Jim and Peggy Hays were enjoying a ski vacation in Jackson Hole... until they suddenly weren't. Jim had a heart attack on the slopes and only managed to survive after a successful emergency response and the support of his wife. Medical miracles aren't really miracles. Instead, they're the result of having the right tools, procedures, and people in place to handle emergency situations, which is what happened to today's guests. Joining host Dr. Alaina Rajagopal are the four people involved in the Jackson Hole case. Peggy and Jim Hays, the couple who bravely survived the incident, Ian Barwell, the ER nurse and patroller on the scene with Jim's event, and Jeff Burke, the author of the article that covered their incredible story. To survive not one but two heart attacks was a feat in itself for the Hays couple, but to top it all off, it all happened right when COVID started. Learn more about their story and hear essential tips on how to stay safe in the mountains.
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How Emergency Response Saved A Life At Jackson Hole With Jim and Peggy Hays, Ian Barwell, And Jeff Burke
What would happen if you had a cardiac arrest on the side of a mountain?
Please, keep in mind that the content of this episode does not constitute medical advice, but is purely for the purpose of education. We'd like to thank our sponsor, the National Geographic Society. We're doing something a little bit different. Our normal episodes are informational or question and answer with an expert, but we're going to tell a story. We have four guests who are going to talk about an incredible series of events, halfway up a mountain in Jackson Hole, Wyoming. Our first guest is Jeff Burke, who is a Jackson Hole ski patroller, and wrote an extraordinary article outlining the series of events. This episode is based on his article. I'm going to let Jeff take it away.
How long does forever last? For Peggy Hays, a visiting skier to Jackson Hole Mountain Resort, forever lasted about fifteen minutes on March 1st, 2020. The moment her husband dropped on the slope to the second which he left the scene in a rescue sled with scarcely a pulse. The call came into ski patrol dispatch at 12:49 PM. The CPR was in progress somewhere on South Pass Traverse. This should come as no surprise to anyone that a heart attack halfway up a mountain is less than ideal.
Not that anyone has ever made a case for a convenient heart attack. The gravity of the situation is quite obvious. Nevertheless, there's a plan and CPR in progress over the airwaves puts that plan into motion. Jim and Peggy Hays graciously gave us permission to relive their story. Not only as a teaching tool for all of us in the outdoor medical field but because it's a relevant anecdote of luck, favoring the prepared when it matters most and an individual who beat unrelenting setbacks after undergoing such an affair. I was able to interview several key players who are a part of this event to put together a timeline and story of how Jim Hays transcended a life-altering experience.
The Lucas device was one of the many amazing pieces of equipment the ski patrol had that helped save Jim’s life.
Jim and Peggy live outside Sacramento, California, where he owns a global consulting firm that advises the high-tech industry on how to sell more effectively. As a younger man, he flew in the Air Force as a navigator and achieved the rank of Captain. While serving, he earned his private pilot's license and, since then, has required an instrument rating and is qualified to fly seaplanes. Until now, he flew often.
He has been a PADI-certified scuba instructor since his early twenties, free diving over 200 feet below the surface on multiple occasions and doing things like night dives with manta rays, or, as l like to say, nope. He's also logged 400-plus freefall jumps as a skydiver. He's active traveling across the globe with Peggy and not what you'd consider a likely candidate for an on-mountain heart attack. Yet there he was.
It was the second time that Peggy and I had been to Jackson Hole and we got a chance to ride behind the draft horses, feed the elk, doing all these iconic things, enjoying the scenery, being on top of the mountain. What we jokingly tell everyone is we had an awesome time, right up until the point where we didn't.
We hit the lift and he wasn't feeling that great. I told him that, “I bet you're probably hungry. Let's go down for lunch.” We took a cat track and that's where I waited for him. He stopped about 6 feet from me and said, “Babe, I don't feel so good.” He fell like a tin soldier. The whole time I'm thinking, “Is this low blood pressure? If it's a heart attack, you're not supposed to be seizing.” He was seizing and foaming at the mouth. I started yelling for someone to call 911.
