Technical Rescue Interface: High and Low Angle Rescue

R. Bryan Simon

INTRODUCTION

High and low angle rescue in the wilderness is much the same as high and low angle rescue in traditional EMS jurisdictions. The specific differences are the type of terrain negotiated, associated environmental factors, and the distances involved in accessing this terrain and eventual evacuation of the patient. The inherent difficulties associated with these factors add greater complexity to the rescue environment. Members of high and low angle rescue teams must be comfortable in exposed situations, have the technical and medical skill sets to work in extreme conditions, and be focused on their own and their patient’s safety.

Definition

Interest in outdoor and wilderness sports continues to increase, with 48.4% of all Americans participating in some form of outdoor activity in 2014.¹ Millions of these participants identified hiking, trail running, mountain biking, hunting, climbing, and canyoneering as their sport of choice. All of these activities bring outdoor users into close proximity to high angle terrain and none more so than climbing, caving, and canyoneering.

According to the Outdoor Foundation, a not-for-profit organization dedicated to the increase in outdoor participation by Americans, sport climbing increased in popularity by 3.5% and traditional climbing and mountaineering increased by 16.0% since 2011. Combined, this accounts for over seven million participants in 2014 alone.¹^,² Some of these climbers will have unfortunate accidents while enjoying the outdoors. Realistic training with an emphasis on safety, medical and technical skills, and the application of this knowledge in a resource-limited wilderness environment is the key to successful rescue, care, and transport of these individuals.

Rescues in traditional EMS high angle terrain are generally associated with human-made structures such as buildings, water towers, silos, power line structures, and radio/phone towers above ground, and vertical tunnel complexes such as sewer, water, and power structures underground. High angle wilderness terrain is defined as any environment where geographic challenges reduce or alter the availability of medical resources and that require rescuers to utilize a rope rescue system where the rescuer and patient are primarily supported by this system. Most commonly this terrain includes cliff lines, canyons, mountains, and vertical caving.

Low angle wilderness terrain has the same medical limitations in care and transport as high angle, and requires rescuers to utilize some aspects of the rope rescue system to assist in the recovery of an injured person. This terrain is most often characterized as mildly sloping land, hillsides, and steep trails leading to or surrounding high angle terrain.

Standards for training and equipment within a high and low angle rescue environment can be found in the National Fire and Protection Association’s (NFPA) documents 1006, 1670, and 1983 (Figure 25.1). NFPA 1006, Standard for Technical Rescuer Professional Qualifications, NFPA 1670, Standard on Operations and Training for Technical Search and Rescue, and NFPA 1983, Standard on Life Safety Rope and Equipment for Emergency Services define and regulate the conduct of operations and types of equipment used in high and low angle terrain.³^,⁴^,⁵ The Mountain Rescue Association (MRA), formed in 1959, is the oldest mountain search and rescue (SAR) association within the United States. MRA teams are spread across the country and this organization has been instrumental in promoting SAR techniques. The International Commission for Alpine Rescue (IKAR) is a global association of mountain rescue specialists and has developed recommendations across a broad range of
high angle rescue topics. These three organizations and the techniques they promote serve as the doctrinal foundation of technical high angle rescue today.

FIGURE 25.1. Photo of NFPA Standards 1670 and 1983. Courtesy of R. Bryan Simon.

Scope of Discussion

The focus of this chapter will be the technical and medical aspects of care within high and low angle wilderness terrain. This includes the specific characteristics and hazards of the operating environment, the makeup and technical skill sets required of rescuers, and the common civilian user groups and their skill levels.

Technical rescue discussions related to mountaineering rescue, including non-snow or glaciated terrain, is discussed in depth within Chapters 30 and 31. Caving rescue is presented within Chapter 29. The fundamentals of medical care within high angle rescue described within the context of this chapter are much the same as the terrains discussed in those chapters as well. Concentration on terrain associated with cliff lines and canyons is the focus of the following discussion.

A particular emphasis will also be made to communication within this operating environment. This aspect of rescue is important whether in traditional or wilderness EMS (WEMS), but can be more difficult due to the vertical nature of a high angle environment, as well as the difference in terminology between recreational rock climbers and canyoneers, and professional rescuers. This chapter will examine the differences between each group to bridge what can be the most difficult aspect of operating in high angle terrain.

