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Rescue operations in the Swiss Alps in 1990 and 1991
Journal of Wilderness Medicine 4,363-373 (1993)
ORIGINAL ARTICLE
Rescue operations in the Swiss Alps in 1990 and 1991 BRUNO DURRER, MD Arztpraxis, CH-3822 Lauterbrunnen, Switzerland
Every year in the Swiss Alps, there are approximately 3000 accidents. Over 90% of victims (1990/ 1991: n = 3500-3800) are rescued by helicopter. In approximately 20% of accidents, a helicopter winch mission is necessary (1990/1991: n = 600-700 rescued persons). Swiss Air Rescue (REGA) is responsible for two thirds of all rescues in the off-road areas (1990/1991: n = 1958/2321 persons). All REGA rescue missions are registered according to medical (National advisory committee for aeronautics (NACA)) and topographical index. Over two thirds of all winch operations take place in accessible, and one third in difficult accessible sites of accidents. Of these, 2% are extremely difficult rescues, e.g. upon the north faces of the Eiger or the Matterhorn. Over 75% of all winch-rescued persons were rated NACA III-VII, where medical assistance is considered to be necessary at the site of accident. The assignment of experienced emergency doctors, trained in alpine techniques, improves the quality of preclinical treatment even in difficult sites, although clinical demands are not always completely practicable in the field and the possibilities of treatment are often limited by adverse climate and/or topography. An efficient medical-assisted helicopter rescue service has an important impact on the survival chances following alpine sport accidents. Key words: mounain rescue; helicopter winch rescue; ambulance helicopter
History In the early age of alpinism, accidents in the alps most likely ended fatally. At that time, rescue operations always took several days of hard physical work. In the early 1950s many ground rescues were replaced by the utilization of fixed-wing aircraft. For a short period of time, rescuers were even dropped by parachute into remote areas. In the mid 1950s, helicopters brought a new dimension into mountain rescue. In the 1960s, the powerful turbo-jet helicopters made winch rescue missions possible, even at high altitudes and under adverse meteorological conditions. For rescue operations, we mainly use the French helicopters 'Alouette III' and 'Lama', the latter for more difficult rescues. Rescue organizations in Switzerland Switzerland, a very small and highly populated country (size: 41000 km 2, population: 6.5 million) has many helicopter companies. Eighteen helicopter rescue bases allow them to reach any site of an accident within 15 min flight after the alarm has been raised. There are three helicopter rescue organizations. REGA (Swiss Air Rescue) is a private, nonprofit professional rescue company and AIR GLACIERS (AIRGLS) and Air 0953-9859 © 1993 Chapman & Hall
Durrer
364
Zermatt (AIRZMT) are two helicopter companies in the southwest (Valais) which perform rescues in addition to their commercial flying work. REGA runs an alert-station 24 h a day and has a special radio rescue network. REGA helicopters are airborne within 5 min during the day and 20 min at night. 95% of all REGA missions are medical doctor assisted and paramedics are in charge otherwise. Ideally the doctor is an active climber and trained in anesthesiology. The medical equipment carried on board is sufficient to cover all traumatological and internal medicine emergencies. Special equipment for difficult crevasse rescues includes a tripod winch and a compressor for digging a tunnel to victims trapped in ice. Avalanche accidents demand special equipment for search and evacuation. In organized rescues, the helicopter brings the avalanche dog to the site of the accident. The dog still has priority, despite electronic search devices. For ground rescue and avalanche search there is a close collaboration with the rescue specialists of the Swiss Alpine Club. GROUND RESCUES
The ratio between ground and air rescues in the Swiss Alps has not changed within the last ten years. Over 90% are still carried out by air. Of the remainder, 5% are combined ground 1air rescues and 5% are pure ground rescues. Quite often, the helicopter rescue doctor is part of the ground rescue team. AIR RESCUES
In both 1990 and 1991, Switzerland had altogether 7500-8000 patients (pat.) transported by an ambulance helicopter [1,2,3]. 5500 of these were rescued directly from the site of the accident (1°helicopter rescues - see Fig. 1). There are about 3800 helicopter rescue missions in the mountains, 1200 missions for road accidents and 2300 hospital transfer flights. REGA is responsible for about two thirds of these missions. For 1990/91, exact data were only available from REGA. All 3500
~ Tot.1°:5651
3000
- - - - - - - - - - - - - 1 ~ Tot.2°:2303 1------1 2500
2000 N: 7954 PAT. 1500
1000
500
o REGA: 5598 PAT.
AIRGLS: 1543 PAT.
Fig. 1. Helicopter rescues in Switzerland, 1991.
AIRZMT: 813 PAT.
365
Rescue operations in the Swiss Alps 2500 ------------------i
2000
11III 1990: 4872 Pat. ~ 1991: 5598 Pat.