Peggy herself is a certified anesthetist by trade who manages airways for a living and has participated in countless codes on the operating table.
He was still moaning, so I knew that he was still moving air. I grabbed his tongue, got it out of his way, open his airway. I use my thumbs to jaw thrust him. He was still breathing at this point. I checked his carotid artery and he still had a pulse. In these split seconds, I'm thinking, “What the hell is this?”
Sheer randomness plays a large role in all of our lives. Dr. Jacob Chapman, an emergency room physician on vacation from Massachusetts, was on South Pass Traverse exactly when Peggy witnessed Jim crumble. He skied upon her struggling with him less than a minute after he went down. Chapman recalled seeing Peggy at Jim's head and she was keeping his airway open and he was rolling around on the ground moaning and not able to talk. He recalled how amazing Peggy was for keeping it together. Chapman knew it was a heart attack. He reached down to feel a pulse and heard someone say that ski patrol had been called. They kept a close eye on him, but then Jim stopped moving as much and they lost his pulse. The team started doing chest compressions.
To be clear, a typical heart attack usually occurs when a blood clot blocks blood flow to the heart. Without blood, tissue loses oxygen and dies. As we discussed in our previous episode on how to save a life, starting chest compression early is a critical step in keeping blood flow perfusing through the tissues so the organs like the heart and brain stay alive.
Jackson Hole Ski Patrol is lucky to have the medical direction of the St. John's Emergency Medical Physicians Group, a cadre of ER docs, physician assistants and St. John's nurses who rotate through the Teton Village Clinic each winter. Dr. Jeff Greenbaum is the main energy center behind our empowered protocols and along with his colleagues, tailor our ongoing training to better suit the potential needs of guests in distress. Dr. Greenbaum and colleagues have tried to define what helps people having emergencies on the mountain versus off the mountain and exactly what needs to happen before and after they are brought down. We drill these emergencies regularly so that when they happen, there's no question. We know what we're doing.
Ian Barwell is an ER nurse and patroller who was on the scene the day of Jim's event.
There's a seamless integration between the clinic and the ski patrol, and as well as EMS and St. John's hospital. Additionally, several of us work in multiple overlapping departments or organizations, so we know each other well and are able to work together easily. We have medical direction coming from the same providers, Dr. Greenbaum and company, that we're bringing the patients, too. All of this adds up to create an enviable situation that can benefit our patients, which is the ultimate goal.
What resources do you have on ski patrol and what training do you have?
Let me give you a rough sketch. Outdoor emergency care, the medical training required for ski patrolling in the US, is essentially an EMT basic certification with an outdoor emergency focus minus the ambulance experience. The St. John's ER group has taken the time to augment that training by providing the Jacksonville Ski Patrol, simple ancillary protocols that allow for slightly modified levels of care in the hill in those initial critical moments of medical emergencies. It's that forethought that gives people like Jim Hays the edge when misadventure comes crashing. The clinic knows exactly what's going on with our protocol because they teach us that protocol. When they hear, “CPR in progress,” on the radio, they know to get the show ready.
The reality of heart attacks in the field isn't uplifting. According to the American Heart Association, around 475,000 Americans per year die from cardiac arrest. Most of those or 350,000, occur outside of a hospital. That's nearly 1,000 per day nationwide. Ninety percent of people who have a cardiac arrest outside of the hospital die, but when CPR has started right away, you can double or triple that person's chance of survival. Adding EMS and advanced medical services can further help the patient's chances.
There are certain arrhythmias to the heart that are shockable, where if an electrical shock is applied to the patient's heart, there's a good chance of it going back to a normal rhythm. These shockable arrhythmias include ventricular fibrillation or ventricular tachycardia and their rate of survival is higher than non-shockable rhythms like asystole, also known as flat-lining and Pulseless Electrical Activity or PEA. Having an AED immediately available helps these patients, as do advanced airways like King tubes, intubation and CPR.
