Hey folks, happy Saturday! It’s the weekend, you made it! If you’re off today, now is a great time to settle down with a nice cup of coffee (or tea, if that’s more your flavor) and think a bit about wilderness medicine.
Earlier this week (on Thursday instead of Wednesday, but who’s counting…) I posted a video of a pretty incredible rappel accident. I invited your input, as if you were the person responding to this incident. What would you do? What sorts of injuries do you anticipate? How are you going to manage this situation? If you haven’t had a chance to watch the video yet, you can head on over and check it out!
The subject of this video is an individual named Eric Shriever, from Lehi, Utah (that’s him in the picture). Shriever and his friend were going to spend some time canyoneering in Zion National Park in 2009. On this initial drop into the canyon, Shriever lost control during the rappel and apparently fell approximately 100 feet to the bottom of the canyon. His friend caught almost the whole thing on tape.
He and his buddy were getting ready for a 300-foot rappel in the park this past Tuesday. Schriever went first while his buddy videotaped him. Right away, though, both knew something was wrong. “I lose control and stop midway because there was a knot in the rope. So that saved me from falling even further,” Schriever explained while watching the video.
But once he untied the knot, he couldn’t stop. Schriever fell more than 100 feet, banging hard against the rock wall before dropping to the rocks below. “I remember the first hit on my head, and it wasn’t until I watched the video that I realized I hit at least two more times on the way down,” he said.
In that split second, all Schriever could think of was his wife, two daughters and his unborn son, who is due in just two weeks. “I was like, ‘I’m going to lose them, or they’re going to lose me,'” he said.
So, what types of injuries should we suspect? I think the best answer I got comes from Dr. Justin Hensley (@EBMgoneWILD; thanks you sir!) who succinctly summed all our worst fears up; “CHI. Pelvis. Spine. Long bones. All sorts of badness. That’s a long fall.” I agree whole-heartedly. So, here’s what I’ll be looking for (and note, this is not an all-inclusive list):
- Is he alive? Quite frankly the first thing I want to know in this situation is, do I have a patient to care for, or will I be organizing a body recovery? That’s pretty self-explanatory. Additionally, if the patient is dead, do we do CPR or not?
- Head, neck, spine injuries: One of the first things I noticed (and I had to re-watch the sequence once or twice just to confirm) is that the patient is not wearing a helmet as he goes over the edge. Now, let’s take a moment and recognize that in a 100 foot fall a helmet isn’t going to do all that much good. But at the same time, in the story above the patient reports striking his head at least once against the canyon wall. Helmets are designed to help in those situations. After that, the patient strikes the wall maybe two more times as he falls 100 feet to the canyon floor. Even though he’s not free-falling (it looks like his fall is slowed slightly by the rope running through his belay device), that’s plenty high to do any sort of damage to the spinal column/cord that we can think of.
- AMS and airway, breathing, and massive hemorrhage: As I thought about the scope of the patient’s injuries, these considerations were almost an afterthought. I almost considered not including them, arguing to myself that it was almost a “duh” thing. I would be very worried about the potential for altered mental status causing the patient to be unable to control his airway. Since we’re dealing lots of force, I’d also consider the possibility of lung and chest injuries, like flail chest or pneumothorax. I’d also be concerned about the potential for external or internal hemorrhage, either from a compound fracture, other soft-tissue damage, damage to a large, blood-rich organ (liver, spleen, etc.), or pelvic/femoral involvement (more about this in a moment).
- Pelvis and femurs: How did he land? Where his feet under him, or did he pancake flat on his back? If his feet were anywhere under him when he came down, I’m very worried about the prospect of pelvic and femoral fractures. My concern here is largely about the prospect of massive internal hemorrhage; this is especially worrying when we consider that pelvic fracture and hemorrhage is a major cause of traumatic cardiac arrest.
- Rope burns: An instinctive self-rescue impulse while rappelling is to grab the rope with the free hand. This can cause rope burns and soft tissue damage to the hand or arm. I’d suspect anything from superficial burns, all the way to potential degloving injuries.
So, how will we treat Mr. Shriever? Here are my thoughts.
- Make contact, early and often: You can actually hear the guy taking the video attempting this at the end of the video. “Hey, are you ok?” I want to get an idea of what I’m dealing with before I drop down to him. If he’s talking to me, that gives me information about his level of consciousness and his airway. I want that information as soon as possible. After I make contact, I’m going to keep checking in frequently (I might even go with continuously) as I prepare to rappel.
- Get help on the way: I want to consider getting help moving before I drop down to the patient. I may not have contact once I drop into the canyon.
- Protect yourself: Most of you are sighing right now, because we’re so used to saying “scene safe, BSI” as we walk into scenarios. That’s important, but that’s not what I’m talking about right now. Imagine for a moment what you’re going to be feeling right after you witness that fall. You’re going to experience a massive sympathetic nervous response (a “fight or flight”) brought on by a surge of epinephrine in your system. This reaction will drop you back to the level of your instinct, and impair your higher brain functions. Now, think of this. While in this condition, you’re going to have to rig yourself for a 300′ rappel to a possibly critically injured patient. Force yourself to slow down. Force yourself to focus on small, individual tasks, one at a time. Check your gear, then check it again. Then check it a third time. Don’t be a second patient.
- Take control of the head and spine: When I arrive at the patient, I want to take control of that head and spine. It’s just me at this point, so I’m not going to just stop there and hold the head. I’m probably going to use a couple of backpacks, or some nice big rocks to remind the patient not to move his head. I can always do a focused spine assessment later and clear the spine. Now is not the time for that.
