A reminder of blood and tears

Having spent yesterday formatting and upgrading Fiona's desktop to Windows 7 from XP I took some files off including some with stuff I didn't deem important and had thought long gone but Fiona obviously thought was worth keeping.  I am glad she did as there's a host of pictures and documents I had binned off my own various computers years ago.  Some pictures of patient care and some letters including my HPC revalidation as a Professional Paramedic from 2005/6. Section G7.  Quite a reminder of the level of care in tricky places I used to provide never mind the A/E  work, Ambulance and theatre electives.  "the busiest mountain rescue team in Scotland" was maybe true back then but not now as Lochaber MRT hold that title. Here's some mountain stuff cut and pasted from the scanned version:

I was quite good at sticking sharps in folk in tricky places

Section G7 Report

• Description of areas of professional practice
• Three Patient Histories

I work for the busiest mountain rescue team in Scotland, Glencoe Mountain Rescue which is a voluntary service similar to the RNLI. We are funded by the Highland Constabulary (Police) and uniquely by the Scottish Executive (Parliament).  I am insured for medical duties including invasive skills by the Highland Constabulary (Police) and when treating a patient will have been called to do so by the Police.

The number of trauma victims and ill patients treated by me practicing for the above rescue service ranges from 26 to 50 per annum. My duties includes the  initial rescue response tailored to the injury or illness, logistical organisation for completion of the rescue task, scene safety of the patient, and rapid assessment and critical interventions at the scene. 

My duties also include liaison with other search and rescue agencies to carry out the primary role of Glencoe Mountain Rescue which is to find, treat as appropriate, and stabilise patients for onward transport via rescue techniques to hospital.  

The medical aspect of rescue provided by me would include:

Scene safety, history of the present complaint or injury, primary survey, resuscitation according to UK Resuscitation council guidelines, splinting and packaging and providing adequate analgesia.  As an example of clinical skills I will provide three examples of patients treated by me:

Patient 1. 

Narrative:  19/02/05 While en route in blizzard conditions to evacuate the body of a fallen mountaineer in a remote location, a rescuer was seen falling over 400ft on hard neve (hard snow).

Scene :  Safe as fallen mountaineer landed on less steep ground

Initial assessment:  Airway with “C” spine control, Patient Alert and Vocalising and Responding to Pain. Breathing rate 12/20 and pulse rate less than 100bpm. Rapid body survey indicated only one chief complaint which was a badly deformed and broken ankle which was exposed and examined for distal circulation which was absent. Cold was an issue as it was -6c and wind was 40/80 knots so protecting the limb from cold injury was also priority. SAMPLE history unremarkable

Treatment provided: The patient was cannulated by me with a 18g Safelon cannula in the antecubital vein. Cyclimorph 15 was drawn up and diluted in 10mls of sterile water (1.5mg per ml) and slowly injected using a visual analogue scale (VAS) to gauge effect from the patient.  When a therapeutic effect and adequate analgesia was achieved which in this case was 4 the ankle was pulled by me and circulation returned.  A rigid vacuum splint was applied.  The patient was put in a warm pre heated casualty bag

Rescue: The patient was evacuated for 3 hours via a circuitous route to avoid avalanche traps until a SAR helicopter was able to come in and uplift him to the Belford DGH.

Outcome: Transfer by road after initial assessment to regional orthopaedic unit for pins and plates and patient is now fully mobile and recovered.  Total rescue time 11 hours

Patient 2. 

Narrative:  22/06/05 while instructing students on an MEL course an instructor stepped back off a ledge and fell “bouncing” 60ft into a gully/watercourse (Lady’s Gully)

Scene :  Steep but made safe. Patient lying in water and unresponsive

Initial assessment:  Airway,“C” spine control and jaw thrust.  Breathing inadequate SAO2 at 80%  so initial resuscitation by BVM and then return of consciousness to GCS circa 11 (aVPu) and SAO2 96% with spontaneous respirations and adequate tidal volume. Breathing 12/20 and pulse 90bpm.  Obvious bleeding from scalp wounds but no other external bleeds found during rapid body survey. Conscious level alternating between AVPu and aVPu. Body check revealed tender left side thorax with good breath sounds and lumbar spine pain. SAMPLE history unremarkable. Core temp 36c by tympanic thermometer.