1500
1000
500
o A
B
C
D
E
F
G
TOPOGRAPHICAL INDEX
Topographical: A Hospital; B Doctor's practice; C Road; D Ski slopes; E Easy accessible (alpine hut, climbing < *UIAA 3,); F Difficult accessible (climbing *UIAA 3+4, crevasse); G Extremely difficult accessible (climbing> *UIAA 5, narrow crevasse). *Climbing difficulties as defined by UIAA (The International Union of Alpinist Associations).
Fig. 2. Topographical index for REGA helicopter rescues in 1990 and 1991 (1°+2°).
1800 1600
II
1400
~ 1991:5598 Pat.
1990:4872 Pat.
1200 1000 800 600 400 200 0
0
II
III
IV
V
VI
VII
MEDICAL INDEX (NACA)
Medical index (NACA): 0 Evacuation, not injured; I No acute therapy (doctor) necessary; II Ambulant therapy necessary; III Stationary hospitalisation necessary; IV Vital danger possible; V Acute vital danger; VI Restitution of vital functions; VII Death (with or without resuscitation).
Fig. 3. Medical index (NACA) for REGA helicopter rescues in 1990 and 1991 (1°+2}
Durrer
366
3000 2500 2000 1500 1000 500
o 1991: 3482 PAT. Landing
1990: 2944 PAT.
Winch Hovering
Fig. 4. REGA evacuation index for 1990 and 1991.
persons rescued were registered according to a topographical and medical index (modified medical index according to National Advisory Committee for Aeronatics: NACA) (see Figs 2 and 3). In 1990 and 1991, two thirds of all rescue missions were topographically rated D-G; 88% of all patients were rated NACA III-VII and 57% were rated NACA IV-VII, where medical (anesthesiological) assistance is considered to be compulsory. In over 80% of all primary missions, the helicopter was able to land at the site of the accident. Nearly 15% of all rescued persons were lifted aboard with the helicopter winch cable (25-70 m) and 5% of all patients were lifted into the helicopter while the helicopter hovered above the site of the accident (see Fig. 4). According to our experience, the hovering procedure is rather dangerous so we try to keep this percentage as low as possible. Winch rescues in Switzerland In 1990 and 1991, about 600-700 persons (in 1983 and 1984 n = 450 per year) were rescued by helicopter winch in Switzerland (REGA 1990 n = 413, 1991 n = 409) [1,4]. Over 75% of all REGA winch missions were rated NACA III-VII (see Fig. 5). Two thirds of all patients rescued by winch were evacuated from accessible sites and the other third from difficult accident sites. Two per cent were extremely difficult rescues, e.g. high angle face rescues from the Eiger or Matterhorn north face. Today, almost every spot in these north faces can be reached by extension of the helicopter winch cable. Practical aspects of helicopter winch rescue The practical consequences for treatment and evacuation depend upon the rescue risks and the degree of injury. There is no significant difference between the data of 1991 and
367
Rescue operations in the Swiss Alps 200 180 f-------1 ~
160
1-------1 140
Tot.1990:413
0
Tot.1991:409
V
VI
120 100 80 60 40 20
o o
II
III
IV
VII
MEDICAL INDEX (NACA)
Fig. 5. REGA winch rescues for 1990 and 1991 (medical index).
1990. For a detailed view, we looked at the helicopter winch rescues in relation to the medical and topographical indexes (Fig. 7). Almost 75% of all NACA 0 (not injured) were rescued from a difficult-to-access area (Topo-Index F+G). For the rescue of hikers stranded in these areas, we use special rescue belts or rescue jackets. In extremely difficult areas, the climbers are evacuated by winch on their own climbing harness without problems. In some cases the uninjured 250
1--------1
200
III 0
Tot.1990:413 Tot.1991:409
150
100
50
o C
D
E
F
TOPOGRAPHICAL INDEX
Fig. 6. REGA winch rescues for 1990 and 1991 (topographical index).
G
368
Durrer 70%
60%
50%
,.: :. 40%
.,. C'l
Z
30%
20%
10%
0% 0
E
F
G
NACA 0 I TOPOGRAPHICAL INDEX
Fig. 7. REGA winch rescues for 1990. Medical index NACA 0 in relation to the topographical index (TOPO).
climbers could hook themselves to the winch cable without rescuer assistance. In the last five years paraglider accidents in the Alps have increased tremendously. Very often, the persons are not injured, but are found in very difficult situations, e.g. on the top of trees or on the cables of cablecars. Case report NACA OITOPO G. Two well equipped and fit young climbers could not continue their ascent of the Eiger north face because of heavy snow fall. After two bivuacs on the 'traverse of the gods' they signaled for help. The next day at 5:30 am a mountain guide was winched from the helicopter down to their belay. Both climbers were
60%
50%
40%
30%
20%
10%
0%
o
E NACA I
F
+ III TOPOGRAPHICAL
Fig. 8. REGA winch rescues for 1990. NACA I+Il/TOPO.
