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Mountain Rescue Doctor
Wilderness Medicine in the Extremes of Nature
By Christopher Van Tilburg
St. Martin's Press Copyright © 2007 Christopher Van Tilburg
All rights reserved.
"Belay on?" I shout.
"On belay," yells Jim.
"Send me down!" I holler back as Jim begins to lower me into the crack in the earth. I can't see much. Not the bottom of the canyon. Not the cliff. Not the nearly dead patient lying on a ledge halfway to the creek. The hillside is thickly tangled with vine maple, ferns, and poison oak. I drop backward in a blind descent on the rope and plow through the brush with my butt and back. A branch catches my helmet and twists my neck. I duck my head to release the branch, which snaps back and pops me again in the face. My boots squelch into the thick muck and leave deep footprints. When I hit soft forest duff, the thickly matted decaying leaves and branches of the forest floor, my feet slip. My knees slam the ground with a sickening thud. Pain shoots into my legs. I hope I didn't break my kneecaps. I start to slide on my knees. The rope holds fast.
As Jim lowers me into the abyss, I also have to haul down the stretcher and medical bag, as the brush is too thick and entangled to drop the gear down on a rope. So in addition to keeping myself upright, bushwhacking backward down the hillside, and trying to watch for the upcoming cliff edge, I am dragging the stretcher. Wiry vine maple branches reach out, grab the stretcher, and pull it back up the hill. As I tug, the vine maple fights back and tears my shirt. Finally I yank the stretcher with all my might. It pops free, slides another ten feet, and nearly bowls me over. The rope goes taut again: Jim's got me.
I am worried. I am dangling on a rope on the edge of a cliff, descending into a remote, rugged canyon in the mountain wilderness. I have the utmost trust in my partner, fellow mountain rescuer Jim Wells, climber and orchardist. When the rescue page goes out, Jim is always among the first to respond. He has me locked securely on the rope. I trust him with my life — no second thoughts. What I'm worried about is the patient, who looks from my vantage point, to be very near death. Earlier, from high on the trail, we spied him through a thin fissure in the rock. She was perilously balanced on a small rocky ledge near the bottom of the cliff but far from the floor of the canyon. Blood was spattered on the rocks. She was not moving.
If that isn't enough, Jim and I are acutely troubled by the four people — two volunteer firefighters and two hikers — who are with the woman on the ledge. The two hikers heard cries for help and the two firefighters from the closest town, Cascade Locks, hiked down an old deer trail to the scene. The mantra of mountain rescue is in the forefront of my mind: no one else gets hurt. Even before rescuing an injured person, protection of the rescuers always comes first. A rescuer does no good, and puts many at risk, if he or she becomes injured. Our own safety is most important: if we can't reach an injured person safely, we won't. Second, protect the team. Third, rescue the patient. The safety of the team is part of Jim's responsibility as incident commander and mine as a member of the rescue team. I am anxious to drop over the cliff and get to the ledge but need to do so safely.
Hood River County, Oregon, is sprawling, rural, and rugged. Forty miles from the town of Hood River at the south end of the county, lies Mount Hood — the 11,239-foot-high, perennially snowcapped, active volcano that dominates the landscape. The mountain lies in the Mount Hood Wilderness, a subsection of the Mount Hood National Forest. The land is populated by old- and second-growth mixed conifer forests. The patriarchal Douglas fir intermingles with noble fir, white pine, western red cedar, mountain hemlock, and western hemlock. The rich green understory is thick and lush with vine maple, sword ferns, thin-leaf huckleberry, Oregon grape, salal, rhododendron, kinnikinnick, and vanilla leaf.
To the north, adjacent to the town of Hood River, lies the great Columbia River. The 1,243-mile-long stream originates in Canada and spews into the Pacific Ocean. The river slices through the Cascade Mountains and flows west past Hood River County. Near the town of Hood River, the river meanders through a deep gorge marked by 4,000-foot-high cliffs, waterfalls, rock pinnacles, deep gullies, narrow canyons, lava beds, and volcanic cinder cones. This area is so beautiful that Congress created the Columbia River Gorge National Scenic Area: a section of land in northern Oregon and southern Washington that begins in the outskirts of Portland and stretches 90 miles east.
When people are injured or lost in Hood River County — most often hikers, bikers, and climbers — they call 911. Our sheriff, like these in most states, is in charge of search and rescue, or SAR. Most rescues in Hood River County occur on Mount Hood or, like today, in the Columbia River Gorge National Scenic Area. The sheriff responds with as many deputies as he can spare and as many volunteers as are available. That's us — Crag Rats, an independent, nonprofit club with a mission to provide search and rescue services. In a rescue, we are officially activated by the sheriff's office and work directly under that authority.
