The Quest for Evidence-Based Medicine in Mountain Areas

Medical and logistical challenges of trauma care in a 12-day cave rescue: A case report

AIM

To describe the case of a patient with a severe head injury at a depth of about 1000 m from the cave entrance in Bavaria, Germany, who received pre-hospital trauma care for 12 days until evacuation.

RESULTS

Search and rescue (SAR) operation involved 728 rescuers, 202 working directly in the cave (for a total of 9239 h) and 7 physicians from five countries. At 6-month follow-up, the patient had recovered completely and resumed his job.

CONCLUSION

This case highlights several pitfalls of trauma care in complex SAR operations, which often rely on expert knowledge and are not yet evidence-based practice.

Epidemiological and medical aspects of canyoning rescue operations

AIM

To describe the characteristics of canyoning rescue operations (CRO), type and severity of injuries or illnesses, and on-site medical procedures.

PATIENTS AND METHODS

A retrospective analysis of all CRO data from an emergency medical rescue team in Aragon, Spain, between 1 August 1999 and 31 July 2009.

RESULTS

A total of 520 patients were identified, with a male to female ratio of 1.4. The median age was 32 years (range 10-73 years). The median time from the emergency call to admission to an acute care facility (or evacuation for uninjured patients) was 90 min (range 10-860 min). In 329 (63.3%) cases technical skills or ability in the terrain with some grade of difficulty was required. Accessibility of the incident site was associated with type of rescue (p<0.0001), where patients in incident sites with moderate to extremely difficult access were more often rescued by ground rescue alone or supported by air rescue than by air rescue alone. 419 (80.6%) patients had trauma-related injuries. The most common injuries involved the lower extremities (74%). The percentage of patients with a NACA score ≥4 was higher for medical/environmental illnesses than traumatic injuries (p<0.0001), despite that the total number was smaller. 175 (33.7%) patients received analgesics. 370 (71.2%) patients required splinting/immobilization. Major life-saving medical interventions were rarely performed on-site.

CONCLUSIONS

The length and exposure to environmental factors validates the importance of emergency physicians and paramedics in CRO. Physicians and paramedics should be familiar with Pre-hospital Trauma Life Support, medical procedures related to environmental, topographical and logistical conditions, and helicopter rescue operations including winch operations.

Defibrillation in rural areas

AIM OF THE STUDY

Automated external defibrillation (AED) and public access defibrillation (PAD) have become cornerstones in the chain of survival in modern cardiopulmonary resuscitation. Most studies of AED and PAD have been performed in urban areas, and evidence is scarce for sparsely populated rural areas. The aim of this review was to review the literature and discuss treatment strategies for out-of-hospital cardiac arrest in rural areas.

METHODS

A Medline search was performed with the keywords automated external defibrillation (617 hits), public access defibrillation (256), and automated external defibrillator public (542). Of these 1415 abstracts and additional articles found by manually searching references, 92 articles were included in this nonsystematic review.

RESULTS

Early defibrillation is crucial for survival with good neurological outcome after cardiac arrest. Rapid defibrillation can be a challenge in sparsely populated and remote areas, where the incidence of cardiac arrest is low and rescuer response times can be long. The few studies performed in rural areas showed that the introduction of AED programs based on a 2-tier emergency medical system, consisting of Basic Life Support and Advanced Life Support teams, resulted in a decrease in collapse-to-defibrillation times and better survival of patients with out-of-hospital cardiac arrest.

CONCLUSIONS

In rural areas, introducing AED programs and a 2-tier emergency medical system may increase survival of out-of-hospital cardiac arrest patients. More studies on AED and PAD in rural areas are required.