INDEX
G
Rescue operations in the Swiss Alps
369
found healthy and were evacuated on their climbing harness. The whole mission took 20 min [7]. The winch rescue of NACA 1+11 patients (ambulatory cases) usually causes no problems (see Fig. 8). These people can be evacuated directly by their climbing harness or rescue belt, and the rescuer usually does not leave the winch cable. This procedure lowers the risks considerably whenever safe belays are lacking or objective dangers like stone- or icefall threaten the mission. Patients with a dislocated shoulder (NACA II) receive sufficient painkillers prior to the winch evacuation. Often, we relocate the shoulder immediately at the site of the accident and winch the patient afterwards.
Case report NACA II/TOPO F. A 28-year-old woman fell into a crevasse. Fortunately, one of her skis was jammed 30 m below and she hung suspended headdown on the safety strap of the ski. Her partner did not have a radio and had to walk back to raise the alarm. A rescue mountain guide was lowered into the crevasse and after 1.5 h the girl was rescued, without severe injuries but with mild hypothermia. After one day in the hospital, she was dismissed. The whole mission took 60 min involving two helicopters and five mountain guides [7]. Over 50% of all patients rescued by winch suffer an injury rated NACA III+IV (see Fig. 9). In difficult to access areas, the rescue doctor often has the dilemma of deciding whether an immediate evacuation or an immediate treatment at the site of an accident has priority, especially when stone- or icefall threatens a mission. Severe head, brain or spinal injuries demand immediate medical treatment and if the rescue risks allow it, the patients receive full medical treatment at the site of the accident. They are fixated and evacuated either in the horizontal-net or -bag with cervical collar or vacuum mattress, if necessary. In narrow crevasses, the 'KED' fixation device is very useful. In difficult sites (TOPO > F), additional helpers may be necessary for fixation or evacuation in the net or bag. A closer look at the diagnosis of winch-rescued patients shows many injuries of the head and trunk. Proper treatment (volume expansion) and body fixation prior to the 70%
60%
50%
,.:
..'"
...<1:
40%
Z
30%
20%
10%
0% C
D
NACA III
E
+ IV / TOPOGRAPHICAL INDEX
Fig. 9. REGA winch rescues for 1990. NACA III+IV/TOPO.
370
Durrer
winch evacuation is therefore essential. Together with intravenous analgesics, the patients usually receive an antiemetic and sedative medication (neuroleptic). During the winch evacuation, the medic always accompanies the patient. This reduces the psychological stress of the patient considerably. Case report NACA IV/TOPO F. Two professional elite climbers tried to climb the 14 northfaces of the 'Bernese Oberland' in winter within 14 days. At 1:30 am, one of these climbers got into an avalanche and was carried down 400 m. His friend was able to raise the alarm by radio and give all the details about the site of the accident. Fog and snowfall made the first REGA helicopter mission impossible. At about 2:30 am, an AIR GLACIERS pilot, who knew this region very well, was able to reach the site of accident from a different valley. The patient suffered an unstable fracture of the lumbar vertebrae and was evacuated in the horizontal sac. This helicopter winch evacuation was carried out at about 3:00 am during mild snowfall. Due to low visibility, the helicopter could only reach the valley and the patient had to be transported to the hospital by ambulance. The X-rays showed 90% of his spinal canal filled up with bone fragments. He was operated upon and luckily recovered without any neurological damage. Two years later, he climbed the 14 northfaces in winter and a year later he managed to climb Mount Everest in 40 h [7]. Adequate medical treatment of severely injured patients requires sufficient space and additional helpers at the site of the accident. In difficult sites, these patients are generally evacuated first and treated properly later. However, in desperate cases (1.5% of all winch-rescued patients) it can become necessary to intubate a patient prior to evacuation in the net. These rescues demand experienced crews and well trained doctors. Case report NACA V/TOPO G. During the celebrations of the 50th anniversary of the first ascent of the Eiger north face a young climber fell 30 m below the 'Hinterstoisser traverse' at 7 am. Due to high temperature, there was an increased risk of rockfall and the responsible officer planned to start the rescue in the early hours of the next day. The 50% 45% 40% 35%
~ 30% --
"-
~ 25%
Z 20% 15% 10% 5% 0% D
NACA V + VI I TOPOGRAPHICAL INDEX
Fig. 10. REGA winch rescues for 1990. NACA V+VIITOPO.
371
Rescue operations in the Swiss Alps 60%
50%
40%
~ Q. ~ 30%
Z 20%
10%
0%
+-------1-c
D
E
G
NACA VIII TOPOGRAPHICAL INDEX
Fig. 11. REGA winch rescues for 1990. NACA VII/TOPO.
partners of the severely injured climber waited desperately long hours for help. Finally, they rapelled down and were able to reach the entrance of a window of the Jungfrau railway tunnel inside the Eiger north face. Since a helicopter rescue still was considered to be too dangerous, the two partners climbed together with a mountain-guide/doctor back to the site of the accident where the unconscious, polytraumatized and hypothermic patient received first medical treatment. Fortunately, the rockfall at the site of the accident was not as dangerous as first thought and a quick helicopter winch rescue took place at about 7 pm. The patient was intubated and then evacuated to the hospital, where he recovered fully after six weeks in a coma.