This rescue started an hour before. Crag Rats had been dispatched to the most popular hiking spot in Columbia Gorge National Scenic Area. Bubbling rapids, high waterfalls, large boulders, and lush vegetation create a picturesque and tranquil Narnia only a thirty-minute drive from Portland. Through thick groves of Douglas fir, western hemlock, and western red cedar, the trail gently rises above the creek. After two miles of meandering through the forest, the trail hugs a steep hillside 500 feet above the streambed. This is the most treacherous spot on the trail, the point at which we found the injured hiker and where Jim lowered me over the cliff.
After thirty feet of descending the steep embankment, I reach the cliff. I should be able to drop right onto the ledge where the patient lies, but I find myself thirty yards up the canyon. I hear water running but can't see a stream; and because he can't see me, Jim keeps lowering me through a trickling spring-fed waterfall, which appears lower on the rock face as if by magic. The seemingly gentle spring spills over jagged basalt, which is intermittently covered in bright green moss and thick patches of mud. I brace myself, but my boots slip on the wet moss and I slam into the incline, knees first again. I try to steer the stretcher down the cliff, but it bangs into me.
Thankfully, the cliff at last becomes a sheer wall and I dangle freely in midair. My harness cuts into my groin and the weight of my heavy rescue backpack pulls me backward, so I have to cling to the rope to avoid flipping upside down. Below me, I see the motionless patient.
Suddenly the heavy thowck, thowck, thowck of a helicopter swamps all other sounds, and the rotor wash pummels me with a blustery whirlwind of leaves, dirt, and water. The helicopter swoops up the canyon as if in a scene from a war movie. I can't see through the dirt and spray, and I can't let Jim know when I'm at the bottom of the cliff. He's still lowering me. In the next instant, my feet hit ground at the bottom of the cliff. With a thundering clang, the stretcher crashes on the rocks right beside me, barely missing my legs.
My footing is anything but secure. The damp mud- and moss-coated talus is as slippery as ice. Barely able to stand upright, I cautiously unhook myself from the rope, then yank it a couple of times, hoping Jim realizes that I am off belay. Maybe a spotter will tell him.
The patient is lying on a rocky ledge, across the dangerous talus slope from where I stand. I make a mental note: wide stance, keep a low center of gravity, make two trips if needed. I wave to the two firefighters, who come over to help pass the stretcher and medical bag across the slope. One heaves it up to the ledge effortlessly like a teenager tossing a hay bale onto a flatbed.
When I reach the patient, I see she is struggling to breathe, her head is matted with blood, and she's unconscious. She's dying. I take a few seconds to size up the situation, to ensure the safety of the rescuers.
"Be careful. Watch your eyes," I shout when the chopper sends another wave of debris flying. "Watch your head." The scene on the ledge is doubly dangerous now. The helicopter buzzes even closer to the canyon wall and blasts us again with its powerful rotor wash. Overhead, a medic twirls precariously on the cable, an umbilical cord stretching thinly from the giant aircraft. He spins seemingly out of control, dangerously close to the branches of the tall conifers. A gloved hand reaches out from the helicopter bay and tries to steady the cable, but with no luck.
The four volunteers on the ledge with me have no protective helmets, goggles, or gloves, no proper footwear, no personal survival gear. The ledge is a pile of melon-sized, sharply pointed rocks coated in moss, mud, and water: large enough for the five of us, but barely. A gentle slope leads down the canyon, so we are okay without a safety line, which would tether us to the cliff and prevent us from falling. At any moment, the medic whirling above could land right on top of us, and the downdraft from the chopper is still showering us with sticks, rocks, leaves, and dirt.
"Everyone, stay low! Don't look up!" I shout.
Then I turn to the patient and pull on my medical gloves. Emergency doctors speak about the golden hour, the first sixty minutes after a patient has suffered severe trauma, during which doctors have the best chance of saving a life — whether the patient has a collapsed lung, a brain injury, or is bleeding severely. This is the time to quickly put the patient on life support, staunch bleeding, and stabilize any fractures. After that first hour, it is more difficult to save a life.
The patient is on her back, unresponsive. Bright red blood oozes from her scalp and face, coagulating on the rocks. A loud stridor — a gurgling, snoring, grunting sound — means her airway is quickly clogging with saliva, mucus, vomit, and blood. Every ten seconds she takes a deep gulp of air: an ominous sign. I've seen this condition in the emergency room and recognize it immediately. It isn't likely a collapsed lung or broken ribs but the apnea caused by a severe brain injury that is interrupting the stimulus to breathe.
Her pulse is weakly palpable at eighty beats per minute. Her skin is cool, pale, and slightly purple, or cyanotic. This means that although her heart is beating and desperately trying to circulate blood, the patient is not breathing enough. You need both — lungs to draw in air and deliver oxygen to the bloodstream and the heart to pump the oxygenated blood to vital organs. This patient has lost a fair amount of blood; so there is less of it to circulate. Thankfully, we don't need to start chest compressions. If her heart stops beating, it will be extremely difficult — almost impossible — to keep her alive with CPR. The ground is unstable, we have only the basic life-support equipment, and we are far from help. If this patient were in a hospital, I would have access to highly trained staff and state-of-the-art lifesaving equipment. On the ledge, I have whatever gear that can be lowered down the cliff and run on batteries.