PREVALENCE

Accidents in vertical terrain occur across the United States every year. High angle rescue teams are often activated in order to locate, access, stabilize, and transport injured persons from the wilderness environment to definite care. There are multiple environmental factors that must be considered during rescue; teams train their members to identify and mitigate these elements in order to safely conduct rescue operations.

Care Environment

Safety

As with other wilderness environments, high angle terrain presents substantial risks to rescuers. Care must be maintained and an accurate scene assessment should be conducted and include risk assessment and hazard identification. This assessment should be ever-evolving as the rescue scenario develops. Particular attention should be placed on changing weather conditions. Safety is the primary concern of all rescuers and not just the assigned safety officer, team leaders, or the incident commander. Safety priorities for team members should be: person, team, patient. All members of a WEMS technical rescue team must take precautions when working in this environment.

Terrain

The chief environmental hazard in high and low angle terrain is the height and makeup of the cliff or canyon where a rescue is taking place. The rock composition of these cliffs and rock walls can vary from solid walls of granite to a crumbly mix of dirt and pebbles. Knowing and understanding the geologic basics of an area forms a helpful foundation for high angle risk assessment. Operations often include a combination of high and low angle terrain and rescuers must be prepared to transition between both types (Figure 25.2). Rock and ice fall does occur during rope rescues and is one of the most common dangers to patients and rescuers. The freeze-thaw cycle at the end of winter and heavy precipitation are nature-related causes for rockfall. Rescuers or other climbers can also inadvertently dislodge rocks from above. Data collected by the American Alpine Club (AAC) since 1951 and included in their yearly book, Accidents in North American Mountaineering (ANAM), showed that 13.4% of all reported accidents were due to falling rock, ice, or objects. This danger is a very real one for outdoor adventurers as well as rescuers and the use of helmets is recommended.⁶ An additional hazard
with rockfall includes damage to rescue gear, particularly ropes. Redundancy of systems assists to prevent catastrophic system failure that may occur due to rockfall.

FIGURE 25.2. Transitioning from high to low angle terrain takes organization and practice. Courtesy of Karsten Delap.

An additional terrain concern for rescues in canyoneering is the proximity of water to the operation. The added complexity of working on rock that is slick from water must be addressed and additional caution should be maintained. In addition, the risk of hypothermia increases both for patient and rescuer when in running water.

Weather

Weather complicates delivery of care in any wilderness environment and cliffs and canyons are no exception. Intense heat or cold, rain or snow, and windchill can create adverse conditions for patients and rescuers and teams must be prepared for these occurrences. Additionally, altitude, lightning, and avalanches should be considered depending upon the season and geographic location of the rescue. These concerns are discussed in detail within Chapters 15, 18, and 31, respectively.

Temperature

The effects that air temperature can have on rescuers and patients necessitate careful planning and preparation. Specifically, extremes in heat and cold must be addressed. It is easy for rescue team members to overlook the effect of even modestly cool weather on a patient while working. Members are hot from exertion and can forget that the patient is often immobile and perhaps not dressed for the conditions. It is much easier to prevent hypothermia and hyperthermia than to treat these conditions. Temperature considerations should be addressed along with other environmental hazards soon after the patient is secured and stabilized within a high angle environment.

Precipitation

Much like air temperature, precipitation can have immediate negative effects on normothermia of a patient. In conjunction with temperature and windchill, precipitation can quickly drop a patient’s body temperature to dangerous levels. Protection from the elements is a priority for care within the wilderness environment.

Wind

Windchill and its effect on rescuers and patients are an important consideration. Protection against hypothermia must be initiated as soon as possible when high winds are present during rescue. There are special wind patterns that occur in the mountains that should be considered by rescuers in high angle terrain.

Gap winds, or channeled winds, are caused by restrictive terrain that can increase wind speeds substantially. This creates a number of difficulties related to rope rescue, specifically communication between rescuers and patients, rescuers and other team members, challenges to rope work, and the prevention of the use of helicopter rescue assets. Terrain blocking is defined as the effect on wind by a land feature that disrupts wind direction and speed. Usually occurring on the leeward side of mountains, it can disrupt communication and alter evacuation plans. Day and night wind shifts should be considered by rescuers for the warming and cooling effect that they respectively can induce on patients and rescuers. The final and most important factor in winds for high angle rescue is an understanding of wind speed versus force of the wind. The force of wind increases exponentially as wind speed increases. For example, a 40 mph wind is four times as strong as a 20 mph wind rather than just double. As with all weather, an accurate and ongoing assessment of current and future conditions must be included in risk assessments for the safety of rescuers and patients.⁷^,⁸^,⁹

Environmental Teams

As with other technical teams, high and low angle rescue teams and team members are categorized into three levels of expertise. These levels, as designated by the NFPA 1006, are divided into the awareness, operations, and technician levels.³ The categories can also describe levels of technical expertise of teams. The
NFPA document does not make recommendations regarding the medical training levels of team members.

