New Hampshire American College of Surgeons by permission of M. Allman(patient) and M. Moslow-Benway(photographer) Compiled by C. Wilmot 26 year old athletic woman became hypothermic in Crawford Notch, mid February, 2000, after getting lost, and fell in river beneath deep snow. She changed all clothes except shoes, took Advil and walked out after 36 hours with her unaffected companion. She was taken to the nearest hospital. The feet were rapidly warmed in 40 degree C water, she was hydrated, given parenteral Toradol, and Silvadene was applied to the toes. She kept the toes warm all night on warmed IV bags. The toes were similar the next am. She flew home to Washington DC, that pm. She saw many surgeons, cared for her feet with bathing and Silvadene to the skin. She needed good pain management. In April she had debridement of the toes, and has had multiple revisions, since then. After PT and swimming, she can run, blisters easily, wears orthotics and has been working full time with many of her non athletic pasttimes resumed. She has some phantom pain. Her sleep patterns have improved and psychologically she has done very well. Left plantar 2 days after frostbite Left toes 2 days after frostbite Right toes 2 days after frostbite Right plantar 2 days after frostbite Left toe tips 2 days after frostbite. She saw many surgeons, cared for her feet with bathing and Silvadene to the skin. She needed good pain management. Her final surgeon agreed to wait until full demarcation. Left toe tip after 2 days Both feet 2 days after frostbite Right toe tips after 2 days Left plantar foot after 7 weeks. Full demarcation preceded decision for debridement. Left foot 7 weeks later Right foot 7 weeks later Right plantar foot 7 weeks later Both feet 7 weeks after frostbite Left foot 3 weeks after surgery Pt. had failure of the left great toe graft, and further revisions were done. Both feet 3 weeks after surgery Right foot 3 weeks after surgery. The demarcation allows that there is healing beneath the initial injury. The Technetium 99 scan can show the extent of permanent damage within 2-3 days of frostbite. Early debridement can be done with the scan delineating the final level of bony death.