Treatment provided: O2 at 15l/min (SAO2 100%), Cervical Collar, The patient was cannulated by me with a 16g Safelon cannula in the antecubital vein flushed to keep open.  Patient packaged good lung down in modified recovery position (WEMS guidelines) even though no obvious lung injury -  in a formed vacuum mattress and casualty bag

Rescue: The patient was evacuated immediately after packaging by SAR helicopter which arrived 2 hours into rescue.

Outcome: I accompanied patient to local DGH for handover where he continued to improve.  No fractures or life threats found.  Admitted for observation for 2 days while obvious concussion resolved adequately for release.  Patient 6 months on still has memory problems which are slowly resolving. Post traumatic psychological injury regarding “trusting himself” not yet resolved.

Patient 3. 

Narrative:  29/12/05  a Lady of 57 years running down mountain path to a bridge in the dark goes over the side into a deep gorge 15mins walk from main A82 road. Husband phones 999 via mobile immediately and local police collect me and other team colleagues called out via radio net

Scene :  Patient found below 60 ft drop face down in water with bubbles from mouth.  Other rescuers arrive and we pull her onto large slimy water worn boulders at side.

Initial assessment:  Airway,“C” spine control and attempted jaw thrust.  Breathing absent

Treatment provided: Initial BVM unsuccessful as head jammed among large rocks with no flat ground around.  Vocal cords not visible via laryngoscope so I elected to intubate using a 37f Combitube Airway.  Successful esophageal intubation visible by chest rise and good breath sounds. Ventilations by colleague via BVM and catheter mount.  Patient had been in cold winter water for 35 mins. and no signs of circulation.  Defib attached and slow sinus rhythm with ectopics observed.  Patient  core 32c but not accurate as water in ear which affects the tympanic thermometer.  Rapid body check revealed no obvious sings of external bleeding but history suggested internal injury and bleeds.  Packaged with spinal precautions and  attached to defib in casualty bag. Rope raise to path and stretcher to awaiting road ambulance. En route to road patient goes into VF and one shock results in RSC. 10 mins later goes into VF again and 3 shocks as per UK Resuscitation guidelines for special circumstances delivered as patient trauma vs. hypothermia victim.  CPR and delivery to road ambulance with no further shocks.

Rescue: The patient was evacuated immediately as “load and go”  - as far as is possible in a technical rescue situation

Outcome: Patient blue lighted to local DGH where pronounced life extinct due to traumatic injuries.

I hope that the above actual case histories show some of the range of professional practice regarding my work for the Police as medical officer to Glencoe Mountain Rescue.

David Gunn

Wednesday, 18 January 2006

Avalanches, Hypothermia, Cojones and a Ramble

My area of interest is avalanche, although we already knows that avalanche survival is best looked at from an education and prevention as well as effective self rescue perspective. Asphyxia is the killer, with hypothermia temperature drop being too long and too slow to have the same metabolic protection you get getting dunked fast in freezing water due to how good modern clothing is in retaining heat. To survive the victim needs to cool rapidly for a protective effect in slowing the metabolic demand for oxygen, and snow itself is also an insulator. That does not mean prolonged burial victims cannot survive (Burnett survived 23 hours, and victims at NR event 18 hours) but it does make the effects of hypoxia more devastating as cooling is too slow to have much of a protective effect. 

Victims who may have expired from hypoxia may paradoxically feel warm to the rescuers touch under clothing as the good clothing retains some warmth. In hospital potassium levels are the best survival indicator and the ICAR guideline sets them quite high as there is theoretically no bottom line temperature or top line level of potassium where survival is not possible. The reality is however that raised potassium means often means a dead victim as cells leach out potassium and die.

If you dig them out fast then you might save them. Avoiding getting taken is the better option so education is key. The standard ICAR survival graph shows a better chance of survival if the victim is recovered in less than 15 minutes. 

Avalanche victims are also trauma victims and I would hate to see the hauling out of victims with poor handling by SAR crews and no other rescuers present. I left MR because I witnessed such an event and took the folk involved to task.  Good careful handling of avalanche victims is vital and was one of the main pillars we built the BASP EMT course on, and which it continues to promote. It's nice to see that what we started some 20 years ago as "casualty packaging" is now the norm in Scottish "Cas Care" so we in BASP got a few things right - and were first!  

