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Sliding fall, Chute, 2019-5-12

Sliding fall, exit of Right Gully

Close call: Fall into deep waterfall hole

As winter turns rapidly to spring, a number of hazards become prevalent in the steep terrain of the Presidential Range and particularly the Headwall of Tuckerman Ravine. Waterfall holes, glide cracks or crevasses, moats around cliffs and rocks, and other deep holes open as the thick snowpack melts. A fall into these holes, which often also have significant amounts of cold flowing water which can quickly cause hypothermia, can be very difficult to escape or be rescued from. Such accidents have resulted in several fatalities in Tuckerman Ravine. A lucky skier had a very close call in this type of accident yesterday.

At 1:58 PM on Monday, April 22, a skier fell over the Tuckerman Ravine headwall and into one of several waterfall holes. Partners and bystanders quickly initiated rescue efforts and also called 911 for emergency response. Unsure of where under the snow the fallen skier was, a beacon search was initiated and could have been helpful, though this was a non-avalanche accident. At 2:18 pm, after 20 minutes out of view to the rescuers, the subject climbed out of a different hole in the snow and slid down to the rescue party below him in the slope. He had lost his skis, poles, and pack.

The subject was alert, oriented, and able to walk but in pain from several impacts during the fall. He was also cold and wet from spending most of the 20 minutes in very cold flowing water, though not submerged. The rescue party quickly changed his clothes to drier ones. They wrapped him in a sleeping bag and briefly transported him in a rescue litter obtained from the nearby Connection Cache of emergency supplies. In effort to warm the subject, the rescue party then helped the subject begin walking down the Tuckerman Ravine Trail towards Hermit Lake.

The fall line glissade track just right of center leads up to waterfall hole and accident site, with partners of the subject shown helping him walk downhill.

Meanwhile, U.S. Forest Service Snow Rangers were notified of the incident by emergency dispatchers. They travelled to Hermit Lake with urgency, aware than similar accidents have historically been fatal. Upon arriving at Hermit Lake, Snow Rangers were told by the AMC caretaker that the subject had extracted himself from the waterfall hole and was walking, with aid, down to Hermit Lake. They proceeded up the trail, meeting the rescue party at 3:20 PM. The subject, still alert and oriented but now warmer, was transported to Pinkham Notch via snowcat and released to the care of friends.

This positive outcome should be regarded as quite lucky and be taken as a warning for all who travel on steep snow slopes in spring conditions in our mountains. Had the subject, who was a strong athlete and also a climber, been unable to self-extricate himself from the waterfall hole the outcome could have been far worse. Many of these deep holes in the snow are impossible for even the strongest individual to climb out of. Extricating a person from these holes can be very dangerous for rescuers and is difficult to accomplish in a sufficiently timely manner to save a life. We know the subject would urge you to learn from this accident, giving potentially deep holes and glide cracks in the snow a wide berth and taking care to not fall above one.

The rescue initiated by partners and bystanders of the subject was a positive example we would also like you to learn from. Partners were paying attention to each other and able to quickly initiate a rescue. They had sufficient dry clothing and emergency supplies to provide proper care for the subject. Several emergency medical professionals observed the accident and immediately helped rescue efforts. Rescuers had knowledge that a litter and hypothermia wrap materials were available in nearby Connection Cache and used them. All individuals on the scene had avalanche rescue gear, as large wet slab avalanches were forecast as unlikely but not impossible that day. While a call was made for professional rescue, this group realized that they could provide timely aid to the subject and took appropriate action that could have resulted in an effective evacuation had professional rescue been delayed or unavailable. This self-reliant level of accident response is commendable. It is also the level of response that everyone travelling in the backcountry should be prepared for, every time you’re out.

Please learn from this accident to have a safer spring ski season, and see you on the hill!

Human Triggered Avalanches

On April 7, 2018, seven avalanches occured in Tuckerman Ravine. All were human triggered. This write-up discusses the weather and snowpack that lead up to these events, an objective summary of the events, and an analysis of factors that lead to at least five people being caught in one of the avalanches.