According to the dispatch log, at 12:50 PM, Bill Fogarty was the first patroller to arrive on the scene approximately a minute after the initial radio call. Dr. Chapman, the ER doc from Massachusetts and a friend were performing CPR while Peggy monitored the airway.
Ian, you heard there was a person who collapsed on the radio. What do you remember seeing when you arrived on the scene?
The first thing I remember thinking when I skied up was, “There's a lot of people here.” Both patrollers and bystanders, there were skis everywhere. My buddy, Jeremy, was there and he's an off-duty ski host who happened to be free skiing with Dr. Chapman that day. He was directing traffic. It was wild to see him on scene. When I made my way to the scene, workers had the airway managed with O2 in place. CPR was in progress and the AED was attached. Another group was readying the LUCAS. The final piece we needed was a co-leader, so I slid into that role. I remember seeing Peggy there answering questions and helping out. Later, when I realized she was Jim’s spouse, I could not believe how composed she was. It was helpful.
I remember screaming at Bill, “Do you have oxygen?” My first thought was airway breathing circulation. I knew he needed airway support and the airway is my area of expertise.
Soon, a second patroller, Nate Fuller, arrived with an oral pharyngeal airway and it got placed in Jim's mouth. The patrollers started appearing with supplementary oxygen, advanced airway management devices, and an AED, then the patrollers brought a LUCAS device.
We want to have all the tools available to make a difference in saving people's lives.
The LUCAS device is a mechanical chest compression device that helps deliver high-quality chest compressions to sudden cardiac arrest patients in the field during transport and in the hospital. The patrollers could turn on the device and keep giving him chest compressions all the way down the mountain to the clinic and then to the hospital.
I believe that the LUCAS was one of the many amazing pieces of equipment that the Ski Patrol had and that helped save Jim's life.
I want to add, not just saved my life, but give me my whole life back.
Before we have these devices, there were different systems in place of trying to do some compressions on the way down the hill of transporting maybe a ski patroller in the toboggan. It was dangerous for the patroller and also not as effective. These devices are game-changers.
I can't imagine giving chest compressions while sledding down a hill.
It was before my time on ski patrol, so neither could I.
Like training, patrollers with their specific tools assumed pit crew positions taught by the ER docs and nurses. Every person has a specific job, and position and all perform these tests simultaneously and with as little talking as possible.
There were so many amazing ski patrollers who pulled me away from the scene. They were cutting away as clothes and getting the AED on and then the LUCAS. They shocked him three times. I don't remember people talking as much as I do. They were so in sync with each other and they knew what to do. That's what it feels like when I'm in the operating room with other anesthetists, who I've worked with a lot, we don't even talk. You know what needs to be done and it gets done.
At 12:57 PM, Patroller Rachel Kunkle relays to the mountain station, “One shock delivered,” she says, “Still working him.” At 12:58 PM, Kunkle offers a follow-up, “Second shock delivered, spontaneously breathing.” At 1:01 PM, Patroller Megan Raczak, radios Mountain Station a third time, “Administered three shockable rhythms and advanced airway in place. About to begin transport.”
Ian, do you recall any specifics about the teamwork on the mountain?
Yes. First, the way the subgroups of the team interacted was impressive. How they transitioned from compression cycle to shock delivered to attaching the LUCAS, that coordination helped to minimize the time that compressions were interrupted. The same was true for loading Jim into the sled for transport. By the time his third shock was delivered, Jim was in the vacuum splint and the sled was right next to him with drivers in position, which is our protocol. Three rounds of CPR and then load and go. By the time we reached the clinic, Dr. Wheeler and the nurses had all their equipment and supplies ready to go, and EMS was already headed our way.
During our interview, Peggy kept reiterating that in spite of the heart attack, how everything else went right that day, which is a pretty stoic position to take in light of such otherwise dire circumstances.
We were on a cat track, not a steep slope. He fell not very far from me. There were people around to call 911, an ER physician skied up not long after he fell and then Ski Patrol arrived with their AED, a LUCAS, a King tube. It was so amazing.
Ian, how do you coordinate who brings what to the field and what's in your med packs?
