Tuesday, 22 October 2019

Reflections on Rescue Medical Care


Way back in through the mist of time as a young mountaineer and volunteer rescuer I remember after yet another harrowing mountain rescue wondering what more I could do for the broken often quite young folk we evacuated. Frequently they were in acute pain and circling the drain hole of life, where survival was at best 50/50 and some sadly not making it home. Mountain Rescuers whether medical/clinically minded or technical have to make two immediate choices on scene. Is it better and safer for the patient (and rescuer) to first rescue the patient from the scene before medical interventions, or is it a critical situation for the patient where immediate medical intervention must take place before rescue from the scene in order to save the patient’s life.

3 Avalanche Victims injured Twisting gully. Hamish overseeing and me doing the splinting. 1977
Let’s be clear, rescue from the scene with good basic first aid is the default position and one which mountain rescuers in Scotland are very adept. But back in the early 1980’s nothing much had changed in the application of basic first aid in the UK for decades. Ambulance service staff were a transport service with limited interventions and the same was true for search and rescue. Pre Hospital care was in its infancy. Changes in the UK were on the way, often reluctantly and based on taking the better aspects of the American DOT Emergency Medical Technician and Paramedic programmes for pre hospital care (i.e think Emergency Care on the Streets by Nancy Caroline) and ATLS the American“Advanced Trauma Life Support” course for accident and emergency doctors coming across the pond.

Late 1980’s I was already as far up the ladder as I could go for “First Aid” and was lucky to be invited onto the first Scottish and only second UK ATLS course. ATLS is a structured approach to managing trauma. I had also done some college courses and gained qualifications in human physiology and pharmacology to help with  background knowledge as a Paramedic and for my next stage which was Advanced Cardiac Care including paediatric care and a course with BASICS the British Association of Immediate Care Specialists. After some clinical placements at that time requiring 40 intubations and at least 40 emergency cannulations this allowed me to become registered as a state registered paramedic of which there were probably only half a dozen in the UK by 1991. I was maybe first in Scotland? I know of a couple of SAR aircrew who also came on board but i am not sure if they were before me. Later came the Health Professions Council (HPC) which I successfully registered with as a Paramedic. The public randomly attribute being a Paramedic to all providers of emergency care, but in fact it is a protected title and those that use it are trained beyond the level of most, and it's not easy to get registered. Its illegal to call yourself a Paramedic if not registered.

Taking this structured and algorithmic ATLS approach to treating immediate life threats (AcBCDE) reducing pain and reducing complications from hidden injuries unseen by using a proactive approach to managing and immobilising a patient (a form of packaging) then perhaps we also could reduce both mortality (deaths) and morbidity (long term consequences) in the mountains as well. It was worth trying. The challenge was applying this in a hostile mountain environment safely, with benefits to the patient, and no delay in rescue or rescue safety compromise beyond that already acceptable to a group of skilled mountaineers. This also required other rescuers coming on board and acting much like the core group of practitioners you will see at any major trauma in a UK A/E dept with folk working simultaneously on various aspects of care.  In addition for mountain rescue, also aspects of physical rescue from the scene such as belays, ropes etc need taken care of so it's an integrated approach.

The rescue team leader takes overall control of the rescue including the evacuation and this left the medical folks, often led in much the same manner as an A/E trauma team to me. I have to pay tribute to Hamish MacInnes for supporting this, and to John Greive who took over after Hamish retired and at a time when, and for almost a decade after there was a big increase in rescues overall and in particular victims with life threatening trauma. Patient centred care with John leading from the front and co ordinating some very difficult rescues leaving me to treat the patients worked well. While this article is about the medical aspects it should never be forgotten that mountain rescue is a team business and strong leadership medically and of the rescue in general gets things done safely and timely. There were times when objective dangers nearly changed the outcome, such as avalanches but these are best talked about over a dram.  I like to think this team approach might just have made the difference for a few poor souls who were able to have a life.

Me patching up on Central Buttress with Andy Nelson who is now GMRT Leader asking is it Henna or Blood
Many of the team's first aiders became BASP EMT’s and were very adept at managing a patient well and my advanced skills were not always required or appropriate. One skill I had which I used more frequently than any other was to give intravenous pain relief with strong opiates or similar medications. Sticking a needle or “Cannulation” into a cold frightened and distressed patient was a skill I was strangely very good at and gladly so for many folks who went from high pain scores to comfortable while enduring long tortuous evacuations over rough ground or down long climbing routes such as North Buttress hanging beneath my legs for 500 feet in bad weather when no helicopter could fly.