Weather

In the week leading up to April 7, 2018, our snowpack saw two rain events. The first was March 29 and 30 which delivered 0.75” of rain followed by 0.32” of rain on April 4. Both of these rain events were followed by hard freezes. On Friday, April 6, light snow showers began just after noon and continued through sunrise the following day. By the time snowfall stopped, the snowplot at Hermit Lake recorded 16cm (6.3”) of 9% snow while the summit recorded between 7 and 8” (this is an estimate based on hourly observations as the total snowfall was recorded as less due to excessive blowing snow) of snow. When snowfall began on Friday, wind at the summit was around 30mph from the south. Overnight, wind direction shifted to the west and speeds increased to 60-70mph. Weather on Saturday April 7 was clearing skies, winds diminishing to around 40mph from the west, and temperatures in the single digits on the summit and reaching into the 20sF at Hermit Lake. This weather pattern built a robust melt-freeze crust over which wind slab was built from new snow and wind April 6-7. This touchy wind slab was the avalanche problem involved in all known avalanches on April 7.

Summary of Events

During the morning of April 7, three avalanches were intentionally triggered by skiers. All three were ski cuts, two occurring in Lobster Claw (both SS-ASc-R1-D1.5-I) and one occurring on the rollover of the Little Headwall (SS-ASc-R1-D1-I). Slab depths were up to 14” and all occured on a layer of softer snow immediately above the melt-freeze crust. Of note in the Little Headwall was that the second skier through was able to trigger the “hangfire”, or slab remaining above the crown of the initial avalanche.

Examining the crown in Little Headwall. MWAC photo.

We have less definitive information on the Left Gully and Chute avalanches, which occurred shortly before and after the Hillman’s Highway avalanches, respectively. We believe that no one was caught or carried by either avalanche, both of which were triggered unintentionally. Left Gully, which was rated Moderate, produced an avalanche from a relatively thick though isolated pocket, while Chute, which was rated Considerable, produced a larger in area avalanche from a thinner slab. Both are estimated SS-ASu-R2-D1.

Unlike the other avalanches this day, the avalanches in Hillman’s Highway did involve a number of people being caught and carried. At approximately 2:00 pm, at least 40 people were climbing and skiing in Hillman’s. An individual climbing uphill from the looker’s right fork to the looker’s left fork triggered the initial avalanche as they entered the looker’s left fork. This person was not carried in the slide. The crown of this avalanche was approximately 300’ below the top of Hillman’s and ran ⅔ of the way down (SS-AFu-R2-D2-I). Of the many people in the avalanche path, at least 5 were caught and carried. USFS Snow Rangers responded to the incident and identified one injured skier who was ultimately transported to Pinkham Notch with a back injury that was not life threatening. Another individual who was also caught and carried sustained a minor injury to their hand.

Looking at the crown of the first avalanche in Hillman’s Highway. Photo by Kurt Schleicher.

The second avalanche was triggered around 2:30pm, within minutes of the initial Snow Ranger team arriving on scene. The trigger was unknown at the time, but consensus of bystanders is that this second avalanche was triggered by the same individual who triggered the first, having topped out on the ridge and beginning to ski the hang fire slab above the initial crown. This second avalanche was smaller (SS-ASu-R2-D1-I) and luckily did not capture any people or result in injuries.

Analysis

Many opportunities for learning are presented by this day which which fortunately did not involve more serious injuries. First, it’s an excellent reminder that avalanche conditions can develop during the spring months which bring crowds of backcountry skiers to Tuckerman Ravine. As with any time of year, these avalanches can widely vary in size and character. Avalanches can be of minimal concern on certain spring days, but April 7 was a day with avalanches as the primary concern for alpine travelers. On any such day, anyone venturing into avalanche terrain should bring a beacon, shovel, probe, and knowledge to use them effectively.

Carrying avalanche rescue gear is a cardinal rule for travelling in avalanche terrain. Another is travelling one at a time through areas exposed to avalanche danger. This requires recognizing avalanche terrain, which includes both terrain capable of producing an avalanche and terrain threatened by avalanches. A phrase often heard in the courtyard is, “It’s just Hillman’s”. All of Hillman’s Highway is avalanche terrain. On top of that, it’s easily the biggest gully in Tuckerman Ravine and is particularly confined. Exposing one person at a time to avalanche danger is crucial, particularly on a day like April 7. It’s likely that nobody would have been injured had this been the case.