Case report NACA VI/TOPO G. A ski alpinist fell 15 m into a crevasse and was buried completely, 1.5 m under the snow. The responsible mountain guide was able to raise the alert by his radio. Fifteen minutes after the alert, two rescue helicopter mountain guides rapelled down and helped to dig out the patient. After 35 min, the patient was found cyanotic without signs of respiration or circulation. The doctor started mouth to nose ventilation in the crevasse while the patient was hanging upside down. After another 5 min oxygen ventilation, spontaneous respiration returned. The epitympanic temperature was 33°C. The patient was evacuated to the hospital and recovered without any cerebral damage within two days. The whole action took 60 mimn. For NACA V and NACA VI results, see Fig. 10. NACA VII rescues. Very often, a helicopter can not properly approach the site of an accident to determine whether the patient is still alive and the doctor has to descend. As soon as the diagnosis of death is made, the evacuation usually causes no problems. The victims are hooked to the winch and evacuated. In some cases of severe hypothermia, the decision of 'who is really dead' is one of the rescue doctors' dilemmas. Taking the core temperature at the site of an accident is additional help for this decision. According to
372
Durrer
our experience, the epitympanic temperature in severe hypothermia with cardiopulmonary arrest does not correspond with the esophageal (core) temperature. For NACA VII results, see Fig. 11. Rescue risks aud difficult helicopter winch rescues For difficult missions (e.g. low visibility, strong winds, night missions, high angle rescues and extension of the winch cable) the rescue risks have to be evaluated in relation to the degree of injury. Due to the risk of rock- or icefall, some rescues can be carried out only during the early morning hours. However, often it can not be determined from the helicopter whether a patient is still alive. Within the last ten years, three ambulance helicopters have been lost during rescue missions. There is considerable danger in the mountains from power cables and transport cables, especially with low visibility. For some difficult high angle rescues, we occasionally operate 'Lama' helicopters, specially equipped with a convex 'bubble' door. Thus, the pilot has direct visual contact to the rescuer underneath. This know-how is derived from the helicopter pilots' experience in 'heli-Iogging' and allows long line (up to 100 m rescues with extraordinary precision [4,5]. Unfortunately, there was a casualty during the rescue of a paraglider due to the downwash of the helicopter. Because of this danger these rescues are carried out usually by ground rescue techniques and only exceptionally by longline extension of the helicopter winch cable. Winch rescues at night (in 1990 REGA rescued 58 persons) demand excellent meteorological conditions and a highly experienced crew. These rescues are only possible if exact information about the site of accident is available. REGA helicopters are equipped with night vision devices and powerful search lights. Future of helicopter rescue in Switzerland For the past ten years, 80% of all REGA flights were doctor assisted and 20% were accompanied by paramedics trained in anesthesiology. For legal reasons, there is the tendency towards 100% doctor assistance. The single engine Alouette III has been in service for over 20 y. For safety reasons a modern twin-engined helicopter is needed. REGA evaluated different types of helicopters in the high Alps. Finally, the Italian Agusta AK 107 was chosen to replace REGA's fleet of Alouette Ills. This should result in safer and more efficient rescue operations in the future. Conclusions Due to the fact that many climbers and paragliders now carry walkie-talkies, the average time lapse between an accident in the mountains and registration of the alert has been reduced considerably. Every spot in Switzerland can be reached within 15 min flight by a rescue helicopter. Consequently, the medics are confronted more often with severely injured patients who would not have survived otherwise [1]. Over 75% of all winch rescued persons were rated NACA III-VII. We consider it essential to have a doctor on board for winch rescues. The doctor has to be physically fit and must be trained in alpine technique as well,
Rescue operations in the Swiss Alps
373
since two thirds of all 1990 and 1991 rescue missions (n = 2944 and 3481) were topographically rated D-G. If the rescue risks allow it and the degree of injury (NACA> III) demands it, we start to treat injured persons, even in difficult accident sites. The assignment of trained air rescue doctors improved the efficiency of first treatment at the site of accident even in difficult and extremely inaccessible mountain areas. Despite the increasing number of people in alpine sports, the casualties during the last years have remained at about 150 deaths per year in the Swiss Alps. An efficient medical assisted helicopter rescue service has an important impact on the survival chances in alpine sport accidents. References 1 2. 3. 4. 5. 6.
Rohrer, W., Klemmer, D., Durrer, 8., Jacomet, H. and Hofliger, C. Swiss Air Rescue Medical Statistics, 1990/1991. Hassler, R., Mosimann, D. and Durrer, B. Swiss Alpine Club reorganized statistics. Schmid, A., Bruchez, G. and Michelet, J. Mountain rescue statistics Valais. Durrer, B. REGA winch rescues 1983, 1984. In: Proceedings of International Aeromedical Evacuation Congress, Zurich, 1985: 108. Durrer, 8. Practical problems of fixation and evacuation in mountain rescue. In: Proceedings of International Congress of Mountain Medicine, Crans Montana, 1991. Bagnoud, B., Durrer, B., Genzelin, R. and Dubas, F. Mountain rescue today. In: Color Atlas of Mountain Medicine, Wolfe Pub\. Ltd, 1991.