That CPR in progress radio call that Jeff mentioned puts everything into motion. There are checklists in every duty station. As responders from the closest station head out the door, they each grab a piece of equipment on that list. If backup’s needed, we can ask for gear specifically. We're fortunate to have things like King tubes and our airway bags. We've advocated to have LUCAS devices and vacuum splints. Kings offer better oxygenation and ventilation to the lungs than a simple oral pharyngeal airway. There are also better downstream effects.
It's not saving his life right now, but also increasing survivability and brain function and ultimately, quality of life later on. Having the LUCAS to provide high-quality compressions during transport in toboggan is a game-changer. As patrollers, we want to have all the tools available to make a difference in saving people's lives. In Jim's, case seconds and minutes mattered.
A King tube is a latex-free, single lumen tube with a distal and proximal balloon that occludes the esophagus or your food tube and the oropharynx, the back of your throat and nose, creating a direct route for oxygen to the trachea, otherwise known as your breathing tube and your lungs. This is in contrast to the oral pharyngeal airway that Ian mentioned, which can be helpful because it keeps the airway open, but a lot of the supplemental oxygen and air can still be directed into the patient's stomach, which then can lead to stomach inflation and distension, vomiting and airway compromise. A King tube is also considered a bit easier to insert than an endotracheal tube we would insert in the hospital. A King tube can save a lot of time if it's inserted properly.
After three cycles of the AED, Jim was taken by a toboggan on high-flow supplemental oxygen as the LUCAS device continued chest compressions for the entirety of his transport. He arrived at the base where the handoff to the clinic staff took place. He was immediately put on a monitor where they detected a pulse in organized rhythm. Nurses got IVs going, push fluids and Dr. Wheeler, the doctor working in the clinic that day, pulled the King tube and intubated Jim using an endotracheal tube. Trailing a couple of minutes behind, Peggy was escorted to the clinic by patrol, where she watched the next chapter of her husband's recovery unfold.
Watching that code go down, and I say this to everyone in our anesthesia department, it was one of the best codes I have ever seen. It's exactly what ACLS should be. Nobody is yelling and shouting. They were just talking in that calm tone, a whole team who knew what they were doing. If there wasn't excellent work right there at the beginning, he never would have made it to Idaho Falls.
Dr. Wheeler pretty much said that the real life saving happened on the hill to have that equipment show up and the AED is what saved his life. That's what got him going again. The LUCAS kept him perfusing en route to the clinic. Once he was in the clinic, he had a pulse and Dr. Wheeler said that we helped stabilize him for sure, but had he not had those things in the field, it wouldn't have mattered what happened in the clinic. Once fully stabilized, Jim and Peggy left the clinic by ambulance to St. John's Hospital. This would mark the beginning of a 33-day odyssey spanning three hospitals in three states.
After leaving Jackson and spending six days in the ICU in Idaho Falls, Jim was then life-flighted to Salt Lake City, where he and Peggy began a nearly month-long stay at the University of Utah Medical Center. Jim's body would endure a heart pump for eleven days, longer than average intubation, and upper and lower GI bleed with an endoscopic clipping, a couple of scares of a stroke and a smattering of CT scans. Plus, his sodium levels remained high and he was retaining 40 to 50 pounds of water.
To add salt to our wounds, he got sepsis from cholecystitis and pancreatitis, adding a midnight trip to interventional radiology for much-needed biliary drainage, too.
Suffice to say, he passed the event horizon on his way to recovery in time for COVID and earthquake. While we're at it, a follow-up heart attack on June 1st, 2020, where he, once again, tested the constitution of his lovely wife. It builds character. Despite two medical arrests and an exhaustive month of hospitalization, Jim wrote out this whole episode with no anoxic brain damage.
That certainly does build character. Welcome to Jim, the survivor about whom this entire episode is written. Jim, do you remember anything about your arrest on the mountain?