Avalanche danger was Moderate in Hillman’s Highway on this day, which forecasts natural avalanches as unlikely and human triggered avalanches as possible. These possible human triggered avalanches can be either small and in many areas or large and in specific areas. With a number of similar avalanches in other Moderate rated areas, we consider April 7 as a small avalanches in many areas kind of day. It’s worth noting that a Moderate rated day for large avalanches in specific areas is sometimes referred to as “scary moderate”, in which you’re less likely to find signs of instability but potentially able to trigger a large avalanche. Further, remember that even small avalanches can ultimately be fatal.

The Chute was rated Considerable and produced a slightly larger in area avalanche from a thinner slab. The primary distinction between Moderate and Considerable is increased likelihood of both natural and human triggered avalanches with greater chance for larger avalanches. Other Considerable areas received little if any traffic, which we suspect is a reason that more did not produce avalanches.

All avalanche problems exhibit some degree of spatial variability. This means that the snowpack is not uniform across the terrain and avalanches can often only be triggered from specific locations. A number of people can travel on a slope, particularly one as large as Hillman’s, before someone finds this specific location and triggers an avalanche. Tracks on a slope do not mean it’s safe to ski or climb.

The Little Headwall was not rated on April 7 for lack of snow, but did have enough snow in one isolated pocket to produce an avalanche. Unrated terrain, which encompasses all of our terrain early and late in the season, can produce avalanches. The human triggered avalanche in Central Gully on Dec 1 of this season is another example. We do issue danger ratings for areas of most concern during the bulk of the season in Tuckerman and Huntington Ravines, but avalanche activity is not confined to areas forecast on a particular day.

Finally, we should touch on ski cutting. The avalanches in the Little Headwall and Lobster Claw were intentionally triggered in a controlled manner through ski cutting. This process of intentionally skiing a specific part of a slope likely to trigger an avalanche, with speed and from one safe zone to another, is an advanced practice and is only appropriate under certain conditions. A book could easily be written about the practice of ski cutting, but a simple explanation is that it is only wise when you possess a high degree of certainty about what the the ski cut will produce AND the consequences if you’re wrong. In particular, ski cutting is inappropriate when an avalanche may initiate above you. On April 7, we had the rare conditions for our terrain in which instability was limited to surface slabs and individuals were able to ski potential start zones for isolated and small pockets of wind slab. Certainty was high both in terms of anticipated result and consequences for being wrong, and avalanches above the individuals ski cutting were nearly impossible. Further, other people were not in the potential avalanche runout zones.

Brody Leven ski cutting in Lobster Claw. Photo by Lincoln Benedict.

The human-triggered avalanches on April 7 did result in injury, but everyone on the mountain lived to ski and climb another day. Luck certainly contributed to this relatively positive outcome, as did the relatively small but widespread type of Considerable and Moderate avalanche danger that day. We who like to travel in avalanche terrain rarely get such valuable lessons without more serious outcomes. Great turns can be had with minimal risk on such days, but only by choosing terrain that matches your preparedness, knowledge, certainty, and skill level.

Human-triggered avalanches, Hillman’s Highway & Gulf of Slides

On Saturday, March 10, 2018, two separate avalanche incidents were reported. During the previous 2 days, 14.5″ of snow was deposited at Hermit Lake from a nor’easter and the upslope snowfall that followed. This storm was accompanied by moderate winds that rose to the 60’s mph the afternoon before. Saturday’s advisory called for 4.5″ more snow with increasing wind shifting slightly to the NW. Avalanche danger was rated Considerable in Hillman’s Highway, along with Left Gully and the Headwall forecast zones.

Around mid-day, a party of three talked with a snow ranger on duty who advised that low visibility and continued wind loading made their plan to travel into Hillman’s Highway unwise. The party hiked to Hillman’s and entered the 75′ wide couloir onto a 15-20 degree section of the otherwise steeper runout. Soon after the party returned to the courtyard and reported that everything the snow ranger had cautioned against had played out. Two were struck by debris, knocked down, and carried downslope. Fortunately, much of the energy of the debris flow was absorbed by boulders and holes from a warm spell which reduced our snowpack substantially. When the threat of natural avalanches occurring is elevated, the risks are as well. The natural avalanche that occurred in Hillman’s Highway was much larger and would likely have been unsurvivable.