As a paramedic I had a range of resuscitation equipment and analgesia to bring to the patients. While I could and did intubate, these poor souls were often too far gone, but close attention to maintaining the patient’s airway and delivering oxygen were crucial.  I had the first ever defibrillator in MR delivered in 1990 from Marquette via RL Dolby. Some ridicule from many in MR circles ensued with comments of “all you will give them is a curly hairdo” from the legendary Mick Tigh.  However, within a year the defib was in action several times and on one occasion the later model Laerdal FR 1 delivered 27 shocks to a patient before her heart re started.
Rod MacIntosh now course director BASP EMT on his EMT course 1999 doing treatment on steep ground. After being delivered by a sea king I managed to get for the scenarios
Around 1991 Tony Cardwell and I, through BASP  the British Association of Ski Patrollers started the BASP Emergency Medical Technician Course. For some 14 years we took turns as course directors. We had the course endorsed by the Royal College of Surgeons (Ed) to give it a bit of clout and for many years pre “Cas Care” it was the go to course for advanced medical care for mountain rescuers and ski patrol. It still runs to this day which Tony and I are very chuffed about. These EMT’s were/are the backbone of medical provision in Scottish MR and none of my advanced training could mean anything without these fellow team players. Often my role was medical team leader keeping a close eye and only stepping in if I had some intervention they could not give such as (rarely) a chest decompression, or when things were going a bit South (a very rare requirement) and my having slightly more experience and diagnostic skills might change the treatment. I take my hat off to them as a very skilled bunch capable of making a difference if I was there or not. Apart from the obvious medical skills one obvious advantage I often had was being very fit and a strong climber so could always get to the patient needing care be it Clachaig Gully or 5 pitches up Swastika or Central Grooves the tale of which I have also hyperlinked.

The other aspect of taking advanced medical techniques to the mountains is medical equipment that’s up to the job. The kit for immobilising fractures had not changed much for decades. Some teams still had Thomas splints but with pre hospital care there was a rethink and re design of some kit. Quite a lot of pre hospital medicine was influenced by dated military practise and some of the equipment. For example, MAST or “Military Anti Shock Trousers” squeezed blood into the patients core like a G suit but then they bled out more (letting the tap run with the plug out) or fluids used to replace lost blood volume increased blood pressure but were not the only true colloid which is blood carrying oxygen, and so morbidity was increased as they bled out. The pre hospital treatment of shock we took and applied was to plug all the holes you can see by looking at the patients back, front, left and right, maybe apply a tourniquet or coagulation dressing, and a helicopter as fast as possible to a surgeon at the local hospital constantly being updated by me directly or via the Police so that their A/E and surgical team were ready.

Geoff Lachlan, Dave Sedgwick, Brian Tregaskis and Belford staff were great support on and off the hill and Dr David Syme then medical doctor to the mountain rescue committee was tremendous support in supporting trials of new kit to me with a view to making them standard MR issues if worthy. Also no article would be complete without acknowledging the tremendous support from within BASP from Dr Ian MacLaren consultant in A/E Monklands and the late Dr John Scott London HEMS both who encouraged and trained me over the years. In particular "the doc" Ian Maclaren who was huge support and always there at the end of the phone for a debrief after a difficult resuscitation. Later players coming into the mountain pre hospital trauma side from the clinical/medical were such as Ian Macconnel then resuscitation officer at Wishaw General who crossed to the light after helping out on EMT courses and being rescued (it's ok Ian so was I!). Ian later joined GMRT and took over as medical officer from me when I left. My last ALS course was by invite from him down to Crosshouse hospital to see how I compared to the hospital pro's. I think I did ok as I passed, despite a hangover. It's well worth asking him to describe running a defib refresher for the teams EMT's at the old Glencoe Police station while a local worthy was locked up in the cells. The noise from the Laerdal Heartstart 2000 put the offender of his head, it's a very good tale.

