Big wave surfing: a doctor’s perspective

  • Terrance Farrell, D.O.
High relevance study
Full article

Location: Emergency Medicine, Medical Director WSL Big Wave Tour, United States

Source: Sports Orthop. Traumatol. xx, xx – xx (2018)

Objective: introduction to the sport and the competition of surfing on big waves. In addition, report the medical support infrastructure for athletes.

Methodology: review article by the author, medical director of the WSL giant wave circuit.

Abstract: This is a high-risk sport, expanded as competition for the biggest wave takes athletes to the limits of human capacity. Preliminary data suggest that there is less than 2% risk of injury, during a three-year follow-up period in official competitions made by the author. Medical support and a trained safety team assisted by jet ski are probably the reason for this low incidence of injuries.

Event organization

The decision to run the competition is made by the WSL commissioner, after the wave forecast exceeds the 30 foot wave made by Surfline’s global data. The event starts with a ” yellow light ” five days before the date of the proposed event and then a ” green light ” 72 hours after the event starts. The call results in the mobilization of 24 surfers and 150 members of the production team and security team to travel anywhere in the world. Four events are scheduled each year; however, in some years, events are canceled due to the lack of favorable conditions (<30 feet). Accommodation is assessed by the WSL team and flights booked by a travel agent in Australia.

The surfers

24 surfers are chosen for each event, including the 10 best competitors from the previous season, two guests from the previous year’s video qualifiers, six local wildcards and six big wave tour wildcards. These highly trained athletes remain active all year round, chasing the biggest waves in the world and training specifically for the risks associated with this extreme sport. Breathing control, water rescue and resuscitation are now part of every surfer’s preparation. The inflatable vest has become an additional safety tool for most; however, the helmet is rarely seen in competition. Much of the training and travel budget for these surfers depends on their earnings and personal savings.

Water rescue team

Team formed by experienced jet-ski pilots with competence in first aid. Events usually have about 10 to 12 members on this team.

The members of this team are organized into zones. A base remains on land and coordinates rescues via radio. Teams of 2 people cover each of the established zones (1 holder and 1 “back-up”), thus preventing many jet skis from staying in the same area and potentially causing an accident. There is also a jet ski with a paramedic who is involved in any rescue that requires medical attention. This is responsible for cases that require PCR, bleeding control or cervical stabilization for transfer to the medical boat or to the beach base, and is also in constant communication with all jet ski teams.

The medical team

The medical team is led by a certified emergency physician in conjunction with a group of highly trained paramedics. Local doctors are usually included in the team to provide local knowledge of the medical system in the event of an injury that requires transfer to the hospital. This local doctor also helps with any language barriers.

The goal of the medical team is to provide emergency medical care and advanced life support to the seriously injured surfer and streamline the transfer process to a higher level of care when indicated. Each event has an ambulance on site, as well as an air rescue and evacuation plan.

The medical kit used at the event was designed to include equipment for intubation and airway management, crichotyrotomy, bleeding control, medications, long and pelvic bone fractures, defibrillators, spinal immobilization, pneumothorax control and includes an ultrasound as an examination help. The team’s main focus is to provide as quickly as possible a high level of acute medical support after an injury. The water safety team trains annually to develop the skills necessary to achieve this goal. There is a strong emphasis placed on preparing for the worst-case scenarios, which are generally uncontrolled and unpredictable. In order to facilitate training and team discussions, videos of previous events at the venue are extensively studied.


The knee injuries seen in large wave surfing most commonly involve the support knee, which has the leash and board attached. The most common mechanism is the traction exerted by dragging the board. This pattern differs from WCT, where knee and ankle injuries are most commonly due to rotational forces and valgus stress associated with curves and aerial maneuvers. The large volume of water moving quickly also greatly increases the chance of lung and ear barotraumas after a “cow”. The bigger the waves, the greater the energy involved in the trauma, so any fall can cause a major injury, especially against reefs and the bottom.

The incidence of concussion may also be underreported. The Nazare 2016 event was notable for three head injuries with three different injury mechanisms. One surfer was hit by a board, the second by a jet ski and the third by the wave itself. The fall of a 30 to 40 foot wave on a non-compressible surface (water), followed by the submersion pressure at 15 to 20 feet by the wave force and the hypoxia period associated with a large wave in the series can result in a concussive response more expanded. This is clearly an area for future research and will be part of the medical team’s protocol before and after the 2018 event.

There is a significant risk of drowning, however, the use of self-activated inflation vests adds a level of safety. The skills and competence of jet ski operators in the water safety team reduce risks, quickly removing the surfer from the dangerous impact zone.

Conclusion: The incidence of injuries remains low in the 9 events that participated. Preliminary data suggest that there is less than a 2% injury rate for this period. The average wave size during these events is 30 to 50 feet and the events are held in five different locations, with varying weather and water conditions. The incidence of fatal injuries has been extremely low, largely due to the training and resilience of surfers, as well as the quality of the water security team in its role in minimizing injuries and preventing drowning.

SID opinion: 🤙🤙🤙🤙. Despite few numerical data, this review is extremely important due to the amount of information about this growing modality in the world of surfing. We have no information as to whether the format of the competitions remains the same to this day.

SID TIP: Know where you are going to surf, be careful. Always warn people who are on the beach where you are going to surf. Perform basic rescue and resuscitation training. Big wave surfing requires not only personal skill in the sport but also a very well-trained support team.