The same day a party of two skiers set a skin track near the middle gully in the Fingers area of Gulf of Slides, in sparse trees. As the terrain steepened, they began to boot along the left edge of the gully next to the trees. The snow was loose and dry with “no shearing and bonding felt okay”. The first skier had been to this area many times and stayed out of the gully as they made their way towards the rollover near the top. They had spread themselves out as they moved up the slope but paused as they reached the rollover because “something felt wrong”. In moments, the slab failed a “couple hundred feet above” the party and hit both skiers. The first skier was carried but, being on the edge of the gully, he escaped the main flow of debris while the other skier clung to a nearby bush. The skier that was carried turned his beacon to search and could not locate a signal of his partner, who was still above him. Shortly after the caught and carried skier texted for help on his cell phone, the pair made contact and eventually were able to call off the rescue response. The skier who held onto the bush lost his poles while the skier who was carried lost all his equipment though eventually recovered one ski.

Later conversations with the skiers in Gulf of Slides revealed a debate as to whether or not they triggered the slope. They considered it likely that they did not trigger the slope, but rather that it had avalanched naturally. From our perspective, the trigger is relatively unimportant in this instance. If the avalanche had not released while ascending, it is possible that they could have made it to the top and triggered the slope on the way down. In that case, much more of the slab could have been above them with more serious consequences likely. After some reflection, looking at weather data and reading the avalanche advisory, the triggering skier admitted that “overconfidence due to personal experience” in that particular area led him to ignore the obvious red flags that existed due to the snow and weather conditions that day. After the period of warm weather and ice crust which had dominated recent ski conditions, it seems likely that the scarcity heuristic was in play as well. The call of fresh powder is hard to ignore sometimes but it is important to remember that good luck can play a role in good outcomes like this one and luck is one thing no one can count on.

Water Immersion Little Headwall

A group of three was descending the streambed between the bowl and the Little Headwall. One snowboarder was unable to avoid an open hole in the snowpack. He fell into the water with his snowboard still attached to his feet. His friends were able to quickly extend a ski pole to him. Despite being pulled by the force of rushing icy water, he was able to hold his position for several minutes. Eventually, he was unable to either be pulled up or hold on, and he was dragged underneath a snow bridge. Meanwhile, other bystanders had come along. One had entered the water on the downhill side and worked at freeing the snowboarder from that end. After a couple minutes, the snowboarder was pulled free from under the snow bridge.

He was hypothermic when extricated, with a diminished level of consciousness. His friends and bystanders worked to remove him from his soaked clothes and begin the rewarming process. AMC employees arrived on scene after he had been pulled from the water. By the time Snow Rangers arrived, his level of consciousness had improved and he was able to stand up under his own power. The snowboarder was able to walk himself down to the parking lot (with borrowed dry clothes.)

Each season, we try our best to inform skiers and snowboarders of the hazards related to riding the streambed. In this case, we had stopped recommending this as a descent route three days prior. The victim and his group stated that they were aware of the hazard presented by undermined snow. In this case, the group was very unlucky in that one fell into the water, but they were also very lucky that he came out of the situation alive. Many others had skied or ridden the slope in the days before this incident, long after the conditions had deteriorated beyond a safe level. Most of these people are unaware of how close they might have been to a similar incident, so in that respect, we see a big difference between this group and all the groups that do the same thing without consequence – at least this group now fully understands the risk involved.

Injured Skier Lunch Rocks

USFS and MWVSP responded to an injured skier being transported from the base of Lunch Rocks sitting on a snowboard provided by volunteers who were sitting at Lunch Rocks. Bystanders were directed to continue to transport the subject to a location away from ice fall hazard. Patient had fallen without binding release and sustained a lower leg injury. USFS and an AMC Caretaker assisted the patient to Hermit Lake where he was transferred to a litter and snowmobile drawn sled. Patient was driven to the Tuck trail/Fire Road junction where transport to PNVC continued with the assistance of two climbers descending from Pinnacle Gully.

Avalanche Accident in Tuckerman Ravine

Two hikers descending from the summit triggered an avalanche that carried them down the Lip of Tuckerman Ravine.  In this incident, a group of four hikers started up from Pinkham Notch Visitor Center. Along the ascent, the group separated into two teams of two. Descending in poor visibility and fading daylight, the faster team lost the trail and inadvertently began descending the Lip. This forecast area had been rated Considerable avalanche danger due to expected wind loading late in the day. The slower team, realizing the other party had gone off trail, followed their tracks to the crown line of the avalanche. From there they were able to verbally communicate with their friends and learn the extent of the injuries. They decided it would be safer to descend the Lion Head Summer Trail to summon assistance.