After many years working as an emergency and wilderness physician, I complete this primary survey in five seconds, much less time than it takes to read about it. Doctors use the mnemonic acronyn ABCDE, or ABCs for short, when evaluating a trauma patient. Airway and breathing are the most vital. Circulation comes next and includes both a check to make sure the heart is beating and that there's no catastrophic bleeding. Next: D for disability. The neurologic exam yields one of four basic findings: alert, responsive to verbal stimuli, responsive to pain, and unresponsive. This patient's neurology exam shows she is unresponsive to all stimuli. In addition to her poor neurologic status, the patient has a head trauma and possibly a cervical spine injury — an injury at one of the seven neck bones, or cervical vertebrae — that can cause paralysis or even death. Emergency doctors have a mnemonic, "C three, four, and five, keep the diaphragm alive." In other words, any spine injury above the fifth cervical vertebrae disrupts the nerves that control breathing and thus the patient cannot live without life support. If the spine is injured below neck bone number five, the patient can breathe but can't move arms, legs, or torso. In trauma cases, we always immobilize the patient's neck and entire spine in case he or she has a back or neck fracture, using a hard plastic cervical collar and a backboard.
Finally, E for exposure: protect the patient from hypothermia. I'll deal with that later. Right now, we have to keep this patient from dying. She needs advanced life support immediately. One hiker reports that she was alert and whimpering a half hour ago. Now she is in a coma. This is a bad sign: she is getting worse quickly.
I pause to make sure everyone is still on the ledge and aware of the rotor wash from the chopper, which continues to hover overhead. It appears that the medic is being winched back to the belly of the two-hundred-ton machine. But he begins to swing back and forth, wildly spinning in big loops as wide as the rotor blades.
"I need help holding her head," I shout over the cacophony. One of the hikers stabilizes the patient's head. I quickly place a three-inch curved plastic oral airway in the patient's mouth to keep her tongue from blocking her throat. Then I gently but rapidly strap on a cervical collar. I have to get this patient's airway secured before she stops breathing altogether.
"Can you get the airway equipment for me, please!" I shout to one firefighter without looking up. I need a laryngoscope, a device that pushes the tongue to the floor of the mouth so I can visualize the vocal cords, and an endotracheal tube that I will pass into the patient's windpipe to breathe for her, a procedure called intubation.
"Can you monitor the pulse for me, please," I ask the other firefighter. "Let me know if it drops below sixty. I'm going to intubate."
In the muck and dripping spring water, I swiftly ready the airway equipment and check it over, and make sure everyone has a job: one Good Samaritan stabilizes the head, one firefighter keeps the pulse, and another helps me with the airway gear. I ask the fourth person to get the stretcher ready. Thank God for the extra help, I think.
An endotracheal intubation is by far the most difficult procedure I do as a doctor; in fact, it is one of the most difficult in all medicine. First, this lifesaving breathing tube always is inserted when patients are on the brink of death: bad asthma causing lungs to fail, a heart attack causing the heart to fail, or congestive heart failure causing both to stop. Or, as in this case, head trauma. Second, it is a difficult procedure; many ER docs do this procedure infrequently. You have to insert the laryngoscope in the patient's mouth, carefully push the tongue out of the way without breaking the teeth, and get a visual on the vocal cords. While holding the scope with one hand, you slide the narrow tube into the windpipe, or trachea. The problem is that the throat is usually full of vomit and sputum and the vocal cords are usually in spasm, blocking the trachea. Third, you only have a few minutes to complete the procedure before the patient begins to suffocate. It is an extremely difficult procedure in a clean, well-lit hospital room with familiar equipment, nurses, and special drugs to sedate, alleviate pain, and temporarily paralyze the patient. Here I am kneeling on the sharp rocks, with the medical bag splayed open, helicopter rotor wash blasting us with debris, and spring water spraying on my helmet. I focus intensely, blocking out distractions, hugely thankful that I have help from the firefighters and hikers.
There's another complication: I'm trying to keep myself clean. I'm not worried about mud on my search and rescue clothing but rather about following universal precautions, techniques that protect healthcare providers from the bodily fluids of patients. Universal precautions came into widespread use with the increasing prevalence of HIV, hepatitis B and C, and other deadly blood-borne pathogens. Medical professionals risk being splashed in the face or mouth during procedures and contracting life-threatening, chronic, irreversible illnesses in the line of duty. Universal precautions help minimize this risk.
This is my one big fear in the uncontrolled setting of a trauma in the mountains. I'm a doctor, but I'm also a father and a husband. For this procedure, I have gloves on, and I pull on my old pair of clear-lens ski goggles, which I keep strapped to my helmet. I'm ready to instantly duck if the patient vomits food, stomach acid, yellow bile, blood, or all four.
Excerpted from Mountain Rescue Doctor by Christopher Van Tilburg. Copyright © 2007 Christopher Van Tilburg. Excerpted by permission of St. Martin's Press.
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