In the absence of randomized controlled trials to support our interventions and conventions in vertical rescue, as well as medicine, where do we turn in order to inform best practices? Often what we end up with are consensus guidelines; while not subject to proper experimental design, they are nonetheless “peer reviewed” to a degree. A good example that I found recently to carry considerable weight is the joint position statement from ACEP, EMRA, CORD, SAEM, and AAEM
recognizing “the growing consensus regarding the efficacy of facial coverings…” While no one single study has yet definitively informed our practice of mask wearing, there exists nonetheless sufficient data and history to convince multiple societies of medical professionals that application of face coverings is essential in suppressing the rate of COVID-19 transmission. While no such consensus statement has of yet been released regarding rescue practices in the high angle environment, we can nonetheless look around and see that professionals in our field are in agreement to a large degree.
Richard Delaney, a universally respected rope rescue instructor recently posted the following to an online rope rescue group: “Mid-face litter-scoop = complete waste of time.” For those a unfamiliar, the practice
referenced is when a litter is lowered from the top of the cliff with at least one rescuer in attendance, and a maneuver is completed to bring the litter smoothly up under an injured patient and situate them in it with minimal motion. It has been taught and practiced extensively in the rope rescue world, often with the scenario involving a patient with an “MOI for a spinal injury” and thus a need to get the patient immobilized with as little movement as possible. Richard is right, and the readers’ comments bore out that consensus supports greater training emphasis on rescuer personal rope skills, which would allow a single rescuer to quickly assess and intervene with an injured subject. The acknowledgement of such from the rescue world, coupled with recent developments in the medical world, make the time right for a paradigm shift in high angle rescue, discussed below.
The goal in EMS is generally considered to be to provide temporizing interventions as appropriate to the environment, and to convey the patient to a location more suitable for the appropriate level of care. In the context of a patient in a cliff environment, the goal of WEMS would be to provide just those interventions which are likely to lead to a better outcome (protection from the elements, avoidance or correction of suspension syndrome, and hemorrhage control) and then to convey to patient ideally to the ground or if not available, an area suitable for more significant intervention. All of this can be efficiently completed by a single technically proficient rescuer in a fraction of the time it would take to involve a basket or other complex system.
In recent issues of the Wilderness & Environmental Medicine (WEM)
journal, articles highly pertinent to the argument above have been published. One is the groundbreaking WMS Clinical Practice Guidelines for Spinal Cord Protection
, and the others are concurrent pieces
on suspension syndrome. Together these make a compelling argument for prompt rescuer intervention to aid the injured or suspended climber, and a general lack of need for complex systems such as litter scoops for initial extrication. The clinical practice guidelines make several statements that should inform the care of patients in a vertical environment: 1) “We recommend that there is no medical role for rigid backboards or rigid cervical collars in a wilderness environment”; 2) Cadaver studies and Newtonian physics suggests that physiological movement is unlikely to result in further [Spinal Cord Injury] SCI in a patient with possible or actual vertebral or SCI. How does this translate into actual rescue practices? Consider the following scenario: we have a lead climber who has taken a long fall, impacted a ledge and then continued past the ledge and is suspended by his or her rope. Their belayer is unable to reach him or her in order to assist. Teams around the world have practiced something similar to this scenario, and for decades, under the enduring paradigm of strict adherence to spinal immobilization and vague anecdotes of the slightest movement causing a dramatic exacerbation of a spinal injury, might have very carefully approached this patient from above, sending an attendant or two with a litter down the face to scoop this patient up in order to immediately immobilize him or her in a rigid litter. What the new guidelines remind us is that physiologic movement of the patient’s spine, either voluntary, or through careful rescuer manipulation during extrication, is exceedingly unlikely to be to our patient’s detriment, and in fact that prompt extrication and treatment is likely to enhance our ability to mitigate other threats which are of greater concern in the scenario.
One of these concerns, which has been greatly elucidated recently in the WEM journal is that of suspension syndrome (see links above). For many years, treatment of suspension syndrome, previously also referred to as suspension trauma and harness hang syndrome, was driven by dogma unsubstantiated by science. Rescuers were instructed to be careful not to lay a previously suspended patient down too quickly, in order to avoid cardiac collapse based on anecdotes from the early 1900s. We now know due to diligent primary research
performed by Rauch et al. that suspension syndrome likely results from venous pooling in the lower extremities due to lack of movement. This pathology can be quickly and easily reversed either by movement of the legs by the patient, or by placing the patient in a horizontal position. While the incidence of suspension syndrome contributing to morbidity and mortality in incidents in the vertical environment is not known, it is likely that long periods of suspension without intervention lead to negative outcomes.
Putting it all together, while we don’t have any double-blind placebo controlled trials to evaluate the efficacy of mid-face litter scoops, we can now point to a chorus of suggestive data that supports the idea that rescues in the vertical environment should be conducted promptly and efficiently, and that initial interventions likely require no more than a single rescuer to improve the situation. Getting patients out of a suspended position, and into a location where greater care can be provided should be the goal, and should not be overly hampered by concerns around worsening a known or suspected spinal injury. Evidence-based medicine has driven our recent paradigm shifts regarding spinal injury and suspension syndrome. While scientific studies evaluating specific rescue techniques are and will likely continue to be hard to conduct or to analyze, we can nonetheless look towards the kind of consensus generated when we evaluate data from multiple related fields to inform our practices.