As an avalanche forecasting center, we were not surprised that the party triggered an avalanche in the location they did. Considerable danger includes “human triggered avalanches are likely” in its definition. Weather conditions in the days prior to the accident created conditions ripe for avalanche activity. About a week before the accident, Mt. Washington was subjected to a warm rain event. This created slick crusty snow surface conditions for future snow and wind-loading land on and create new stability problems. In the 48 hours prior to the event, about 10.5” of new snow had fallen, with 1-3” having been forecasted for the 28th. During this time, west and northwest winds also increased in speed from 30-40mph to 60-80mph. This created a situation with increasingly dense slab building on top of weaker layers, all of which sat on the pre-existing crust.  This is a typical scenario for Mt. Washington; one in which we regularly see human triggered or naturally triggered avalanches.

The hikers rode the avalanche to the base of the Open Book, adjacent to Lunch Rocks. Along the way they sustained non-lifethreatening injuries. In the debris, they ended up only partially buried or on top of the snow, one was at the toe of the debris and the other at the top of the debris. They reported taking about a half hour to collect themselves and figure out what happened. They also did not understand where exactly they were, or that the Tuckerman Ravine Trail could be followed downhill from their location. They knew they had fallen a long way below the trail they intended to descend, so they began to climb back up, which is when they began communicating with their friends above.

The uninjured hikers arrived at the AMC Caretaker’s quarters to tell her of the accident. She quickly notified USFS Snow Rangers, who began mobilizing rescue teams. Rescuers included USFS Snow Rangers, members of Mountain Rescue Service and Androscoggin Valley Search and Rescue, caretakers from the AMC and HMC cabin, and a handful of helpful bystanders who were staying overnight at the Harvard Cabin. The rescue itself was not particularly noteworthy. A rescue team climbed to the injured hikers, assessed and treated their injuries, and short-roped them down to the floor of Tuckerman. From there the hikers walked down under their own power to Hermit Lake to a waiting snow tractor. They were then transferred to an ambulance at the bottom of the Sherburne Ski Trail.

Analysis:

This is an accident that could have been avoided if just a couple small factors played out differently. Most obviously, if the group had stayed together and stayed on the Lion Head Trail, they would never have entered avalanche terrain.  The two more experienced hikers had been planning to do an overnight at Hermit Lake, while the two with less experience were only doing a day trip. Hence, the two with lightweight daypacks were able to move more quickly than the heavily-laden duo. This was the primary reason for one group going faster than the other, as we understand. The plan had been for the hikers to all regroup at the summit, but the faster group went down ahead. Often in incidents involving missing or overdue hikers, splitting the group is a contributing factor. Many times there is no contingency plan made, or if there is one it is not followed. In this event we don’t know exactly what their meeting plan was. However, if they had either kept the group together for the duration, or stuck with the plan to regroup,  the chances for staying on the trail and avoiding the incident would have been better.

Three Human Triggered Avalanches- Center Bowl

This was a very warm and busy day with three human triggered avalanches, three head lacerations, and two lower leg injuries. Avalanches were a concern as recent snowfall had developed slabs in lee areas a couple days earlier. These slabs had been subject above freezing temperatures for a full day and night, leading to the Lip, Headwall, and Bowl being posted at Considerable on Friday the 24th and Moderate danger for the 25th. Additionally, the potential for falling ice from the Sluice and Headwall areas was another cause for concern.

The first patient of the day fell in the center Bowl area and injured his lower leg in the fall. One Snow Ranger and one Ski Patroller had to briefly delay hiking to him as a safety measure. When the area became sufficiently clear of traffic, they brought a litter to the patient, loaded him into it, and quickly moved to a safer location for further assessment. The second patient fell in the upper Chute and injured his knee and thigh during the fall. As a safety measure, lookouts were posted above the patient as well as off to the side. Both patients were splinted and transported to Pinkham with the help of numerous bystanders who were willing to help out.

All three head lacerations were bandaged and the patients were able to walk themselves down to Pinkham. One cut the back of his head when he attempted a backflip on a man-made jump in the floor of the ravine. A second fell off a cliff while skiing the left side of the Headwall. The third fell while carrying his skis down a steep section between the Little Headwall and the Lower Snowfields. He slipped and fell into another person’s ski edge, causing a facial laceration.

