riding a big wava at the Praia do Norte, north beach, Nazare in Portugal.

As you may have noticed, a massive swell came through the Atlantic produced by the St Jude North-Atlantic Storm Front. The picturesque village of Nazare turned into an arena for Big Wave Surfing, when a massive swell with 60-80 ft faces arrived.

The internet flooded with footage of Carlos Burle charging one of the biggest waves of the day. During the same session, a female big wave surf legend, Maya Gabeira, got towed into a massive wave by Carlos Burle. While riding the wave she missed a bump in the wave, twisted and broke her ankle, and vanished under a huge amount of water. Luckily they could retrieve her in time and preventing her to die from drowning.

See the video here of her retrieval out of the water and the arrival of the local authorities.

Trauma in Big Wave Surfing

There is very limited data registered about incidents and injury patterns, although the development of Big Wave Surfing over the last decades has become more prominent and massive swells are being chased all over the world. As consequence there is a high demand for the professionalization of the medical setup of events, including risk-assessments and the presence of qualified pre-hospital care teams. Big wave surfers get exposed to a different kind and severity of injuries then “normal” professional Surfers, due the violent forces that are involved in big wave surfing.

Trauma Mechanism, Injury Cascades and Marine Retrieval

Population

Prepared & fit young athletes (20-40 yr). Legends who are charging these water monsters are physically and mentally prepared. In case of injury we can assume they have more compensation capacity in comparison to the average human being.

Environmental factors

Size of wave, water temperature, seafloor.

Wave impact is likely related to the risk and severity of injury. The colder water, the more prone the injured surfer is exposed to hypothermia. This is unfavourable, especially in a patient with major injuries, due the hypothermia related induction of coagulopathy.

Trauma-Mechanisms

Direct impact; In incident of Maya Gabeira, the initial contact with the water on high velocity caused her primary injury.

Acceleration/Deceleration; through direct contact and the “flushing” effect of the wipe-out.

Baro-trauma; the surfer rapidly reaches depths where the pressure  difference is high enough to cause barotrauma in all air filled spaces in the body.

Injury Cascades

Severe head & C-spine and trunk/pelvic injuries occur due direct impact.

Violent acceleration/deceleration forces can give internal injuries and ligament tears, luxations of joints and fractures.

Big pressure differences due hold-downs and impact of wave can cause baro-trauma; drum perforations and pneumothoraxes can occur.

Long “hold downs” producing high risk to drowning with pulmonary complications, like ARDS, due to latent complications of drowning.

Marine Retrieval

Retrieval of the injured surfer can be complicated due challenging water conditions. The main aim is to remove the surfer from its hazardous environment, while minimizing the risk of the care provider. Risk assessment and preparation are vital to prevent more harm to the patient or care provider self.  As you can see in the video, safety for the rescuers is vital to be able to provide care for the victim. Entering a heavy shore break will flush away your equipment and team.

In the moment of the exact water retrieval, C-spine control is always desirable, but often challenging to perform. In the waterski retrieval pulling with a cord can be lethal, because of prolonged exposure to airway blockade and risk of hypoxia due to drowning.

Resuscitation should start immediately when returned back on the beach on a safe location, with focus on airway management and treatment of hypoxia due to drowning injury. Due the high energetic trauma and risk of drowning the patient should be evacuated to the nearest trauma centre for further evaluation.

Mortality and Morbidity

There have been several deaths in big wave surfing over the last decades, our prayers are with them. Mavericks 1994,2011; Waimea Bay 1998; North Shore of Oahu 1997; Ghost Threes 2007. An estimation of mortality and morbidity is hard to asses, as there are much more unregistered incidents.

The Future

The ASP tour recently announced their “Big Wave World Tour”. Therefore, we might see more incidents and receive more insight in big wave surfing Injuries and underlying trauma mechanisms. Now that big wave surfing has entered the professional agenda, this will have to be met by state of the art medical care, with qualified medical and lifeguard teams at the scene, and will most likely lead to innovations in equipment and protective gear. Authentic research within this population will enable to improve the understanding of the injuries and trauma mechanisms in big wave surfing.

The EASD aspires to unify all the evidence-based concepts of marine rescue, life guarding and life support for the potentially critically injured surfer, in their Advanced Surfing Medicine Life Support (ASLS) Course.

The EASD ASLS Course features a wide array of theory from patient assessment, diagnosis and treatment of wounds, marine envenomation, musculoskeletal injuries, drowning and hypothermia, rescuing techniques, theory about waves, tides & rips among others. The participants get practical training by experienced surfing doctors, wilderness medics and surf lifeguard instructors. They will teach the ASLS students how to work with proper medical kits, splint injured extremities, and rescue victims in open water, among others. 

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