WMS Conference Student Ambassador, Derek DeBruin, interviews one of this Summer’s featured speakers, Dr. Hermann Brugger.
Dr. Hermann Brugger
A native of South Tyrol in Italy, Hermann Brugger, MD is a mountain traveler with summits and ski descents in Europe, Asia, and the Americas. He began practicing medicine in 1983, both as a general practitioner and emergency physician for the Mountain Rescue Organization in the Dolomites of South Tyrol—where he has participated in thousands of rescue operations in the Dolomites. He has served on various boards over the course of his career, including the Austrian and Italian Societies of Mountain Medicine, the Medical Commission of the Union Internationale des Associations d’Alpinisme (UIAA MEDCOM), the International Commission for Alpine Rescue Mountain Emergency Medicine Committee (ICAR MEDCOM), and the International Society of Mountain Medicine (ISMM).
Dr. Brugger has held appointments at the University of Padova and Innsbruck Medical University. He has authored or co-authored hundreds of publications, spanning topics such as hypothermia, avalanche accidents, and high-altitude physiology, as well as the 2021 textbook Mountain Emergency Medicine. In 2009, he founded the Institute of Mountain Emergency Medicine at Eurac Research in Bolzano, Italy.
This body of work has earned him various awards and accolades throughout his career, commensurate with his contributions to the field. He is the opening speaker for the upcoming 8th World Congress on Mountain & Wilderness Medicine. We corresponded via email for this interview.
Derek DeBruin (DD): Given your lengthy career, I’m sure you’ve seen many changes to how both medical care and technical rescue are conducted in the mountains. What do you consider to be one of the most significant advances that has been made in the last few decades? Conversely, do you feel there are things that have been lost over time--skills, techniques, or ideas that are worth revisiting or reinforcing?
Hermann Brugger (HB): Before the turn of the millennium, many mountain rescue operations in the Alps were conducted on the ground, leading to extremely long operating times and high risks for the rescue teams. The "golden hour", considered the critical target time for rescuing severely injured casualties, was rarely achieved. The introduction of helicopter rescue and a dense network of air bases significantly shortened response times. Today, the evacuation times for casualties from mountains and remote areas and their outcomes are comparable to those in urban settings. Another milestone was the adoption of long-line rescue techniques, enabling helicopter crews to evacuate casualties from vertical walls. Consequently, ground rescue operations are now performed only when weather conditions prevent air rescue. However, I acknowledge that these optimal conditions are not generalizable to other mountainous regions beyond the Alps, where resources may be limited and distances greater.
On the other hand, emergency helicopters are staffed with physicians and paramedics who primarily work in hospitals. They may not always be familiar with patient management in out-of-hospital settings, particularly in hostile environments. As a result, certain technical skills, such as rope techniques, navigating difficult terrain, and mountaineering, may be lacking.
DD: You've authored or co-authored a large amount of research. Would you like to highlight any specific research, whether your own or by others, that you feel is important yet underappreciated or overlooked?
HB: Good question. I'm thinking of frostbite, an injury as old as humanity itself. Despite advancements, we still haven't found a proven method to treat frozen limbs effectively and prevent eventual amputation. We employ complex, multi-functional treatments, but the results are less convincing than we would like. Basic research into the tissue changes that occur during freezing and thawing is still lacking, which may be why we can't identify the optimal treatment. While I understand the ethical concerns surrounding animal testing, it seems to be the only way forward to advance our understanding of the underlying pathophysiology and improve treatment options.
DD: Often, the lessons that stick with us are hard earned. What's a lesson you've learned in your career—perhaps one that resulted from a misjudgment or misstep—that would be important for others to learn from?
HB: My life and professional career has been full of ups and downs, including near-accidents while rock climbing, a fall into a crevasse, and disappointing moments in my work as an emergency physician. When I was unable to save a life that should have been saved, the negative experience often lingered for weeks or even months. I believe it's not possible to transfer one's own experiences to others directly. Only through education and practice can missteps and frustration be prevented. However, negative experiences or even trauma can also strengthen our resilience and make us more resistant. Misjudgments and missteps are inevitable, but they provide valuable opportunities for improvement.
DD: Could you share some thoughts on your approach to risk in the mountains, particular during a rescue/evacuation where competing hazards must be managed for patient care?
HB: Balancing one’s own risk against the potential benefit to the patient in an outdoor rescue is one of the most difficult tasks for a rescue team. This challenge is present in scenarios ranging from road accidents involving hazardous substances to accidents in mountainous or wilderness areas. Many mountain rescuers worldwide have lost their lives in the line of duty, often succumbing to avalanches as they approached the accident site.
In time-critical situations, the interval between the accident and the arrival of the rescue team significantly influences the risk-benefit assessment. The longer the delay, the lower the victim's chances of survival, which must be factored into the decision-making process. For example, if an avalanche victim has been buried for hours, I would not risk my life. However, if the time since the accident is short and the survival rate is high, I would be willing to take greater risks.
Additionally, it is crucial to develop an instinct for recognizing dangerous situations when approaching an accident site. This awareness includes being alert to potential rockfall, the possibility of a second avalanche, or unsafe terrain, if you are not secured.
DD: Emotions can run high in a medical emergency and psychological care can be just as important as physical care. What have you learned about managing and working with the people involved in care, whether the patients, bystanders, or a team of rescuers/providers?
HB: A severe accident involving multiple people is extremely stressful for conscious casualties, their less injured or uninjured companions, and bystanders. These situations can quickly become chaotic and distracting for medics and rescuers. If the chief of the rescue team and the emergency physician or paramedic show any signs of insecurity, it can be devastating to the rescue operation. The rescuer or physician who remains calm under the worst conditions is the most effective. Moreover, if a rescue doctor can calm an agitated patient, it significantly improves the situation. This allows medical treatment to proceed without haste or panic and helps ease the patient's pain.
DD: Finally, you're the opening speaker for the upcoming WMS/ISMM conference, where you’re expected to showcase the Eurac terraXcube. Could you highlight some of the key learnings thus far from practicing the delivery of care in this high-fidelity mountain environment simulator?
HB: The lab terraXcube helps us refine research methodologies in high-altitude physiology and emergency medicine. While chamber studies may lack the adventure and excitement of field studies in wilderness and high mountains, they offer the advantage of studying specific parameters under controlled conditions. Walking through the Khumbu Valley towards Everest Base Camp, witnessing Ama Dablam, and sleeping in lodges with locals and Sherpas is an irreplaceable experience. However, field studies are often compromised by numerous confounders, such as uncontrolled eating and drinking, variations in physical exertion, and ambient temperatures. This may explain why studies on altitude illnesses yield variable results regarding incidence rates, symptom severity, and physiological changes.
In the terraXcube, we can minimize these confounders, improve the precision of measurements, conduct more invasive medical exams and tests, and perform research in a safe environment for both participants and researchers. The terraXcube allows us to simulate altitudes equivalent to Everest, adjust temperatures between -40°C and +60°C, and create wind, rain, and snowfall.