One ordinary winter day in 2012, three patients arrived at the Whitehorse General Hospital with severe frostbite. They had gone out for a day trip, snowshoeing and cross-country skiing close to town, as many Northerners do on a weekend. But the temperature fell suddenly. It was the kind of weather shift that can catch even locals off-guard — and that’s exactly what happened.
Most doctors only see frostbite cases a handful of times in their careers, but not Alex Poole. Having been in Whitehorse for a number of years, Poole was familiar with frostbite cases and was the surgeon who spoke to the patients who arrived that day. Frostbite is essentially frozen tissue. In Whitehorse at that time, it was treated by thawing it out and then later, if the tissue didn’t survive, by surgically amputating it. But this time, the patients asked for something new—a European medication that had been used by some practitioners for treating frostbite.
Something sparked in Poole’s memory — an article he’d read in The New England Journal of Medicine. It was written by a specialist in France named Dr. Cauchy, who was treating frostbite with a drug called iloprost to help save fingers, toes and other extremities from amputation.
Poole called the hospital pharmacy looking for iloprost, and pharmacist Josianne Gauthier answered the phone. But the news wasn’t good. Not only did the hospital not have any iloprost, they couldn’t order it, either. It wasn’t commercially available in Canada.
The snowshoeing patients were treated that day, but only with rewarming, not with medication, , and the outcomes weren’t ideal.
If serious frostbite isn’t treated, the parts that don’t recover, most often fingers and toes, hands and feet, eventually die and turn black over days, weeks, and months. Several surgeries are often required in order to amputate the parts that cannot be saved. Unfortunately, this is what happened for one of those patients.
But Poole and Gauthier weren’t done. The incident sparked a desire to figure out what the best frostbite care in the world could look like. They had no idea at the time that it would change the direction of their careers.
This whole journey with frostbite “was sort of accidental,” says Poole. The surgeon has a clear, economical way of speaking, and an air of wanting to get to the point. He says he didn’t set out to become an authority on frostbite treatment. He just did what any good doctor does. He looked for the best available information, and then discovered it wasn’t easy to find. “We were just looking up what to do.”
Both Poole and Gauthier share a similar story. What they were looking for was some accessible, clear material on how best to treat frostbite in a northern setting. Their search led them to specialists in Europe using medications they didn’t have access to, and to research conducted by large urban hospitals in cities like Minneapolis and Winnipeg with sophisticated imaging equipment, which they also didn’t have access to in the Yukon.
“Frankly, we didn’t have access to much,” Poole explains.
Many people might have stopped there, but they didn’t. As sometimes happens in the North, Poole and Gauthier realized they couldn’t rely solely on outside knowledge to address this issue. Essentially, they had to become the experts they were looking for.
“We did a deep dive into frostbite care,” Gauthier says. “We did an extensive literature review, Alex did a 10-year retrospective of our prior frostbite cases, we contacted experts in France, and we spoke with people in Alaska as well.”
Among friends, Gauthier is known to be systematic and organized, someone who puts her children to bed at the same time every night. But her commitment to best practices goes far beyond simply being organized. From initiation through to implementation, Poole says their frostbite research collaboration benefited from Gauthier’s knowledge and detail-oriented work ethic.
But iloprost remained out of reach. Then Gauthier had an idea. Though it wasn’t commercially available, she knew as a pharmacist that some unapproved drugs could be accessed through a special Health Canada program.
“So, I made the attempt,” she explains. “I requested access through that Health Canada program, saying why we wanted to use the drug, how it appeared to have some advantage in [treating] frostbite, and how in our specific remote context, it had a lot of advantages.” Health Canada refused.
Frostbite doesn’t look like much from the outside. The skin might be pale and waxy, but there won’t be a lot to see or feel, at first. “People often don’t recognize they have frostbite until it’s too late to treat,” says Gauthier.
Frostbite is caused by ice crystals forming inside the body, in the spaces between cells. As freezing occurs, the other fluid in that space becomes more concentrated, and pulls liquid out of surrounding cells by osmotic diffusion, dehydrating and damaging the cells in the process.