We skied down Jackson Hole, one of the slopes there, which is a beautiful mountain, but we'd stopped to rest. There was a giant Yeti statue and we took time to do a quick selfie there. I remember skiing away, not feeling that good and that's it. I don't remember anything else. Thankfully, all that work that was being done, I don't remember a thing. It was a blessing for me.
What's the first thing you remember after you woke up?
I woke up pretty far away from Jackson Hole. In Idaho Falls and then Salt Lake City again. I woke up after they finally extubated me eleven days later. The first thing I remember thinking was, “You've had your butt kicked. I don't know exactly what all this is, but I know this is where you're going to prove that you're as tough as you think you are, because this is not going to be easy, but it's going to be worthwhile. You've been given, at that point, a second chance.” I began three so far. “This is going to take a lot of grit and determination. We're going to take an easy, great, wonderful life and you're going to keep it that way by staying focused and counting on the love of friends and family to get you through this.”
Peggy has been such amazing support for all of this. From the first second having her, there is amazing. One thing you mentioned was that when you had cardiac arrest, COVID didn't exist. When you woke up, it was a full-on pandemic. Do you guys want to talk a little about the shock associated with that?
I was going hour to hour and day to day. I was in a bubble. I'm 100% focused on, Jim. I didn't know about this pandemic going on until my friend called and said, “Salt Lake City is going to start closing down. Get some food at the store.” I was like, “What's going on?” Anyway, I ran immediately to the store. There was one loaf of French bread left seriously and some organic peanut butter. I grabbed them both thinking, “I can live on this. That's all I need, peanut butter and bread.” My hotel was threatening to close down and it didn't end up closing down. I had my car packed, ready to go at any time. I was going to sleep in the parking lot at the hospital that it was so unbelievable, all of the different tests I had to go through.
Do you, Peggy, remember when Jim first woke up and when you were finally able to talk to him again?
They would give him a sedation vacation is they called it and he would always lean towards my voice still when he was intubated. He knew I was there with him. After they extubated him and he woke up, the ICU nurse and I were trying to determine if he knew where he was. He became so indignant with us. He was like, “I know where I am. We're on a naval air station.” He was so funny. That was probably one of the best things. He was positive.
When did you realize you were not, in fact, on a naval air station?
When everybody gave me that look.
There were so many challenges you guys faced on the road to recovery. All of that stuff that Jeff named would require hospitalization in its own right by itself, but to experience one thing after another, in those moments, how did you stay positive and face each of those challenges?
For me, it took a long time. What I did was I took one hour at a time and then maybe the next week, I would go, “What happened to the morning? What happened to the afternoon?” It helped me to stay in the now and to not look too far down the road at what was ahead of me. My brother flew in hours after all of this happened and he was my pillar through most of it. He kept me through North Star, through it all and not wondering what's going to happen down the road. Also, we have a huge network of circle of friends and family. I leaned on them a lot.
You had to spend so much time being such strong support for Jim. I'm so glad that you also had such a strong support network because that's what you need to get through difficult times like this.
It's hard because this is where COVID came in because now the flights weren't coming to Salt Lake. All of our friends would want to fly out to be supportive. I had two great friends and they said, “To hell with COVID, we're coming out. If I have to do your laundry, I'll do your laundry, whatever needs to be done.” That helped hugely to have familiar faces there. Our other friends, drove my car from Sacramento all the way to Salt Lake City just so I would have transportation number one, but also a piece of home. That was amazing. They flew on back. That was another great thing when I saw their faces and it was a slice of home. That helped a lot.
A good education and skill set are your best survival tools.
Ian, do you have any suggestions for our readers about how to stay safe in the mountains?
The obvious lesson here is to marry an anesthetist. Barring that, it's important to have the training and CPR and wilderness first aid or even better, would be a wilderness first responder course. A good education and skill set are your best survival tools. Second, I'd recommend understanding the specific hazards at the places that you like to recreate. For instance, snow science and avalanche education. Something we take pretty seriously here. A lot of locals here have a lot of that education. Lastly, being able to contact local search and rescue ski patrol and other rescue organizations is critical. Have those numbers in your phone and be able to give a good location before you enter the wilderness before you need them and never travel alone.