ORIGINAL ARTICLE
Rescue operations in the Swiss Alps in 1990 and 1991 BRUNO DURRER, MD Arztpraxis, CH-3822 Lauterbrunnen, Switzerland
Every year in the Swiss Alps, there are approximately 3000 accidents. Over 90% of victims (1990/ 1991: n = 3500-3800) are rescued by helicopter. In approximately 20% of accidents, a helicopter winch mission is necessary (1990/1991: n = 600-700 rescued persons). Swiss Air Rescue (REGA) is responsible for two thirds of all rescues in the off-road areas (1990/1991: n = 1958/2321 persons). All REGA rescue missions are registered according to medical (National advisory committee for aeronautics (NACA)) and topographical index. Over two thirds of all winch operations take place in accessible, and one third in difficult accessible sites of accidents. Of these, 2% are extremely difficult rescues, e.g. upon the north faces of the Eiger or the Matterhorn. Over 75% of all winch-rescued persons were rated NACA III-VII, where medical assistance is considered to be necessary at the site of accident. The assignment of experienced emergency doctors, trained in alpine techniques, improves the quality of preclinical treatment even in difficult sites, although clinical demands are not always completely practicable in the field and the possibilities of treatment are often limited by adverse climate and/or topography. An efficient medical-assisted helicopter rescue service has an important impact on the survival chances following alpine sport accidents. Key words: mounain rescue; helicopter winch rescue; ambulance helicopter
History In the early age of alpinism, accidents in the alps most likely ended fatally. At that time, rescue operations always took several days of hard physical work. In the early 1950s many ground rescues were replaced by the utilization of fixed-wing aircraft. For a short period of time, rescuers were even dropped by parachute into remote areas. In the mid 1950s, helicopters brought a new dimension into mountain rescue. In the 1960s, the powerful turbo-jet helicopters made winch rescue missions possible, even at high altitudes and under adverse meteorological conditions. For rescue operations, we mainly use the French helicopters 'Alouette III' and 'Lama', the latter for more difficult rescues. Rescue organizations in Switzerland Switzerland, a very small and highly populated country (size: 41000 km 2, population: 6.5 million) has many helicopter companies. Eighteen helicopter rescue bases allow them to reach any site of an accident within 15 min flight after the alarm has been raised. There are three helicopter rescue organizations. REGA (Swiss Air Rescue) is a private, nonprofit professional rescue company and AIR GLACIERS (AIRGLS) and Air 0953-9859 © 1993 Chapman & Hall
Durrer
364
Zermatt (AIRZMT) are two helicopter companies in the southwest (Valais) which perform rescues in addition to their commercial flying work. REGA runs an alert-station 24 h a day and has a special radio rescue network. REGA helicopters are airborne within 5 min during the day and 20 min at night. 95% of all REGA missions are medical doctor assisted and paramedics are in charge otherwise. Ideally the doctor is an active climber and trained in anesthesiology. The medical equipment carried on board is sufficient to cover all traumatological and internal medicine emergencies. Special equipment for difficult crevasse rescues includes a tripod winch and a compressor for digging a tunnel to victims trapped in ice. Avalanche accidents demand special equipment for search and evacuation. In organized rescues, the helicopter brings the avalanche dog to the site of the accident. The dog still has priority, despite electronic search devices. For ground rescue and avalanche search there is a close collaboration with the rescue specialists of the Swiss Alpine Club. GROUND RESCUES
The ratio between ground and air rescues in the Swiss Alps has not changed within the last ten years. Over 90% are still carried out by air. Of the remainder, 5% are combined ground 1air rescues and 5% are pure ground rescues. Quite often, the helicopter rescue doctor is part of the ground rescue team. AIR RESCUES
In both 1990 and 1991, Switzerland had altogether 7500-8000 patients (pat.) transported by an ambulance helicopter [1,2,3]. 5500 of these were rescued directly from the site of the accident (1°helicopter rescues - see Fig. 1). There are about 3800 helicopter rescue missions in the mountains, 1200 missions for road accidents and 2300 hospital transfer flights. REGA is responsible for about two thirds of these missions. For 1990/91, exact data were only available from REGA. All 3500
~ Tot.1°:5651
3000
- - - - - - - - - - - - - 1 ~ Tot.2°:2303 1------1 2500
2000 N: 7954 PAT. 1500
1000
500
o REGA: 5598 PAT.
AIRGLS: 1543 PAT.
Fig. 1. Helicopter rescues in Switzerland, 1991.
AIRZMT: 813 PAT.
365
Rescue operations in the Swiss Alps 2500 ------------------i
2000
11III 1990: 4872 Pat. ~ 1991: 5598 Pat.