Once frostbite warms up and thaws (imagine thawing meat from a freezer)—it looks a lot worse as the body’s inflammatory response responds to the injury—it may swell up to double in size or more, often blisters, and turns red or dusky and dark. There is also a lot of pain. For mild cases, ibuprofen can be enough, but severe cases require pain control with narcotics.
It’s in this moment right after thawing that a critical window for treatment emerges. As blood rushes back toward the injury, the swelling reaction itself can cause blood vessels to constrict and clots to form, blocking the flow of blood back into the tissues to repair the damage to cell walls.
This is where iloprost comes in, as it combats vessel constriction and may even help break down the clots. A class of medication called thrombolytics, which are used in heart attacks and strokes to break up clots, began to be used to treat frostbite in the 1990s in Minneapolis. These are still the medications used most often in The United States for treatment of severe cases. But these medications can’t be used easily in remote settings, they carry a risk of bleeding or hemorrhage, and they have to be given within 24 hours.
Iloprost works similarly, but with some key differences. It was developed in Germany in the 1980s and was initially used to treat Raynaud’s disease and other circulation conditions. Its use in frostbite was first documented in Austria in 1994. More data is needed, but so far, it appears that it may be more effective than thrombolytics at helping the body repair frostbite injury, with less serious side effects (mostly headache and flushing). Also, it can be given to more patients--patients who can’t receive thrombolytics, patients with a wider range of frostbite severity (grade 2 through 4), and patients who get to emergency departments up to 72 hours after frostbite has occurred. In short, it's the best medication that can be used reliably in a remote northern setting.
Health Canada’s rationale for initially refusing to grant Poole & Gauthier permission to use iloprost was that they claimed there were other therapies available.
But Poole and Gauthier weren’t giving up that easily. “Alex said, ‘We’re not going to take “no” for an answer. Let’s appeal,’” explained Gauthier.
So, the two wrote a follow-up letter, asking what the alternative therapies were, and Health Canada responded by granting them permission through its special access program to use iloprost in treating frostbite. This helped to overcome the first hurdle — it gave them access to the drug.
The next hurdle was getting Whitehorse General Hospital to approve its use. At the small northern hospital where the standard process is to follow protocols developed in the south, the administration wanted to consider this new, northern-led procedure very carefully.
In February of 2015, three years after those three frostbite patients walked into their lives, the hospital’s ethics committee gave Poole and Gauthier the OK to use iloprost as part of their new standard protocol for treating frostbite.
It all came together just in time. The weekend after the approvals were granted, two extreme winter events started in Whitehorse: the Yukon Quest — a multi-day dogsled race — and the Yukon Arctic Ultra — a foot-race that follows the same trail over hundreds of kilometres.
“I have a good picture of the Yukon Quest leaving and the mushers and what they're wearing because we rarely see mushers with significant frostbite,” explains Poole. “The very next day, it was the start of the Yukon Arctic Ultra, and [the athletes] were wearing spandex and glorified running shoes… The joke is this is a frostbite researcher’s dream: extreme temperatures, and a planeload of spandex-clad Europeans who want to run to Dawson City.”
It was a cold year for the races. Many of the international ultra athletes might have been used to –20, but not the temperatures they faced on the trail, especially in the valleys.
“Minus 40 is completely different,” says Pool. “You can stay out for less time, and a more rapid exposure leads to freezing.”
Sure enough, frostbite victims from the race soon began arriving at the hospital. Poole and Gauthier treated them with their new protocol, the first to use iloprost in North America.
What’s in the protocol? Essentially, it’s a recipe for diagnosis and treatment of frostbite, combining the latest research from Europe and around the world with specific order sets for medications appropriate for treating each stage of frostbite. and there are a few of things about it that are uniquely helpful in northern and remote contexts.