Aberdeen, Dundee and Glasgow have ECMO which has been shown to be better than currently used extra corporeal rewarming. This then raises the question of the old adage "getting the right patient to the right hospital in the right time". With  SAR Helo capability this then raises the possibility of direct transfer of a severe hypothermia victim to a trauma or re warming centre? Maybe after triage at a local hospital or on scene? 

We also have http://www.emrs.scot.nhs.uk/ who will bring intensive care to the patient. 

Survival from profound hypothermia is better in the young and those who cool rapidly specially in extremely cold fresh water see Anna Elisabeth Johansson Bågenholm as an example. Another paradox from rapid cooling immersion in very cold water may be water in the lungs enhancing the rapid core cooling and not decreasing survival as used to be thought and possibly increasing survival as the core cools rapidly. Scottish examples of survival include a little girl in the ski area at Cairngorm who a friend (RAF MRT) resuscitated. 

When it comes to decisions, folk including rescuers can be more worried about buck passing and watching their arses than making command decisions on what's best for the victim and telling folk how its going to be.  Be a storng the patient advocate and get them to the best place.

Its still fecking cold even with a dry suit!

On the subject of cojones, balls, testicles or whatever as an analogy for courage and making decisions.  Every winter a plethora of outdoor centres, guides and instructors take to the Scottish hills with "clients", "students" or whatever educational label can be attached to define a teacher/pupil relationship in the mountains.

In times of avalanche risk which is frequantly at "considerable" then with local knowledge and attention to the SAIS forecast then some safe venues for climbing or general mountaineering can be arrived at. The average weekender isn't daft and watches where these professionaly led groups go, and get a free ride on someone else's knowledge and decision making process's, which  by and large is better than theirs (you would hope) as they have qualification and experience. However they will not have gone through the processing of information a professional has.

When the risk gets into the "localised" (minefield) or bands of the brown/red cake on the avalanche forecast wagon wheel of death, then approaching corries and climbing venues, or picking routes of descent becomes much more thought provoking and life threatening. 

There is a commercial imperative to give a paying "client" value for money among the organised groups with clients. That clients are safer under instruction is I think true.  But when macro decisions of route choice become micro decisions on the ground in high risk conditions the lay hill going public are not perceptive enough (IMHO) to see the minute adjustments in route choice made by a guide or instructor, nor the process by which decisions are made dynamically as the journey unfolds. All it takes is a shortcut across a gully apron to where a guide might be roping up and they the followers might enter the white room.

So what am I getting at. I guess that there are some days when the risks as so high that the commercial imperative should be put aside.  It sets a bad example during high risk periods that in all conditions safe routes can be found.  There are enough dead guides and instructors to show that this is the case.  If they can get taken then what about Joe public who follows in their path. The public perception is that if there are professional groups in locations it must be safe for them too. 

Tales From the Debris Pile - Again!

Skier triggered avalanche on a popular off piste run with extensive crown wall.
West aspect of Glencoe Mountain

I wouldn't say I am risk averse, but this weekend when faced with crossing an open slope on ski's above the Cam Glen Gulch I bottled it. It felt so dodgy and with that gaping below me after having done a stability test and seen the results I thought it a turn too far. It made me feel like a chicken shit though. On my first MTB XC race back in December I ko'd myself on a practice lap and didn't remember the the first lap until my bruises hurt, and on the second race of the season I tore the labrum of my femoral head clambering over windblown tree's with the red mist of battle  I didn't feel a thing and finished quite well up the field. My total of fractures is quite impressive and most folk I road race with will tell you I will mix it up in the pack.  All good excuses for being a chickenshit! This last two months has been quite reflective though with my disc prolapse, as at one point I thought maybe I couldn't ski again. I looked back at all the friends who I have lost to the mountains. As Tom Patey once said "never underestimate the importance of staying alive". A maxim he didn't do too well with himself having abseiled of a plain gate krab that Hamish had discarded as the gate was fecked. All good excuses for me backing off, but there you are.

137 landing on.  The debris had turned 90 deg right and traveled along the valley floor into the gulch.
Even with an airbag above such a massive terrain trap was no go for me!

