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
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
, 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
These descriptions also make a great basis for realistic training scenarios. Further information on caving rescue is contained in Chapter 29
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
Experienced (>3 years)
Moderate Experience (1-3 years)
Little/No Experience (0-1 year)
Unknown Experience Level
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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