1500
1000
500
o A
B
C
D
E
F
G
TOPOGRAPHICAL INDEX
Topographical: A Hospital; B Doctor's practice; C Road; D Ski slopes; E Easy accessible (alpine hut, climbing < *UIAA 3,); F Difficult accessible (climbing *UIAA 3+4, crevasse); G Extremely difficult accessible (climbing> *UIAA 5, narrow crevasse). *Climbing difficulties as defined by UIAA (The International Union of Alpinist Associations).
Fig. 2. Topographical index for REGA helicopter rescues in 1990 and 1991 (1°+2°).
1800 1600
II
1400
~ 1991:5598 Pat.
1990:4872 Pat.
1200 1000 800 600 400 200 0
0
II
III
IV
V
VI
VII
MEDICAL INDEX (NACA)
Medical index (NACA): 0 Evacuation, not injured; I No acute therapy (doctor) necessary; II Ambulant therapy necessary; III Stationary hospitalisation necessary; IV Vital danger possible; V Acute vital danger; VI Restitution of vital functions; VII Death (with or without resuscitation).
Fig. 3. Medical index (NACA) for REGA helicopter rescues in 1990 and 1991 (1°+2}
Durrer
366
3000 2500 2000 1500 1000 500
o 1991: 3482 PAT. Landing
1990: 2944 PAT.
Winch Hovering
Fig. 4. REGA evacuation index for 1990 and 1991.
persons rescued were registered according to a topographical and medical index (modified medical index according to National Advisory Committee for Aeronatics: NACA) (see Figs 2 and 3). In 1990 and 1991, two thirds of all rescue missions were topographically rated D-G; 88% of all patients were rated NACA III-VII and 57% were rated NACA IV-VII, where medical (anesthesiological) assistance is considered to be compulsory. In over 80% of all primary missions, the helicopter was able to land at the site of the accident. Nearly 15% of all rescued persons were lifted aboard with the helicopter winch cable (25-70 m) and 5% of all patients were lifted into the helicopter while the helicopter hovered above the site of the accident (see Fig. 4). According to our experience, the hovering procedure is rather dangerous so we try to keep this percentage as low as possible. Winch rescues in Switzerland In 1990 and 1991, about 600-700 persons (in 1983 and 1984 n = 450 per year) were rescued by helicopter winch in Switzerland (REGA 1990 n = 413, 1991 n = 409) [1,4]. Over 75% of all REGA winch missions were rated NACA III-VII (see Fig. 5). Two thirds of all patients rescued by winch were evacuated from accessible sites and the other third from difficult accident sites. Two per cent were extremely difficult rescues, e.g. high angle face rescues from the Eiger or Matterhorn north face. Today, almost every spot in these north faces can be reached by extension of the helicopter winch cable. Practical aspects of helicopter winch rescue The practical consequences for treatment and evacuation depend upon the rescue risks and the degree of injury. There is no significant difference between the data of 1991 and
367
Rescue operations in the Swiss Alps 200 180 f-------1 ~
160
1-------1 140
Tot.1990:413
0
Tot.1991:409
V
VI
120 100 80 60 40 20
o o
II
III
IV
VII
MEDICAL INDEX (NACA)
Fig. 5. REGA winch rescues for 1990 and 1991 (medical index).
1990. For a detailed view, we looked at the helicopter winch rescues in relation to the medical and topographical indexes (Fig. 7). Almost 75% of all NACA 0 (not injured) were rescued from a difficult-to-access area (Topo-Index F+G). For the rescue of hikers stranded in these areas, we use special rescue belts or rescue jackets. In extremely difficult areas, the climbers are evacuated by winch on their own climbing harness without problems. In some cases the uninjured 250
1--------1
200
III 0
Tot.1990:413 Tot.1991:409
150
100
50
o C
D
E
F
TOPOGRAPHICAL INDEX
Fig. 6. REGA winch rescues for 1990 and 1991 (topographical index).
G
368
Durrer 70%
60%
50%
,.: :. 40%
.,. C'l
Z
30%
20%
10%
0% 0
E
F
G
NACA 0 I TOPOGRAPHICAL INDEX
Fig. 7. REGA winch rescues for 1990. Medical index NACA 0 in relation to the topographical index (TOPO).
climbers could hook themselves to the winch cable without rescuer assistance. In the last five years paraglider accidents in the Alps have increased tremendously. Very often, the persons are not injured, but are found in very difficult situations, e.g. on the top of trees or on the cables of cablecars. Case report NACA OITOPO G. Two well equipped and fit young climbers could not continue their ascent of the Eiger north face because of heavy snow fall. After two bivuacs on the 'traverse of the gods' they signaled for help. The next day at 5:30 am a mountain guide was winched from the helicopter down to their belay. Both climbers were
60%
50%
40%
30%
20%
10%
0%
o
E NACA I
F
+ III TOPOGRAPHICAL
Fig. 8. REGA winch rescues for 1990. NACA I+Il/TOPO.