Avalanches torque and squeeze and I guess I have seen too much and having been on the wrong end I am twitchy. My winter business of avalanche safety gear is not about making money as I am sure many will attest to as I sell at rock bottom prices. Prevention is a key component as is learning lessons and sharing thoughts and information. The prevention side didn't work this weekend sadly, with the loss of someone else who I new (but not well).  The causes and circumstances are too close to home and tragic and the loss is grievously felt among the folk I help in the ski patrol and their friends.   I will put some general pictures up in the manner of which I have done before and hope that we all continue to celebrate those who live life at full tilt going to meet their maker with the perfect carving turn on the fantastic snow we have this spring, while also making sure the candle of those who live life to the full burns for longer if we can learn from it.

50cm  Avalanche JENGA

I feel a bit like an old sage at times issuing warnings of avalanches and sometimes feel like some old sage in an alpine valley warning that over the next ridge there are demons, or if you trip trap over the rickety bridge the Troll will get you. Maybe I am Billy Goat Grough!

Snow pit site Sunday with the sad recovery of the victim in the background

Avalanche & Hypothermia Resuscitation. Part 2

The Past ..........

The Future ...............

ECMO

"If the airway of a patient who was buried more than 35 minutes is free, the physician should not give up hope, even in the absence of vital signs," (Dr. Brugger said) "Especially if the cardiac arrest occurs during the rescue procedure or transport, that has been frequently reported, they should be treated optimistically and transported under continuous cardiopulmonary resuscitation to a centre for extracorporeal rewarming"

That statement highlighted above is not new.  Even 12 + years ago at the excellent "Freezing to Death" seminar hosted by Cairngorm MRT and Glenmore Lodge this was discussed. This seminar came about in particular because of a terrible tragedy involving a family with children on the plateau in bad weather in the summer, as well as few bad winters for avalanche accidents.  Conclusions at that time were that Glasgow could supply the necessary equipment for re-warming but the time taken to get it into action was hours. Only Aberdeen could get things up and running in a timely manner and had the most up to date equipment. North sea disasters and oil money made this a reality from necessity. Within Ski Rescue at that time we had Prof Page and  Mr (now Prof) James Ferguson from ARI as our medical advisers. Both were key players in treating those from Piper Alpha. I was there at the time representing GMRT along with Dr Ian MacLaren from Ski Patrol.

At the seminar there was a kind of West/East split with medical professionals in the West taking the view that trauma was also a major factor and overflying would jeopardise lives that could be saved from early interventions. Trauma was the priority with more conservative re-warming such as "Bear Huggers" and lavage.  For hypothermia II and III this is fine even though it is little more than boiling the kettle and putting a duvet over the patient with a hair dryer under it. But, if your a trauma victim or in old fashioned terms mild to moderately hypothermic then this will save your life.

Bair Hugger (Giant Hair Dryer - It Works Though!)

However.  If the victim is an immersion or avalanche victim without life threatening trauma and has hypothermia III or IV then the above statement from Dr Brugger becomes very important as Aberdeen is the only place to go, and controversially someone has to make that decision.  Watching the BBC news reporting of the terrible avalanche tragedy in the Chalamain Gap I thought it bold and entirely appropriate seeing the victims being taken into Aberdeen. Whether that decision could have been made on the West I don't know.  

With a contract SAR helicopter service  more hypothermia IV victims without life threatening trauma could/should be taken to Aberdeen as it's the only definitive center for re warming in Scotland with ECMO and a team that can be up and running fast.  How this will work if at all from the West of the country I don't know.  It's extra flying time for sure, but only by going for it and starting case studies will it ever be known if extra lives are saved.  Perhaps another seminar to nail down these issues is long overdue.  My own take is that we Scotland have enough cold victims to formally declare that like Alpine nations we have our own definitive re-warming centre and an integrated mountain/ski rescue and ambulance service working with SAR helo assets to make it work.  

Conclusion: This was all discussed in "Freezing to Death" all those years ago so it's not new.  Flying logistics, weather and injuries might make this transfer to a specialist centre a very rare occurrence indeed, but if it's ever going to happen then with all this change to single services then maybe it's time for folk to sit around the table and chew the fat over it. Another seminar?

CPR during transport to hospital Auto Pulse