Awareness Level

At this level, an individual can recognize high and low angle rescue situations, resources needed, and related hazards. This is the minimum capability of organizations that respond to SAR operations and individuals at this level act as support for these incidents. Members of a team at the awareness level can competently conduct site control and scene management at the location of a high angle rescue.

Operations Level

At the operational level, individuals can recognize technical rescue situations and its related hazards, respond using appropriate equipment, and apply knowledge of the needed systems in conjunction with the technician level responders. Examples of technical competencies at this level of training include selecting anchor points and constructing anchor systems, selecting and conducting belays, performing self-rescue if necessary, ascending and descending a fixed line, and loading, securing, and negotiating a patient using a litter.

Technician Level

The technician is capable of identification of high angle rescue situations and its associated hazards, has the knowledge of the equipment and systems to select, employ, and apply advanced techniques to coordinate, perform, and can supervise high angle SAR incidents. Within the technician level, there are two designations: Technical Rope Rescue Technician I and II. These individuals can conduct all techniques associated with rope rescue and often develop policies and procedures for the team, provide leadership, and serve as instructors for their organization.

Additional details related to the specific technical skills of high angle rescue teams and their members at each level can be found in Chapter 5 of NFPA 1670.⁴ This chapter provides a systematic framework from which high angle rescue teams can develop training, insure competencies of members, and provide high and low angle rescue within their area of operations.

In addition to the technical competency levels, members of high angle rescue teams must also have some level of medical training. While many teams are composed of “rescue first” and “medical first” team members, the best teams are composed of members who are strong in both technical rescue skills and medical skills. Requiring a certain level of medical training as each level of technical training is acquired results in teams that can better respond to, and care for, patients who need assistance in high angle terrain. Without this redundancy of training for all members, care for injured persons could be delayed and critical assessments and interventions missed until providers with additional medical training arrive at the scene or until the patient is transferred from the high angle environment. In our opinion, a minimum medical standard for official teams responding to high and low angle rescues is Emergency Medical Responder (EMR), ideally with a wilderness modular addition.

EPIDEMIOLOGY OF INJURIES IN A HIGH ANGLE ENVIRONMENT

Identification and knowledge of the most common injuries sustained in a high angle environment is the foundation for all technical and medical rescue discussion. In the past three decades, researchers have completed multiple studies examining the epidemiology of injuries for all types of climbing. The majority of these studies identified chronic or overuse injuries of the upper extremities to be the most common injuries sustained by rock climbers of all types, but these injuries are rarely categorized as emergencies and generally do not require the response of SAR assets. Acute injuries, most often from falls while climbing or from falling objects such as rock and ice, are the primary reason for need of rescue. Other causes contributing to the activation of high angle rescue teams include inability to successfully negotiate high angle terrain by the climbing party and environmental exposure.

Climbing injury research began in the 1960s with a study conducted by Ferris of accident data gathered from the AAC.¹⁰ Other early research, such as the studies by Addiss et al.,¹¹ and by Schussman et al.,¹² drew data from National Park Service (NPS) reports and from SAR agencies and detailed acute injuries related to falls (75% and 92%) being more common than overuse injuries. Other studies, drawing data from emergency departments (EDs), found the same trends.¹³^,¹⁴^,¹⁵ A large study with data collected between 1990 and 2007 found a 63% increase in the number of climbing patients seen in EDs during this period.¹³ This study found that climbing falls were the most common cause of injury (77.5%) and the most common injuries to be: fractures (29.0%), sprains and strains (28.6%), lacerations (17.1%), and soft tissue injuries such as contusions (16.9%).¹³ The most common anatomic location of these injuries was the lower extremities, and this trend is exemplified within the greater body of literature related to acute injury.¹³