INDEX
G
Rescue operations in the Swiss Alps
369
found healthy and were evacuated on their climbing harness. The whole mission took 20 min [7]. The winch rescue of NACA 1+11 patients (ambulatory cases) usually causes no problems (see Fig. 8). These people can be evacuated directly by their climbing harness or rescue belt, and the rescuer usually does not leave the winch cable. This procedure lowers the risks considerably whenever safe belays are lacking or objective dangers like stone- or icefall threaten the mission. Patients with a dislocated shoulder (NACA II) receive sufficient painkillers prior to the winch evacuation. Often, we relocate the shoulder immediately at the site of the accident and winch the patient afterwards.
Case report NACA II/TOPO F. A 28-year-old woman fell into a crevasse. Fortunately, one of her skis was jammed 30 m below and she hung suspended headdown on the safety strap of the ski. Her partner did not have a radio and had to walk back to raise the alarm. A rescue mountain guide was lowered into the crevasse and after 1.5 h the girl was rescued, without severe injuries but with mild hypothermia. After one day in the hospital, she was dismissed. The whole mission took 60 min involving two helicopters and five mountain guides [7]. Over 50% of all patients rescued by winch suffer an injury rated NACA III+IV (see Fig. 9). In difficult to access areas, the rescue doctor often has the dilemma of deciding whether an immediate evacuation or an immediate treatment at the site of an accident has priority, especially when stone- or icefall threatens a mission. Severe head, brain or spinal injuries demand immediate medical treatment and if the rescue risks allow it, the patients receive full medical treatment at the site of the accident. They are fixated and evacuated either in the horizontal-net or -bag with cervical collar or vacuum mattress, if necessary. In narrow crevasses, the 'KED' fixation device is very useful. In difficult sites (TOPO > F), additional helpers may be necessary for fixation or evacuation in the net or bag. A closer look at the diagnosis of winch-rescued patients shows many injuries of the head and trunk. Proper treatment (volume expansion) and body fixation prior to the 70%
60%
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,.:
..'"
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Fig. 9. REGA winch rescues for 1990. NACA III+IV/TOPO.
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winch evacuation is therefore essential. Together with intravenous analgesics, the patients usually receive an antiemetic and sedative medication (neuroleptic). During the winch evacuation, the medic always accompanies the patient. This reduces the psychological stress of the patient considerably. Case report NACA IV/TOPO F. Two professional elite climbers tried to climb the 14 northfaces of the 'Bernese Oberland' in winter within 14 days. At 1:30 am, one of these climbers got into an avalanche and was carried down 400 m. His friend was able to raise the alarm by radio and give all the details about the site of the accident. Fog and snowfall made the first REGA helicopter mission impossible. At about 2:30 am, an AIR GLACIERS pilot, who knew this region very well, was able to reach the site of accident from a different valley. The patient suffered an unstable fracture of the lumbar vertebrae and was evacuated in the horizontal sac. This helicopter winch evacuation was carried out at about 3:00 am during mild snowfall. Due to low visibility, the helicopter could only reach the valley and the patient had to be transported to the hospital by ambulance. The X-rays showed 90% of his spinal canal filled up with bone fragments. He was operated upon and luckily recovered without any neurological damage. Two years later, he climbed the 14 northfaces in winter and a year later he managed to climb Mount Everest in 40 h [7]. Adequate medical treatment of severely injured patients requires sufficient space and additional helpers at the site of the accident. In difficult sites, these patients are generally evacuated first and treated properly later. However, in desperate cases (1.5% of all winch-rescued patients) it can become necessary to intubate a patient prior to evacuation in the net. These rescues demand experienced crews and well trained doctors. Case report NACA V/TOPO G. During the celebrations of the 50th anniversary of the first ascent of the Eiger north face a young climber fell 30 m below the 'Hinterstoisser traverse' at 7 am. Due to high temperature, there was an increased risk of rockfall and the responsible officer planned to start the rescue in the early hours of the next day. The 50% 45% 40% 35%
~ 30% --
"-
~ 25%
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NACA V + VI I TOPOGRAPHICAL INDEX
Fig. 10. REGA winch rescues for 1990. NACA V+VIITOPO.
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~ Q. ~ 30%
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NACA VIII TOPOGRAPHICAL INDEX
Fig. 11. REGA winch rescues for 1990. NACA VII/TOPO.
partners of the severely injured climber waited desperately long hours for help. Finally, they rapelled down and were able to reach the entrance of a window of the Jungfrau railway tunnel inside the Eiger north face. Since a helicopter rescue still was considered to be too dangerous, the two partners climbed together with a mountain-guide/doctor back to the site of the accident where the unconscious, polytraumatized and hypothermic patient received first medical treatment. Fortunately, the rockfall at the site of the accident was not as dangerous as first thought and a quick helicopter winch rescue took place at about 7 pm. The patient was intubated and then evacuated to the hospital, where he recovered fully after six weeks in a coma.