As mentioned, three human triggered avalanches took place, all in the center Headwall area. This area, as well as the Bowl and Lip (including the Sluice) were rated at Moderate avalanche danger. The avalanche advisory for the day discussed the unusual avalanche issues for the day related to continued warming of recently developed slabs over an older more stable bed surface. Despite the Moderate rating, numerous people were skiing almost every line imaginable in the Headwall area. Just prior to noon, the first slab avalanche was triggered by sluff created as a person attempted to descend the center Headwall. A little more than an hour later a second and slightly smaller slab released farther left of the first slide. This snowboarder was carried with the debris but not buried. The third avalanche involved hangfire that remained between the first two slides; the trigger for this one was able to remain on his board and not be carried with the slide. In addition to the Headwall, we were concerned about stability issues in the Lip and Sluice. Stability was decreasing as the day progressed due to increased melting; however, skier compaction of the Lip from the day before and early on this day helped stabilize this area before the decreasing strength of the slab reached the critical threshold. Somehow, the Sluice did not see any traffic except for a couple riders at the very end of the day. The avalanches that occurred are not the usual type for Mt. Washington. As an example, the second slide released after many people, perhaps up to 30, had already descended the same area that day. Warm slabs can still retain their cohesiveness while the meltwater breaks down their tensile strength. We believe this is what happened to the slabs that released here. In these cases the trigger was human but it also could have been entirely natural.

It is difficult for us, as professional avalanche forecasters, to fully understand the human factors involved in the decisions visitors were making throughout the day. We believe there existed a wide variety of attitudes and perceptions of the hazards on the mountain this day. The vast majority of visitors listened to our advice and made safe decisions. Others listened to our safety messages then allowed other human factors to take priority. There were also some who understood the hazards and willingly chose to accept the risk involved. We also believe there are others who truly did not understand the magnitude of risks they were dealing with. In this case, several key pieces of bulls-eye data existed (i.e. recent avalanche activity in one part of the Headwall gives a clear indication that snow may be unstable on other similar slopes). We are thankful for the relatively low number of injuries on such a busy day and feel lucky that no injuries resulted from the three avalanches. We want to emphasize that our role in Tuckerman Ravine each spring goes beyond helping out those who are injured. We firmly believe that with good information visitors will make better and safer decisions. We are here to provide information and guidance that will help you have a positive experience. Please seek us out anytime you have questions about what hazards exist on a given day!

Four Injuries

USFS Snow Rangers and the Mount Washington Volunteer Ski Patrol assisted with four injured visitors. Each patient was able to evacuate themselves without further assistance beyond Hermit Lake. The first patient was a participant in the Inferno pentathlon who fell during the ski leg and dislocated his shoulder. The dislocation was reduced and the shoulder immobilized. The second patient fell while climbing Left Gully, sustaining abrasions to both forearms as a result of his efforts attempting to self-arrest without an ice axe. The third patient fell while climbing above Lunch Rocks. He also dislocated his shoulder; this dislocation was reduced and immobilized for his walk to Pinkham.

The fourth incident of the day is worthy of further analysis. This skier began to descend the Lip in the late afternoon when he realized the surface was much more firm and steep than he had anticipated. At some point before descending, he dropped his ski poles down the Lip, stepped out of his skis, and began to climb back upward to the ridge. He traversed over to the top of the Sluice, where conditions were not much better than in the Lip. Upon descending, he lost control and began a tumbling fall that ended just short of Lunch Rocks. He was able to walk himself down the Snow Ranger Quarters at Hermit Lake where he was examined by Snow Rangers and the MWVSP. It was determined he may have suffered a minor concussion but was otherwise all right. At the request of the caregivers, he returned later in the evening for a follow-up evaluation before spending the night at his shelter. This incident involves a few common hazards we see each spring. First, when the sun begins to set behind the ridge, the snow surface can quickly turn very icy and slick. Second is descending an unknown route without first climbing it to determine its nature. The Sluice is every bit as steep as the Lip, but also has cliffs and a runout into Lunch Rocks making falls especially precarious. Skiing at the top of your ability in unfamiliar terrain without poles and with a large pack can be very challenging; sometimes walking down can be a good option. Kudos to the patient’s friends for encouraging him to get checked out by trained personnel.