Studies that gathered data from SAR agencies, the NPS, and EDs across the United States routinely found that acute injuries were the most common type for rock climbers. Later studies, utilizing data obtained by online, on-site, or postal questionnaires, showed the opposite. These studies found overuse or chronic injuries to be the most common type suffered by climbers and the underrepresentation within earlier studies is understandable due to the lack of acute injury that required immediate care.¹⁶ Traumatic injuries from climbing falls often require the activation of high angle rescue teams, transport to
an ED, and along with environmental related effects, are the primary concern of this chapter.¹⁷

Currently, there is an underreporting of climbing accidents within the United States. The AAC attempts to gather as much data as possible for inclusion in their yearly book, Accidents in North American Mountaineering (ANAM), renamed Accidents in North American Climbing (ANAC) in 2016. ANAC is the most comprehensive source of climbing-related accident data and relies on SAR teams, the NPS, state park officials, and individuals involved in accidents to voluntarily submit details of climbing accidents and injuries (Figure 25.3). All high angle rescue teams are encouraged to submit reports to the AAC for inclusion. Submissions to ANAC are helpful to the climbing community to learn from and help prevent future accidents and are useful to high angle rescue teams in the identification of past incidences in an operational region. Accurate injury data are also extremely beneficial to current researchers as every case adds to the growing body of knowledge regarding accidents and resulting injuries. Additionally, the accounts produce outstanding and realistic vignettes that teams can use to develop training scenarios.

Other high angle environments include vertical caving and canyoneering. In comparison to current climbing literature, there are far fewer instances of research regarding injuries sustained within these environments. Hazards in caves and canyons are similar to that of rock climbing and research has shown that injuries are similar in type and location. A large study of caving accidents from 1980 to 2008 found that caver falls was the most common cause of traumatic injury (74%) and caver fatalities (30%) with the lower extremities being the most common anatomic area of injury (29%), followed by the upper extremities (21%) and the head (15%).¹⁸ Many rescues in this environment are not related to injuries but instead are due to the inability of participants to exit the cave they are exploring. The National Speleological Society publishes American Caving Accidents on a yearly basis with a mission to pass on hard gained experience to others. As with ANAC, this publication tracks all reported accidents within the caving community and gives some insight into the type of accidents and resulting injuries that occur in caves (Figure 25.4).¹⁹ These descriptions also make a great basis for realistic training scenarios. Further information on caving rescue is contained in Chapter 29.

FIGURE 25.3. Reported climbing accidents in the United States (1951-2014). Data from MacDonald D, ed. Accidents in North American Mountaineering. Golden, CO: The American Alpine Club; 2015.

There is even less published information regarding injuries requiring rescue for canyoneering. A study published in 2007 related the injury patterns and first aid training from a small sample size utilizing a web-based survey.²⁰ This study identified environmental exposure (hyperthermia and hypothermia) as being the top reason for major injuries with orthopedic injuries (generally to the lower extremity) as the next most common. Of all 38 respondents, only two needed outside assistance and
both were due to lower extremity fractures.²⁰ Hypothermia is a particular risk to canyoneers due to the close proximity of running water that has the ability to cause rapid heat loss even when wearing a neoprene wetsuit.

FIGURE 25.4. Reported caving accidents in the United States (1986-2015). Data from National Speleological Society. American Caving Accidents. 2016. https://caves.org/pub/aca/. Accessed July 6, 2017.

As detailed in all three areas prominent for high angle rescues, the most common reasons identified in the literature for activation of assistance include traumatic falls and environmental exposure. The most common injury type and site includes fractures of the lower extremity. These issues will be discussed in detail within this chapter.

PATIENTS IN THE VERTICAL ENVIRONMENT

Having gained an understanding of the common injuries, illnesses, and other causes that result in the need for high angle rescue and medical care in the wilderness, it is also crucial to understand the background, knowledge, and capabilities of the user groups who may find themselves as patients in high and low angle terrain. Recreational climbers, cavers, and canyoneers use much of the same equipment as rope rescue teams though there are some differences, and younger or inexperienced climbers may be unaware of some of the equipment used by rescue personnel. Climbers may have never heard or seen a figure 8 descender, brake bar racks, or an ascender. On the opposite end of the spectrum, there are many very experienced climbers who can assist in their own or others’ evacuation.