One vital bit of kit I was pleased to introduce first to mountain rescue was the American “Hartwell" Vacuum Mattress. Spinal injuries are not uncommon in fallen mountaineers.  Before the vacuum matt we had no way of immobilising these life changing injuries. We were also the first to routinely apply extrication collars which when used appropriately are life and limb savers. I am absolutely sure GMRT saved many people from devastating life changing injury by the careful handling and immobilisation of their spinal or neck injury. I also had LOTS or “Level One Trauma Splints” sent across from the USA and some of these excellent splints are still in use. Other notable imports were the Colorado “Wiggies” casualty bags to keep the patient a bit warmer and the first Pulse Oximeters to monitor SpO2.  
Trussed up like a Turkey and going no where. Packaged!
LOTS splints in action
SpO2 is not so reliable in mountain injuries due to cold and the oxygen dissociation curve moving left, but it also gives a pulsatile flow rate (HR equivalent) and a wave form to monitor how strongly the blood is flowing and the heart is beating. This also proved useful when reducing fractures into alignment to ensure blood flow. A useful tool in the context of other checks. I am very pleased that maybe my skills and the equipment brought to bare made a difference. What I hope you take out of this is that at the time of my training, pre hospital care was in its infancy and up a mountain advanced medical care thought impossible. Speaking purely about the rescue team I was involved with I can with some pride say they bought into the concept whole heartily and along with the teams leaders and enthusiastic first aiders/EMT’s we achieved a quality of medical care and patient centred decisions which was ahead of its time. Chapeau to all those folks, some of whom are still rescuing the day and night shift.

Morphine and Cyclizine on board then package. Hartwell Vacuum Matt in use below Ossians cave 
One of my first mountain rescues was an avalanche when about 16 so in 1972 when I was a team apprentice and mad on climbing. I wasn’t allowed to be full member until I was 18 and could be insured. The climbing I did as a youth gave my parents many sleepless nights not least of when rescued hanging at the end of a rope November 1972 on the North Face of Aonach Dubh with Euan Grant and two others, all stuck when the rope ran out in an icy gully. It was kind of fitting that my last Glencoe mountain rescue was also an avalanche where 3 folks had lost their lives and I probed and found the last victim.  As a medic and climber I was oblivious to background issues and driven by sticking to the guidelines that have proven to save lives such as ICAR’s for avalanche victims. When seeing these ignored by another agency, I would speak my mind. This often brought me into conflict with them and sometimes other rescuers. In the heat of battle/rescue things happen and its important to talk about them and learn for the next time. Fiona was struggling to continue to support me. 30 years married 3 kids and wondering if her husband would come back and if she was to be a single mother takes its toll. Families need 100% confidence that their partners rescue colleagues are their “brothers keeper”  and she began to doubt this. I knew I could look after myself up a mountain but it was just plain not fair on the family if they were scared of loosing their dad. I still miss it though, that sense of tribe and sense of purpose, and ironically as an older mountaineer with decaying skills I think I would be safer as just a grunt on the ground working for others at the sharp end, but that’s nostalgia perhaps. Ski rescue certainly has it moments and digging an avalanche victim out still alive was a bonus rarely enjoyed in mountain rescue.

My probe find. Yet another sad tale of mountaineers not "being searchable"
The unsung heroes of MR are those back home. Seldom acknowledged, they get no fancy gear allowance, free dinners or the kudos of membership of an exclusive tribe. And it is exclusive. Don’t imagine it's easy getting out of a warm bed on a bad night to wander over the Aonach Eagach looking for someone. Rescue team members need exceptionally good hill and mountain skills and not everyone has them or is a good fit to an often very close knit group.  I was fortunate that my rescue colleagues were often my climbing partners and so working together on a rescue was easy. I would say it’s still mostly the same and I see a very dynamic and young rescue team in action now and doing a great job. I don’t think that when I hear the whack of rotors going over the house or knowing there is a rescue, the increased heart rate and wondering what it is will ever leave, but it’s good to know there are folk willing to bust a gut to go out in all weathers and make a difference. I can’t quantify if I did, but maybe. Also these folks now have access to TRIM something not available to my generation. Stress did take its toll at times. PTSD and Talking

Day shift work, no head torch required
These days I still rescue from the mountains on day shift with Glencoe Ski Patrol. That as mentioned also has it’s moments, but that’s another story. I have let my Paramedic registration lapse as at 62 I don’t feel my clinical skills are sharp enough and the yearly CPD is a toil. I do complete the ski patrol training requirements and annual refreshers so not all my skills are lost, and new ones are found as things change.  For the last 8 years I have run avalanche rescue courses and become a trainer for Recco. I am also a pro member of the American Avalanche Association and an Ortovox avalanche safety partner. I train MR teams in Recco and advise on other aspects of avalanche equipment and rescue. Oddly to just about every other team than the one I was in for 38 years! Joking aside, they have a plethora of knowledgeable folk of their own.  Climbing is still a big part of my life and I still run, bike and ski. Goals for 2019 is to send a 7b sport route in better style. I had an epic on the Tunnel Wall route “Uncertain Emotions” but still doing ok sending up to 6c/7a and V6 so life in the old dog yet.
Me contemplating getting my leg over the "Snotter" 6b+ last year
Thanks to all my colleagues past and present and most especially my family. And safe rescuing to all those on the 24 hour shift that is mountain rescue. 

