Several days ago, I posted a YouTube video showing a rescue in Banff National Park. I asked y’all to tell me what you thought. If you haven’t seen the video, you can check out the post here.
Basic synopsis: 50-ish climber is struck on the head by falling rock and falls sixty feet. He lost consciousness for 3-5 minutes, and sustained cracking to his helmet, a head injury, and an injury to his left ankle. He’s still altered, and is AO x 1 with GCS of 14.
So, here’s my thoughts:
- Any force which causes that kind of damage to a climbing helmet should be taken very seriously. They make climbing helmets out of very tough stuff, so a cracked helmet should make you expect a head injury. It should be noted that we don’t really know whether the crack in the helmet was caused by the falling rock, or by the subsequent 60 foot fall.
- As an aside, if this doesn’t convince you of how important helmets are, you’re missing something. If he hadn’t been wearing that helmet, my guess is that whatever caused that damage (the fall or rock fall) would have been fatal, and this would have been a very different incident. This demonstrates beautifully that while helmets will not shield you from all injury, they can make otherwise fatal incidents survivable.
- By whatever metric you want to use, a 60 foot fall is bad news, and for several reasons. A fall of that distance builds up enough force to shear internal organs and cause major internal bleeding, not to mention the trauma that can be caused by bouncing off rock on the way down. Assuming the patient in this video weighed around 160 lbs (75ish kg), and fell the full 60 feet (around 25 meters), he would have fallen for 2.26 seconds, and be traveling 22.14 m/second (79.7 km/h or about 50 mph) at the end of the fall. So, essentially, jumping out of a car traveling at 50 mph. Not good.
- Loss of consciousness (LOC) especially lasting more than a few seconds is an ominous sign. Continued disorientation after regaining consciousness is also bad. The skull is very good at protecting the brain; when your bell gets rung well enough to cause your brain to stop functioning for a few moments, let alone a few minutes, it means you’ve been exposed to a lot of force. See the point above for clarification.
- The ankle injury suggests he landed on his feet. While this is definitely better than landing on his head, it can still cause his body to be subjected to pretty significant compression forces down the length of his body and back. This can cause compression fractures in the spine, long bone fractures in the legs, and cause pressure/crush damage to internal organs.
Based on the mechanism of injury (MOI), what types of injuries (in addition to the obvious ones) should you be looking for? We’ll start at the head and work down.
- Just to be clear, obvious injuries I see include a bleeding laceration or contusion to the head, as well as a closed injury to the left ankle.
- Brain injury: He’ll probably at least have a concussion, with some short-term memory loss, but he may have sustained more serious injuries such as bleeding inside the skull, a skull fracture, diffuse axonal injuries, etc. Signs of more serious head injuries include decreasing level of consciousness, “weird” respiratory patterns, combativeness, and uneven or non-reactive pupils.
- Neck/Spine injuries: Landing on your feet at 50 mph can cause compression fractures in the vertebrae, as well as whiplash-like injuries in the neck. It can also cause the cartilaginous discs which pad between vertebrae to burst or herniate, which in addition to being REALLY painful can put pressure on the spinal cord. Signs of neck and spine injuries include deformity and point tenderness on palpation of the neck and back, lots of pain, tingling or loss of sensation in the extremities or other anatomy, and paralysis.
- Internal Bleeding: When a car comes to a sudden stop against a tree, the people inside continue moving forward until they are stopped by something, usually the inside of the car. In the same way, when a human body falls and then stops suddenly, the internal organs continue moving until they run into something, or until they’re brought to a stop by the blood vessels and connective tissue that tethers them in place. If the force is too severe, blood vessels can be torn by this force or internal organs can be lacerated, causing internal bleeding. Signs of internal bleeding include symptoms of shock which cannot be explained by external bleeding, decreasing mental status, decreasing blood pressure, and increasing heart rate (as the body tries to compensate). Other signs of blood pooling under the skin include bruising, the abdomen becoming firm, distended, or rigid, and the abdomen becoming “hot” to the touch.
- Lower extremity and pelvis injuries: Force is transmitted up from the point of impact, and can cause injuries to the long bones of the leg as well as to the joints. It’s important to look past the obvious, lower leg injury, and remember that damage could have been done higher up as well. It’s especially important to not miss a femur fracture, as the femoral artery runs right next door. Signs of extremity injuries include pain on movement or at rest, deformity, decreased range of motion, and tingling or altered sensation in the extremities. Keep an eye out for one leg that is shorter than the other, or a leg that is rotated to the outside; these finding suggest a femur fracture. A leg that is rotated inwards can suggest a hip-joint fracture or dislocation.
So, how should we proceed? What are some considerations we should have as far as treatment goes? Let me also say that I don’t have any problem with the care shown in the video. We see them place a cervical collar on the patient, and also splint his ankle with a vacuum splint. What else can we do?
- Maintain patient and provider safety: This seems like a no-brainer, but sometimes stressful situations cause us to forget obvious things. At a complicated belay station, it can be very easy to think you’re tethered to the anchor when you’re actually not. Add distractions like injured patients or complicated treatments, and it can become very easy to not finish knots, lock carabiners, etc.
- Maintain airway: Patients with head injuries tend to vomit. Additionally, some people deal with airsickness better than others. Finally, the patient is altered with potential for deterioration, which means he may get to the point where he can’t manage his own airway. There isn’t really anything we could do to secure the patient’s airway at the moment, but we should have a plan to tip him and clear the airway if he vomits during the hoist operation.
- Head/Neck/Spine: If you listen very closely, you can hear the medic report that the patient wasn’t put on a long spine board because there wasn’t room to do it at the belay stance. As a hypothetical, let’s pretend there was room to put the patient on a backboard; would you do it? Spinal immobilization is a hotly debated topic, and I don’t like back-boarding people more than I have to. In this case, you wouldn’t be wrong to. The patient sustained significant MOI, and is altered. For the most part, even the most generous spinal clearance protocols wouldn’t allow you to clear this patient’s spine.
Hopefully this is helpful; we will make this a weekly pattern. If you have a suggestion for a scenario or situation you would like discussed, contact me!