- Airway, breathing, and massive hemorrhage: I’m going to have the patient open his mouth so I can look for blood, broken or missing teeth, or secretions. If the patient is unconscious, I’ll open the airway for him, check, and place an adjunct like an OPA if I have one. We need to clear any obstructions we see. I’m also a big advocate for directly visualizing the patient’s chest; lift the shirt, look at the skin, and look for holes that shouldn’t be there. I’d auscultate the chest, listing for lung sounds and pneumothorax clues. If I see arterial bleeding on my arrival at the patient, I’ll probably manage that first; military medicine is teaching us that stopping arterial hemorrhage first is better than managing airway first. Otherwise, I can manage whatever other bleeding I see after I clear the airway and chest.
- Pelvis and Femurs: I’ve been awakened (mostly through the talks of the late Dr. John Hinds, “The Flying Doctor,” about high-speed motorcycle trauma) to the incredible danger of pelvic fractures. If I suspect pelvic fracture in this patient, I’m going to place an improvised pelvic binder on the patient. I can do this with a jacket, a blanket, or whatever longish piece of material I have at hand. If I see evidence of mid-shaft femur fracture, I’ll draw traction on that extremity, and secure it inline. If you want to learn more about how to improvise a pelvic binder, I’ve included two brief videos; one is from NOLS Wilderness Medicine, and is from a wilderness medicine perspective. The second is more of a front-country approach.
- Burns, injuries to hands, and other assorted musculoskeletal injuries: After I treat the big stuff, I’m going to move into the little stuff. Rope injuries to hands can be nasty, but they generally are fairly easy treat; I’ll stop bleeding, consider cleaning/irrigation (if you’re way out in the backcountry; if you’re more front country, consider leaving that for the hospital). I can splint any other fractures with material at hand.
- Evacuation: My evac decision will be patient condition dependent. If the patient isn’t badly hurt, or has minor/moderate injuries, and can pass a focused spinal assessment, it may be faster to clear the spine and walk with the patient to definitive care. On the other hand, this patient could easily become a carry out or a fly out, depending on condition.
So, what actually happened to Eric Shriever? He survived. In fact, he survived with very minor injuries. The stories I read report that he sustained minor burns to his hands from attempting to grab the rope on his way down. If you’d like, you can see a story about this incident here.
However, all he suffered were burned fingers from grabbing the rope to try and slow his fall. “I hit the bottom and I realized I was OK; completely humbled, because I realized that I had just experienced a miracle, because there’s no way I should be here today,” he said.
But here he is, back in Lehi, still not completely sure why. “It just was not my time to be called home,” he said.
Schriever admits he didn’t use the right gear and rope and he didn’t wrap his safety line enough times around his rope. He’s hoping this video will show others who love to rappel that no matter how experienced you are, you should always be 100 percent careful — you usually don’t get two chances.
Before I sign off on this, I’m going to talk briefly about some thoughts I have about why this accident took place. Now, I’ll freely admit that I don’t know all the details of this situation. I also recognize that some would say, “well, who are you to talk about what happened here?” Fair enough. I wear a bunch of hats; most of my time is spent as a paramedic, or as a paramedic/EMT instructor. But I’m also a rock climber, and have been since I was six. I’m a climbing guide, and I’ve worked for various camp and outdoor education programs, as well as a private guide service. So, here are some thoughts.
- I have some concerns about the attitude towards safety these guys show in the video. I don’t think they fully appreciate the environment they’re in. Right from the beginning, you hear the guy carrying the camera say “Let’s see how close to the edge I can get without falling.” That’s a red flag for me. If they’re that casual at the edge, I suspect that attitude will continue with other things. I’m suspicious of their anchor. I didn’t get a good look at it (the video is jumpy, and spends a very short amount of time looking at it), but it didn’t look good to me.
- Wear a helmet. We can debate all day the merits of helmets, and I recognize that helmets are not a magic bullet that will prevent all injuries and harm. But what helmets do really well is keep moderate injuries from becoming fatal. In this case, given that Mr. Schriever struck his head on the wall during his fall, he’s lucky he didn’t end up with a head injury.
- Don’t rappel with a backpack on. As I watch Mr. Schriever rappel, I notice he’s wearing a large pack, and has to keep reaching up with his left hand to grab the rope; what he’s doing is holding his body forward against the weight of the pack. Large packs should be suspended below the climber on a tether, as their weight may unbalance the climber.
- Use the right equipment, AND know the limits of your experience. The news story reports that Mr. Schriever is experienced at rappelling. However, near the end of the news story on this incident, there is a telling statement: “Schriever admits he didn’t use the right gear and rope and he didn’t wrap his safety line enough times around his rope.” As I look at the picture of Schriever with his gear (you can see it at the top of this post), the rope he’s holding looks very thin, and doesn’t look like climbing rope. In fact, to me it looks a lot like marine line, like what you might get at a hardware store. A forum I read said he was using 8 mm line (I can’t independently verify this), which is very thin rope. I use 8 mm line for prussik loops and cordelettes, not for main ropes. My point is, while it definitely sounds like Mr. Schriever has rappelled in the past, it seems he may have drastically overestimated his abilities and attempted something he did not have the gear or experience to do. Once he hit a snag (the knot in the rope), he was unable to regain control due to lack of experience and improper equipment.
- Obtain qualified instruction: Hire a guide. Hire a guide. Hire a guide. Do some training. Learn the good ways of doing things, so you don’t end up in this situation.
Thanks for playing this week, folks! We’ll have another one up next week!