Wilderness Evacuation What to do when it all hits the fan Jonathan Miller, MD Maine Medical Center Department of Emergency Medicine

Case 1: A missed jump in the backcountry results in a broken leg What type of evacuation is needed? Helicopter Evacuation by foot Carry Litter What resources do we have available Where are we???

The mode and urgency of the evacuation is decided on several factors Severity of the illness or injury Psychological condition of the victim Rescue and medical skills of the rescuers Physical/Psychological condition of the rescuers Availability of equipment and/or aid for the rescue Danger/difficulty of extracting the victim(s) by the various means available

Time Distance to care, or the car… Terrain Weather the possibility of deteriorating weather COST

If you decide to use an outside rescue group THEN DON’T WAIT!!! The longer you wait to make your decision, the worse your patient is going to get… The entire group, including the patient (if possible), should be in the decision making process

What deserves an evacuation? Orthostatic dizziness Syncope Altered mental status Progressive weakness Intractable vomiting/diarrhea Inability to tolerate fluids Head injuries Debilitating pain Sustained abdominal pain Signs and symptoms of high- altitude illness Infections that continue to progress for >24hrs despite appropriate treatment Chest pain that is clearly not from a musculoskeletal injury Serious wounds Open fractures Impaled objects Suspected spinal cord injuries Partial and full thickness burns that cover >15% of the body are urgent evacuations Burns to the neck and face require urgent evacuation Blistered burns require evacuation but not urgently

Helicopter evacuation Evacuate with a helicopter only if: A victim’s life will be saved The victim has a better chance for full recovery Pilot believes the conditions are safe Ground evacuation may be unusually dangerous Not enough rescuers for ground evacuation Remember that a ground evacuation may still need to be made to a suitable landing zone

Helicopter evacuations Assign someone to protect the landing zone – remove debris and mark the LZ with a large green or red material Indicate wind direction using streamers or by standing with your backs to the wind and your arms forward Never approach a helicopter until a signal has been given by aircraft personnel, and never approach a helicopter from the rear Ground transportation may be safer if patients have suspected pneumothorax or decompression sickness Remember that helicopter rescues aren’t always an option – high altitudes, hot temperatures, poor visibility, bad weather, and terrain can all prevent rescues.

Ground evacuation Self Rescue Always send at least 2 people when walking out with a patient Litter carries require 6-8 or more depending on the terrain Outside rescue Write down the information: assess the patient, the situation, and give a detailed location. Assess potential hazards to the rescuers and their vehicles. Taking the time to write out a detailed note ahead of time will decrease total evacuation time

Be nice… It’s inappropriate to ask for help out of convenience, when you have the capabilities to carry out your own rescue Request assistance as a last resort, when life or limb is threatened Remember, that getting rescued is rarely free Improvising a litter will typically aggravate existing injuries, consider waiting for a real one. Remember that your patient can talk to you (sometimes) – get their opinion as they are obviously part of the rescue.

Carries Assisted walk Four handed seat Back carries Rucksack method The ‘boy scout’ method Rope coil method Webbing carry

Litters Daisy chain method Limb/paddle/shirt/blanket/”what ever else I can find around me method” A real litter! Snow rescue? Think about their sleeping bag? DON’T forget to PAD!

SOURCES: Wilderness Medical Society: Wilderness Medical Society practice guidelines for wilderness emergency care. William W. Forgey, MD. 5 th ed. Mountaineering: The freedom of the hills. Steven M. Cox and Kris Fulsaas, 7 th ed.