Case report NACA VI/TOPO G. A ski alpinist fell 15 m into a crevasse and was buried completely, 1.5 m under the snow. The responsible mountain guide was able to raise the alert by his radio. Fifteen minutes after the alert, two rescue helicopter mountain guides rapelled down and helped to dig out the patient. After 35 min, the patient was found cyanotic without signs of respiration or circulation. The doctor started mouth to nose ventilation in the crevasse while the patient was hanging upside down. After another 5 min oxygen ventilation, spontaneous respiration returned. The epitympanic temperature was 33°C. The patient was evacuated to the hospital and recovered without any cerebral damage within two days. The whole action took 60 mimn. For NACA V and NACA VI results, see Fig. 10. NACA VII rescues. Very often, a helicopter can not properly approach the site of an accident to determine whether the patient is still alive and the doctor has to descend. As soon as the diagnosis of death is made, the evacuation usually causes no problems. The victims are hooked to the winch and evacuated. In some cases of severe hypothermia, the decision of 'who is really dead' is one of the rescue doctors' dilemmas. Taking the core temperature at the site of an accident is additional help for this decision. According to
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our experience, the epitympanic temperature in severe hypothermia with cardiopulmonary arrest does not correspond with the esophageal (core) temperature. For NACA VII results, see Fig. 11. Rescue risks aud difficult helicopter winch rescues For difficult missions (e.g. low visibility, strong winds, night missions, high angle rescues and extension of the winch cable) the rescue risks have to be evaluated in relation to the degree of injury. Due to the risk of rock- or icefall, some rescues can be carried out only during the early morning hours. However, often it can not be determined from the helicopter whether a patient is still alive. Within the last ten years, three ambulance helicopters have been lost during rescue missions. There is considerable danger in the mountains from power cables and transport cables, especially with low visibility. For some difficult high angle rescues, we occasionally operate 'Lama' helicopters, specially equipped with a convex 'bubble' door. Thus, the pilot has direct visual contact to the rescuer underneath. This know-how is derived from the helicopter pilots' experience in 'heli-Iogging' and allows long line (up to 100 m rescues with extraordinary precision [4,5]. Unfortunately, there was a casualty during the rescue of a paraglider due to the downwash of the helicopter. Because of this danger these rescues are carried out usually by ground rescue techniques and only exceptionally by longline extension of the helicopter winch cable. Winch rescues at night (in 1990 REGA rescued 58 persons) demand excellent meteorological conditions and a highly experienced crew. These rescues are only possible if exact information about the site of accident is available. REGA helicopters are equipped with night vision devices and powerful search lights. Future of helicopter rescue in Switzerland For the past ten years, 80% of all REGA flights were doctor assisted and 20% were accompanied by paramedics trained in anesthesiology. For legal reasons, there is the tendency towards 100% doctor assistance. The single engine Alouette III has been in service for over 20 y. For safety reasons a modern twin-engined helicopter is needed. REGA evaluated different types of helicopters in the high Alps. Finally, the Italian Agusta AK 107 was chosen to replace REGA's fleet of Alouette Ills. This should result in safer and more efficient rescue operations in the future. Conclusions Due to the fact that many climbers and paragliders now carry walkie-talkies, the average time lapse between an accident in the mountains and registration of the alert has been reduced considerably. Every spot in Switzerland can be reached within 15 min flight by a rescue helicopter. Consequently, the medics are confronted more often with severely injured patients who would not have survived otherwise [1]. Over 75% of all winch rescued persons were rated NACA III-VII. We consider it essential to have a doctor on board for winch rescues. The doctor has to be physically fit and must be trained in alpine technique as well,
Rescue operations in the Swiss Alps
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since two thirds of all 1990 and 1991 rescue missions (n = 2944 and 3481) were topographically rated D-G. If the rescue risks allow it and the degree of injury (NACA> III) demands it, we start to treat injured persons, even in difficult accident sites. The assignment of trained air rescue doctors improved the efficiency of first treatment at the site of accident even in difficult and extremely inaccessible mountain areas. Despite the increasing number of people in alpine sports, the casualties during the last years have remained at about 150 deaths per year in the Swiss Alps. An efficient medical assisted helicopter rescue service has an important impact on the survival chances in alpine sport accidents. References 1 2. 3. 4. 5. 6.
Rohrer, W., Klemmer, D., Durrer, 8., Jacomet, H. and Hofliger, C. Swiss Air Rescue Medical Statistics, 1990/1991. Hassler, R., Mosimann, D. and Durrer, B. Swiss Alpine Club reorganized statistics. Schmid, A., Bruchez, G. and Michelet, J. Mountain rescue statistics Valais. Durrer, B. REGA winch rescues 1983, 1984. In: Proceedings of International Aeromedical Evacuation Congress, Zurich, 1985: 108. Durrer, 8. Practical problems of fixation and evacuation in mountain rescue. In: Proceedings of International Congress of Mountain Medicine, Crans Montana, 1991. Bagnoud, B., Durrer, B., Genzelin, R. and Dubas, F. Mountain rescue today. In: Color Atlas of Mountain Medicine, Wolfe Pub\. Ltd, 1991.