There are few recent studies that describe in detail the demographic data of climbers, though some basic information can be gleaned from the data collected in climbing medicine and injury studies over the last two decades. The mean age of climbers participating in these studies was 30 years with a range of means among the 10 studies being from 27 to 35.2 years of age.¹⁵^,²¹^,²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹ The mean gender breakdown in these studies that reported this metric was 79.6% male and 20.4% female.¹⁵^,²¹^,²²^,²³^,²⁴^,²⁵^,²⁷^,²⁸^,³⁰ The data are similar in both categories to an Outdoor Foundation study conducted in 2005 that found the mean age of climbers to be 28 years of age with the gender breakdown of 73% male and 27% female. Additionally, this study found that 93% of climbers fell within the age range of 16 to 44.³¹ While none of these studies delineated the mean age and other demographic data of injured climbers, it is appropriate to generalize that the demographical data of injured climbers would be similar.

Based upon the epidemiological data discussed earlier and the demographic data mentioned above, the most likely patient encountered by a high angle rescue team would be a person within the 16 to 44 age range with a roughly 75% probability of the patient being male. This climber most likely was injured in a fall and has likely suffered trauma to the lower extremity. So what about the experience level of this injured climber?
According to data gathered in reports to the AAC since 1951, accidents occur to climbers throughout the range of experience.⁶ Understanding the patient population and the most common types of injuries that cause activation of a rescue team is the first step in planning and preparation for rescue and care of these persons (Table 25.1).

Table 25.1 Accidents by Experience Level (1951-2014) AAC Accidents in North American Mountaineering

Experience Level of Injured Climber	Accident (%)
Experienced (>3 years)	28
Moderate Experience (1-3 years)	21
Little/No Experience (0-1 year)	22
Unknown Experience Level	29
Adapted from MacDonald D, ed. Accidents in North American Mountaineering. Golden, CO: The American Alpine Club; 2015.

PLANNING AND PREPARATION

Planning and preparation for high and low angle SAR accidents are key components to successfully care for injured patients. Careful conduct of both results in safe, efficient rescues, improved patient care, better contingency planning and reaction, and confident rescue personnel. Planning involves team leadership along with the EMS medical director and others. Preparation involves acting on the components agreed upon in the planning phase and includes working with the local community, local outdoor groups, conduct of training, and maintenance of individual and team skills.

The planning portion entails identification of areas with high angle accident risk within operational zones and the training of personnel to meet the needs of a particular area. Identification of regions that contain high angle terrain is the first step in building contingency plans for potential accidents. Team members can survey areas and identify access points and trails to the cliff tops and base, identify locations that are conducive to raises and lowers of patients, and identify potential landing zones or evacuation points. Environmental hazards should be assessed and plans developed to mitigate these hazards. Training can then be developed and conducted at these sites creating realistic scenarios that may mimic actual future rescues (Figure 25.5). All training should replicate as true of conditions as possible without jeopardizing safety. All personal protective equipment (PPE) should be worn during training exercises. Leadership should always be mindful of training for the worst possible scenarios to insure team skills are adequate to meet these criteria.

The planning phase is continuous in nature to maintain the technical and medical skills of the team and its members. These skill sets must match the technical environment of the area. Understanding the technical environment allows for training that is focused on skills that will be employed regularly. Additionally, knowing the patient and common injuries of the region is helpful to direct medical training toward treatment of common injuries. Identification of past incidents and associated injuries (epidemiology of the region) can help focus medical training refreshers toward likely injuries in future incidents. While it is important to stay proficient in all skills, both technical and medical, it makes little sense to focus training on situations that you rarely encounter such as multi-pitch rescues in a single pitch environment or litter raises where there is no cliff top access.

FIGURE 25.5. Realistic training in the operational environment best prepares teams for emergency response. (Courtesy of Seth C. Hawkins.)

Preparation for incidents involves three aspects of training: technical, medical, and physical. All three are of equal importance and are required of each team member to assure a successful rescue operation. Rescue personnel who are confident in their technical and medical skills are more composed in emergency situations, work fluidly with each other during these incidents, have a better focus on safety, and can respond to unexpected situations in a calm manner. This results in better patient care and a safer environment for rescuer and patient.

The physical aspect of training is of equal importance. Physically fit team members can respond to the physical stressors of a situation more adequately. As anyone who has worked a litter on the side of a cliff or was part of a litter team during a multiple mile journey across difficult terrain can attest, a focus on routine fitness pays huge dividends for the rescuer, and most importantly, the patient in a rescue situation.

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