Tuesday, 22 February 2022

Reflections on Rescue Medical Care

All of us had an interest in first aid. Some more than others. I was an early school leaver with no qualifications other than cutting down trees and hard work. Then I was persuaded by Fiona that I was clever and bored at school so should do some adult learning and get some qualifications, so I decided I wanted to become a doctor. Along the way I collected qualifications in human physiology, pharmacology and eventually became one of the first UK paramedics. I never got to be a doctor but I did get invited into the Royal College of surgeons Faculty of Pre Hospital Care as a founder member and BASICS full member.  Life is journey and I would never swap these early years in the woods and the people I met for any degree, or the adventures life brought later. Some of the best of which was my time with Joint Services Mountain Training and the folk I met and had fun with.

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 by the establishment, and those adopetd based on taking the better aspects of the American DOT Emergency Medical Technician and Paramedic programmes for pre hospital care (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 the 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 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 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, so it's an integrated approach.

The rescue team leader takes overall control of the rescue including the evacuation, this leaves the medical folks to treat the patient, often led in much the same manner as an A/E trauma but without the monitors and scanners. 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 not an article.  I like to think this team approach might just have made the difference for a few poor souls.

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 with my advanced skills 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 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 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 having soloed some big routes and survived some epics and lost friends, 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. Ski rescue certainly has it moments and digging an avalanche victim out still alive was a bonus rarely enjoyed in mountain rescue.

A probe find by the author. 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. It’s good to know there are folk willing to bust a gut to go out in all weathers and make a difference. 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 had 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 10 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 bike and ski. Goals for 2022 is to still send onsight a 7a sport route in better style. I had an epic on the Tunnel Wall route “Uncertain Emotions” but still doing ok sending the odd  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 and of course the hard working ski patrol pro's on hard dayshifts 

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 this wasn't comfortable for the patient or me! 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

1 comment:

  1. Great article Davy. It was great to be one of your colleagues on the Team. Many memories ...