Here's a selection of pictures from a collection of many. All survived!


Sean, Malcolm, Ian, Frazer and Paul waiting on the yellow taxi.  Rock climber both lower legs #

Pneumothorax (see the air around the eyes, surgical emphysema). and frostbite

North Buttress in winter. Direct spinal injury and lowered by Andy Nelson on ropes for 500ft between my legs. Rescue from the scene due to bad weather.
As above with bony injury obvious.  Good recovery though

Keep your ice axe in your hand while self arresting

Warthogs go into the ice not your palm

Wearing a ring rock climbing
Pattern Bruising - what lies beneath?

The stranger side of MR. Called to a burn victim camping who had sat on the BBQ. Treatment was immersion in the river Etive then burn gel.






Monday, 7 October 2019

The Black Swan

After a good training weekend with an excellent lecture by Dr Stephen Hearns on EMRS and Peak Performance Under Pressure I thought it might be useful to re-post this blog article from 2016:

I am reading a philosophy book, The Black Swan. I like philosophy and it runs in the family. This particular book was one highly recommended to folk working in avalanche education which I do a little. Much is currently made of the human thinking traps with heuristics being the topic in vogue among professionals. Clearly there are thinking traps. And if we are aware of them maybe we can change our actions. 20:20 hindsight it's easy to see the mistakes. Thinking forward is not so easy. Do we only learn backwards...............

"Before the discovery of Australia, people in the Old World were convinced that all swans were white, an unassailable belief as it seemed completely confirmed by empirical evidence. The sighting of the first black swan might have been an interesting surprise for a few ornithologists (and others extremely concerned with the colouring of birds), but that is not where the significance of the story lies. It illustrates a severe limitation to our learning from observations or experience and the fragility of our knowledge. One single observation can invalidate a general statement derived from millenia of confirmatory sightings of millions of white swans. All you need is one single (and, I am told, quite ugly) black bird" 

We humans have a bias for the anecdotal rather than empirical and as the book above challenges, even empirical data can be wrong. But, in science its all about proof and the requires research and if its from more than one source then these empirical "black swans" are less likely as we increase certainty. Everything including travelling in avalanche terrain is managing uncertainty. As the cause of death in avalanches is researched by many alpine nations there is a lot of good data to support the statistic that folk mostly die because they either cant breath, or what they are breathing is not rich in oxygen.

I wouldn't say the book is to every body's taste but much like "Thinking Fast- Thinking Slow" and "Managing Risk in Extreme Environments" and even "The Checklist Manifesto" it's another take on how we think and how we learn from our mistakes. If we learn from our mistakes? may well be the take home from the above book, as when we change how we think with hindsight, we maybe just move the uncertainty somewhere else. You probably need a good strong hash cookie with your' coffee for this book.

I have re bought an old favourite book which is one of the few that rivalled "The Avalanche Enigma" it's called "The Avalanche Hunters". I am enjoying going back to these old books and realising that our knowledge of the subject has not had a quantum leap and these old tomes still teach lots. These books were all important to me as way back early to mid 1970's there was little formal training. We were fortunate in GMRT that Hamish was well connected and brought folk across to run training from Europe, and as early adopters had the first transceivers, but on understanding the subject a lot of self learning was needed.

I reflect back and realise we never really applied much of it to ourselves and skied off piste with total bravado ignoring things that happened to other people. Skiing back to Verbier off piste with Fiona's dad and a group after coming off Mont Gele, then the group of three strangers behind gets killed later is just one example, and it horrifies me to look back at the sheer stupidity and randomness. As we were with friends in a group it was total group think and feeling safety in numbers. Another example in Switzerland was saying nothing when Fiona skied the back route down to Rougment off the Videmanette with a high risk with Roger Clair and then getting lost in the dark. These were mere tasters to ducking the ropes later trips and bollockings from pisteurs. One time they even stopped the cable car above us as we ducked into a 45deg horror fest. If on ski patrol now, I would arrest myself ! These trips were not package tours but often two or three week stays in Chalets of lifelong friends of Fiona's parents, so the skiing was pretty immersive and full on with a lot of group bravado. All bad stuff in avalanche terrain.

I often wondered if it was MR that made me interested in the subject of risk, but looking back its the sum of lots of parts that all add up, and ski near misses and realisation that your were an ignorant fool - that's probably the biggest one! Thankfully, leading rescue parties and leading guiding/climbing these lessons were learnt. However, as a climber pushing towards the limits is all part of the game - within reason. As Don Whillans said, never underestimate the importance of staying alive.