Scenario 6: You are rock climbing with a friend, Melanie, when you hear a yell from across the crag

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Scenario 6 You are rock climbing with a friend,
Melanie, when you hear a yell from across the
crag
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followed by some anxious shouting. It seems
someone has fallen and injured themselves.
Melanie is leading up the first pitch. She puts
in a bombproof piece of gear and ties off. You
unclip from your belay and run round to have a
quick look.
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Another climber, Adrian, has fallen and pulled
all his gear out, resulting in a fall of about 8m
onto the rough sloping ground at the bottom. His
mate says he thinks he landed on both feet but
then sort of cartwheeled over onto his right
side. He is now lying head down on his right
side, muttering unprintable expletives through
gritted teeth.What do you do next?
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Accident Illness Protocol!Take charge and
assess for danger. In this case there is no
particular danger you are on sloping ground that
quickly levels off. The ABC in the primary survey
is clearly OK. You look for bleeding, without
moving him and find blood coming through a torn
shirt sleeve by his right elbow. The elbow is
obviously swollen and deformed. There is a small
amount of blood around his mouth. Neither of
these would amount to a deadly bleed. It is a
hot day and you feel that it will be all right to
move on and complete your secondary survey
without covering him up.
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What features in the secondary survey are
youparticularly going to focus on and why?
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The mechanism of injury immediately makes you
think of spinal cord injury. Your history and
examination will be directed in this direction.
Use of the Canadian C-spine rule will assist you
in deciding whether you will need to immobilise
the neck before evacuation. Similarly the
mechanism of injury will also make you suspect
fractures in the ankles and / or legs. You also
need to exclude significant head injury and have
look inside his mouth.Stiell IG, Wells GA,
Vandemheen K et al. The Canadian C-spine Rule for
radiography in alert and stable trauma patients.
JAMA 2001 286(15) 1841. Accessible at
http//jama.ama-assn.org
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Adrian can recall the entire episode and although
admitting to banging his head as he landed, did
not lose consciousness. Although his elbow is
causing him severe pain, he is able to co-operate
with your history and examination. He does not
complain of any pain in his neck or back and
doesnt seem to have pain anywhere else either.
On examination he has no midline tenderness in
his neck or back. You examine the other bits
that you can get to with him on his side. His
left arm seems OK, with no injuries other then a
few scratches and CSM is intact.
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His right leg is fine too, CSM intact, but as
soon as you feel around his left ankle he yells
out. You pull up his trousers to see a very
swollen ankle. There is tenderness over both
malleoli. CSM is intact.You move back to his
neck to finish your assessment. He is able to
actively rotate his neck without difficulty.You
want to roll him over to make him more
comfortable and to finish your examination,
particularly of his injured elbow.Given your
initial concern about possible cervical spine
injury, is it OK to roll him without cervical
immobilisation?
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Yes, he passed all the Canadian C-spine rule
tests.You could argue that you havent assessed
neurological status of his right arm and
therefore havent completed a full neurological
assessment.True, but in any case he has a
fractured right elbow (that much you already
know) and interpretation of neurological function
will be affected by that fracture.
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With the help of his friends, you roll Adrian
over paying attention to his head and neck, his
elbow and his ankle.You rip his shirt sleeve
open further. He clearly has an open fracture
with a very deformed elbow. His hand is cold and
he complains of pins and needles in his ring and
little fingers. You cannot feel a radial
pulse.A quick examination of his chest and
abdomen suggests nothing untoward.
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Sensibly, you step back and take stock of the
situation unstable open fracture R elbow with NV
compromise. Probable bimalleolar (possibly
tri-malleolar / Pilon) L ankle, plus a few cuts
and bruises.You have four helpers, the car is a
10 minute walk down the hillside on a reasonable
path, and then there is an hours drive, mostly
on gravel roads, to the nearest town. There is no
mobile service until half way to that town. You
have your usual small first aid kit with you.
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What have you forgotten? What is your plan?
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You seem to have forgotten Melanie in all the
excitement. Sensibly, she has escaped from her
climbing ropes, tied them together and clipped
them through the piece of gear and then abseiled
offyou now have 5 helpers!The first part of
your plan is to quickly share your findings with
Adrian and his friends and explain that you will
need to manipulate his elbow. You consider
reaching for the phial of lignocaine in your
first aid kit, but then realise that you wont be
able to assess your efforts if you put in a
block!
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You manipulate the fractured elbow and do your
best to pad it with whatever you have immediately
to hand.You discuss your thoughts with the
group. You will need to administer suitable
analgesia and stabilise both fractures prior to
evacuation. You discuss whether to evacuate him
yourselves or whether to send someone to phone
for an ambulance.
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What would you consider to be suitable
analgesia?How are you going to stabilisethe
fractures?Will you evacuate him yourself or not?
Why, or why not?
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These are severe injuries and the stronger the
analgesic, the better. Hopefully your first aid
kit contains an injectable opiate (morphine or
tramadol). Diclofenac suppositories (effective,
but not quite so popular!) or injectable
ketorolac would be good alternatives.The extent
to which you will construct makeshift splints
will depend upon whether you will evacuate him
yourself, or wait until ambulance officers arrive
with ready made splints.
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There probably isnt a right answer here. If you
opt for the go and get an ambulance approach it
will probably be 2 ½ hours before they actually
arrive, however, the evacuation will be smoother
as they will have proper splints and a stretcher.
You will also have two extra people to help carry
Adrian.That 2 ½ hours spent lying under the crag
would be quite unpleasant for Adrian at least
its hot and not raining! It is only a 10 minute
walk down a decent path and there are five of
you, so you should manage.
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You decide on the evacuate him yourself option.
You give him some analgesia, and as you havent
got much in the way of stuff to improvise splints
with you, you send Melanie to run back to the car
to find something.She sprints down and opens
the back of the car
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Have a think about what is in the back of the
car.What is there that you could take back up
to use to make splints?
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The bits of rope and straps are obvious save
chopping up your expensive climbing stuff,
likewise the towel and fleece top will make
useful padding.Melanie also grabs the plastic
jerrycan and races back up to the crag
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A plastic jerrycan will make an ideal splint for
both fractures. Cut along the dotted lines and
you have two rigid L-shaped channels. These can
be padded with clothing. In the case of the elbow
it can be retained with a triangular bandage as
part of a broad arm sling. For the ankle it will
be necessary to tie it in place with the
straps. Remember, effective splinting reduces
pain dramatically.
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Having fashioned the splints and checked the NV
function of Adrians right arm, you are now faced
with the prospect of getting him back down to the
car park. Even carrying someone this short
distance is hard work.What is likely to be your
best option, given the available equipment, the
number of rescuers and the nature of Adrians
injuries?
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A modification of the two person split coil seat
would work well here. A climbing rope is coiled
in the traditional fashion and then divided into
two as shown. Adrian would not be able to use
his his right arm for balance, so a third person
walking behind and supporting his back would help.
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And so, Adrian was carried back to the car park
and made comfortable in the back of his car.You
had checked CSM regularly on the carry and it had
remained intact. You wrote some notes to assist
the treating doctor at the hospital to which he
was heading.You wondered whether you should
have gone with Adrian to the hospital or whether
it would have been overkill