Chapter 47. Rescue from remote places
Rescue teams require specialist training, equipment and physical conditioning for working in the remote or austere environments. Paramedics must be fully trained team members, otherwise they may become a liability, placing the other team members at risk. At other times, such as on expeditions, paramedics may have to work alone using their own resources.
Your medical skills are of value only if your physical fitness and specialist training are appropriate
Remote locations
• Mountain rescue
• Cave rescue
• Ski patrolling
• The Lifeboat service
• Search and rescue helicopters
• Remote industrial and agricultural sites
• Expeditions.
• Environmental injuries: hypo- and hyperthermia
• Dehydration
• Fatigue
• Any physical illness including myocardial infarction
• Near drowning
• Multisystem trauma resulting from falls
• Limb fractures and knee/ankle sprains
• Spinal fractures
• Skull fractures
• Burns.
Planning
A risk analysis and review of any previous audit or reports will help to identify the most common problem areas that a paramedic may face in a particular environment.
Find out:
• The precise location of the incident
• The type of incident and its cause
• Any potential or real hazards
• Access to the casualty with possible approach routes
• Number of casualties.
Much of the planning process used in the Major Incident Medical Management and Support (MIMMS) system of incident management is still applicable to remote rescue.
Mountain rescue
Mountain rescue in this country is undertaken by teams of volunteers, many of whom will possess advanced first-aid skills
• A doctor may or may not take part in the actual rescue work but will frequently provide advice to the team via radio
• Mountain rescue teams will usually provide or perform:
• Cervical, full-spinal and limb splintage
• Intravenous access
• Control of external haemorrhage
• Intravenous fluids
• Wound dressings
• Monitoring
• Oxygen
• Analgesia including administration of morphine
• Whenever conditions permit, the patient will be evacuated on a special mountain rescue stretcher; UK devices include the McInnes mark 5 and Bell stretchers
• The MIBS stretcher is finding favour because of its portability and relatively compact design
• If the team carries a vacuum mattress the patient should be enclosed in this before being put into the mountain rescue stretcher
• The handover to the ambulance crew will be the first opportunity for a more detailed patient survey
• Special consideration should be given to the possibility that the patient may be hypothermic, since rough handling can induce a cardiac arrhythmia
• Sufficient clothing should only be removed to allow the necessary examination, lest further lowering of core temperature results
• A hypothermic patient cannot be certified dead until they have been taken to hospital and rewarming attempted.
Altitude
When deploying to altitudes of 10 000 feet (3000 m) and above, altitude sickness is a potential problem. Prevention is easy to achieve and the paramedic should be actively involved in the planning of trips to altitude.
The rate of ascent should be no more than 300 m (1000 feet) per day, preferably with a rest day every 3 days. The aim is to climb high during the day and sleep low. If chemoprophylaxis is desired then acetazolamide (Diamox) should be taken, 250 mg slow release daily. Paraesthesia is a common side-effect.
There are three forms of high-altitude illness:
1. Acute mountain sickness (AMS)
2. High-altitude pulmonary oedema (HAPE)
3. High-altitude cerebral oedema (HACE)
• HACE can be considered the endpoint of untreated AMS
• HAPE is usually considered a separate illness, but can be preceded by AMS
• AMS commonly affects otherwise fit and healthy individuals who ascend rapidly to altitude. In general, the symptoms will disappear after 5 days provided no further ascent is made
• HAPE occurs in up to 10% of those ascending very rapidly to 4500 m. It typically presents with dyspnoea on exertion and reduced exercise tolerance. Symptoms may progress to dyspnoea at rest and particularly at night
• AMS precedes HACE and the typical feature is ataxia and confusion. Any ataxic and unwell person at altitude should be considered to be suffering from HACE until proven otherwise
• If altitude sickness is suspected, no further ascent should be made. Typically, symptoms settle after 24–48 hours of rest. If symptoms progress or there are any symptoms of HAPE, descent is essential
• Oxygen, nifedipine, dexamethasone and recompression bags all have a useful place in management, but descending back below the level at which symptoms began is the only effective treatment.
Symptoms of acute mountain sickness (AMS):
• Headache
• Nausea
• Vomiting
• Lethargy
• Disturbed sleep.
Cave rescue
Many of the difficulties encountered in mountain rescue also apply to cave rescue. Additional complications arise because of the physical environment: narrow tunnels, waterfalls, sumps, flash floods and underground lakes.
These dangers, combined with navigation difficulties, low temperatures and the total absence of ambient light, make cave rescue especially hazardous.
• Common problems include falls and the medical complications of diving
• Hypothermia is frequent and patients should be left in their wetsuit and wrapped in an exposure bag before being put on a suitable stretcher such as a Stokes litter or a Neil Robertson stretcher
• Remember that an injured person who has been diving should not be given nitrous oxide/oxygen mixtures (Entonox).
The injured diver must never be given Entonox
Ski patrolling
The first layer of planned medical provision on ski slopes is provided by ski patrollers.
In the UK, such persons may well be members of the British Association of Ski Patrollers and this organisation runs courses in advanced first aid.
• Hypothermia and fractures and soft tissue injuries of the lower limb are prevalent
• Extremities showing signs of possible frostbite should not be actively rewarmed during the transportation phase.
The lifeboat service
Rescue around the coasts and seas of the UK and Ireland is efficiently organised by a combined operation involving statutory organisations, voluntary bodies and the armed forces.
• The Royal National Lifeboat Institution (RNLI) responds to approximately 6000 calls per year
• Each lifeboat station has a lifeboat doctor known as the station honorary medical adviser (SHMA)
• The SHMA undertakes a variety of duties, including advising on the health of the crew and first-aid training, and is encouraged to attend regular exercises and go to sea as part of the lifeboat crew
• Provision is also made for any member of a lifeboat crew who has paramedical skills to have access to appropriate equipment and to make use of these skills when on a rescue
• Special reference is given to prolonged care and monitoring of the rescued as it may take a considerable time for such persons to reach hospital
• Lifeboats usually carry a basket stretcher and a Neil Robertson stretcher.
Search and rescue helicopters
Search and rescue (SAR) helicopter services are currently provided in the UK by the Royal Navy and Royal Air Force, although civilian contracts are likely in the future.
• Requests for helicopters are usually made via the police
• The crewman and winch operator will have had advanced first-aid training
• When carrying out SAR over mountainous terrain, helicopters may be used to deliver mountain rescue personnel to the accident location
• Equipment available on air–sea rescue helicopters:
• First-aid kit
• Drug box
• Laerdal suction apparatus
• PneuPAC-type ventilator
• Nitrous oxide inhalation (Entonox)
• Traction splints
• Pneumatic anti-shock garment (PASG).
Remote industrial or agricultural sites
Certain types of work such as quarrying, oil drilling, fish farming, forestry and estate management take place in remote areas, requiring a lengthy journey to hospital.
• Different sites and companies will have a wide variation in their provision of on-site medical support
• Sites with special hazards, e.g. oil rigs, will have a nurse or paramedic with extended skills directed to the particular problems of their working environment
• These sites will have access to equipment such as survival bags, stretchers, splints, rigid cervical collars, resuscitators, nitrous oxide (Entonox), oxygen and manual suction equipment
• If cyanide is used a dicobalt edetate (Kelocyanor) kit should also be available.
For further information, see Ch. 47 in Emergency Care: A Textbook for Paramedics.