The protocol starts with rewarming in hot water at 39C, a technique developed by Alaskan researchers in the 1960s and still currently considered best practice. Next, where many previous frostbite treatment descriptions relied on specialized imaging equipment, the Yukon Frostbite Protocol only requires a visual assessment to grade frostbite severity on a four-point scale. This means it can be used at remote nursing stations as well as bigger hospitals. Third, the treatment includes iloprost, which if authorized, can be administeredby a single doctor or nurse in remote locations.
The outcomes were good. Untreated, cases of grade two and three frostbite carry a moderate to high risk of amputation. But Gauthier says they had no amputations for grade two and three frostbite.
While Gauthier and Poole were treating the Arctic ultra runners, they documented their results and then published an academic article — a case report in the Canadian Medical Association Journal that came out the following year. From there, their work started to gain momentum.
“When that got published, we started getting phone calls and emails… It really sparked a lot of interest,”Gauthier says.
The first call came from Golden, B.C., asking to send a patient up to Poole and Gauthier. The Whitehorse team convinced the callers to send the patient to Calgary instead. But it marked a turning point; med-evacs almost always travel from the north to the south, not the other way around. Ever since that first article, Poole and Gauthier have been fielding communications and presentation requests from across Canada, and now from other circumpolar countries, too.
“Frostbite presents in emergency departments where people are busy, and they don't always know how to treat it — they may never have seen it in medical school,” says Gauthier. “So, doctors will sometimes come across our protocol and then they pick up the phone and they call Alex or call me and say, ‘OK, we have a patient right now,’ and that’s how Alex became a sort of on-call expert.”
The duo have come to be regarded as part of a small pool of frostbite experts worldwide. And they’ve continued their research in several important ways. First, Poole and Gauthier shared their protocol, called the Yukon Frostbite Protocol or the Whitehorse Frostbite Protocol. It’s available for free to healthcare providers and the public on the Yukon Government website, and easily searchable on the web. Any doctor across the world can now quickly assess the level of frostbite severity and sign the protocol to initiate treatment. They don’t have to create the treatment from scratch. This is important because when it comes to treating frostbite, the faster, the better.
“The longer you wait to treat, the greater the risk of amputation, so with frostbite, we say, time is tissue,” explains Gauthier.
Now, in 2023, Poole and Gauthier are working with a cross-Canada team called the Canadian Frostbite Collaborative. Formed primarily by a small group of doctors and medical students, the Collaborative is calling for more research into frostbite care, and is in the early stages of building a website to serve as a frostbite information hub for medical professionals and the public. Gauthier and Poole have also just released a new academic article in The International Journal of Circumpolar Health, called “Iloprost for the treatment of frostbite: a scoping review.”
It’s clear they are proud of the work they’ve done to compile frostbite care protocols in an accessible way, and of the steps they’ve taken to research new treatments. The Yukon Frostbite Protocol has now been implemented at all Yukon Hospitals, as well as at Yellowknife and Iqaluit Hospitals, and has been adapted for use at larger hospitals in Vancouver, Calgary, and beyond. Poole was recently asked to speak at a NATO event about military applications for this treatment and the Whitehorse team continues to have conversations with colleagues in Anchorage, Helsinki, Chamonix, Fargo, the Himalayas, and Minneapolis, among other places.
The two continue to make advances in frostbite care, which is good news for anyone who spends time outside in cold weather. Sometimes, there is an impression that Northern healthcare is a revolving door, or that this is a place where practices developed elsewhere have to be reduced to lesser versions. But Poole and Gauthier tell a different story.
Like so much of the work happening in the North, though, they have done this research off the side of their desks, in their free time, while keeping up with busy work and family lives. Neither Poole or Gauthier started out as researchers, nor have they had any formal support or funding from academic institutions.
Gauthier says it took many days of working late into the night after her small children were asleep to complete the scholarly articles they’ve published so far.
For Poole, who may only treat four or five cases of frostbite a year, the impact of the research has begun to define his job. As his son told someone recently, “My dad is a frostbite doctor.”