That's all great advice. Have you often seen, particularly backcountry skiers, carrying GPS has improved their ability to be rescued?
Every phone has it. Our dispatcher won't very often use that if the person is unfamiliar with the terrain, which happens a lot. She'll ask that person to send them their coordinates. They can pull up their GPS on the phone or even they'll drop a pin. I'll give him my cell phone number and say, “Text me or drop a pin.” Jeff and I went out on a rescue in the Granite Canyon, where we had the guy's location. I was able to use my phone to bring me straight to them. Who knows how many hours that saved?
I had no idea our phones could do that.
You can pull up a compass, we’ll give your GPS coordinates on it or if you text me, you can send me your location direct there.
As far as the rescuer goes, it empowers the rescuers. It gives Ian and me the confidence to be like, “This guy's close and we can follow his signal until we can find his tracks.” Simultaneously, he and I can be talking in real-time to one another about what we're thinking, we're going to come across, and how we're going to make a safe egress all the way back into the mountain resort. It's an empowering tool.
The fear there is getting too low. You never want to get too low because then you're useless. You have to send another round of people, which uses more resources. It's helpful and empowers us to make good decisions because we can move with confidence.
I bet you guys have a lot of interesting stories of various rescues.
Honestly, you can make this stuff up.
We'll save that for another episode. Jim and Peggy, after everything that you've experienced, do you have any advice for our readers related to navigating the medical system or any advice?
Yes. One of the first things I did was I had a friend grab a small notebook. You can get them anywhere. Most of the time, in the little shops in the hospital, you can grab one. What I did was I wrote down that day’s nurses, doctors and Jim’s progress. I felt more in control when my world had blown up and later gave me the names of all the people to think. Here is my advice to the medical colleagues out there.
Allowing families to participate in morning rounds was huge for me. I could hear that day's plan. I could ask my questions. I felt like I was a part of his care. The other thing I did was I assigned one person to disseminate all of the information to all of our friends and family. I would text that day's progress or what had happened and then that person will disseminate it to hundreds of people that were interested in what was happening with Jim.
That's another biggie. Otherwise, you're just answering so many texts, because everyone's concerned, but you cannot put your energy to all of that. That's one of my other tips for people when a catastrophe happens. Mostly, we want to give hope to those who have also been given a poor prognosis. Jim was given a 5% chance of survival. Here we are a part of that 5%, but we are surviving and thriving. Here's to the five percenters.
That's so incredible to hear and to think about, knowing the odds that you overcame to be here. Jim, what surprised you most about everything that happened?
One of the most amazing things to me, especially after hearing all this from Ian and Jeff and hearing again from Peggy, is that I didn't suffer any mental impairment. That said, life clearly has changed a bit. Aviation has been a huge part of my life and I'm not allowed to pilot planes anymore as a result of my new automated internal cardiac defibrillator that lives in my chest. I won't be able to get medical clearance to fly anymore. That's a big no-no for the FAA. It's okay. If you die, they don't want you to become unconscious because the thing zapped you.
Can you still fly with an instructor?
I can and I have. I went zipping around on a sport motorcycle from Sacramento to Calistoga. I'm still living a life of adventure, just different kinds of adventures.
That verifies that you’re thriving.
He works out with a trainer two times a week to get his core and his arms stronger. He walks 3 to 5 miles pretty much every day. He is doing well for a man whose ejection fraction’s 20%.
There's no better way to say it besides not just surviving, but thriving. You're taking advantage of all of the time that you have. Hearing your story gives me a greater appreciation for the everyday. It's incredible to see what you guys are doing.
Peggy, when you sent the email to AJ Wheeler or maybe it came from Drew to AJ Wheeler, I was in the ER that day working with him. I came in at 1:00 that day and he had been there since 7:00 AM and he said, “Ian, remember that guy from Southwest?” I was like, “Yeah.” He's like, “He's alive.” I was like, “What?” I couldn't believe it. We never know what's going to happen afterwards.