EMTs in a cave

[George Dasher]

I think we've gone "off thread..."

We're discussing medical protocols, etc., when the original thread regarded being comfortable with the cave environment.

You can really know your stuff medically, but if you're freaked out by the environmental the patient is in, you're not going to be very effective. Put another way, you can't help the patient if you have trouble with the low crawl or the confusing breakdown to get to him.

And, to be truthful, we're all going to be freaked out by some kind of environment. We can't be "good" in all of environments, or in all emergencies.

We had a rescue in West Virginia in the early 1070s. What I was told was that the EMTs all got to the patient and just sat there, clearly freaked by the crawlway and vertical drop they'd done. The doctor didn't want to do the crawl, but they got him through it. Then he yelled down instructions from the top of the drop and bolted for the entrance.

So let's be honest, caving ain't for everyone, and sometimes being comfortable with the environment is more important than medical protocols.

[NZcaver]

I think we've gone "off thread..."

We're discussing medical protocols, etc., when the original thread regarded being comfortable with the cave environment.

I think you missed the connection. Greg's original post talked about being comfortable with the cave environment when you are providing patient care. Caves are generally a wilderness environment, and wilderness medical protocols are taught as tools to help responders and give them more options (and more confidence to treat patients) in these kinds of situations. I don't really see how this is off-topic.

You can really know your stuff medically, but if you're freaked out by the environmental the patient is in, you're not going to be very effective. Put another way, you can't help the patient if you have trouble with the low crawl or the confusing breakdown to get to him.

And, to be truthful, we're all going to be freaked out by some kind of environment. We can't be "good" in all of environments, or in all emergencies.

Agreed. And even many "seasoned" cavers aren't always 100% happy in the tightest squeeze, the deepest drop, or ducking under the occasional sump.

We had a rescue in West Virginia in the early 1070s.

The early 1070's? Wow - you have been caving for a while!

So let's be honest, caving ain't for everyone, and sometimes being comfortable with the environment is more important than medical protocols.

You might be right, but feeling comfortable and being appropriately trained are not mutually exclusive. Some may even say that good training leads to feeling more comfortable... knowledge + practice = confidence? Consider this comparison. An ill-prepared spelunker may feel totally comfortable visiting a cave, whereas a newbie caver on a grotto trip may feel a little nervous. Forgetting our medical topic for a moment, which person would you rather have around in a cave?

Take a look again at my first post in this thread. My suggestion is that anyone serious about this would do well to get some training in both cave rescue and wilderness-oriented first aid/medicine. This means cavers and non-cavers (responders) alike. In my opinion, any non-cavers likely to be involved in cave rescues could further benefit by tagging along on recreational caving trips once in a while to improve their "comfort factor." Sort-of like tncaveres mentioned in his post.

[james huffaker]

Gents and Ladies(?) Good afternoon. I'm glad to see the thread still alive!

Just a few thoughts; Wilderness Medicine: limited equipment, and either you can't get your patient to a hospital in a timely manner or there is no hospital to get your patient to. Street EMS is predicated on the concept of rapid transport to a hospital. Thats why street protocols don't work well in "wilderness" environments. When you measure your transport times in hours or days, the protocols need to be changed to reflect that.
When your a team medic, your responsible for the care of the team as well as the patients. This can involve a UTI in a female team member, a dental abscess, or vet skills for the animals. This is more primary care then emergency medicine and is an example of how a well trained medic can support a teams operations.
As mentioned above, you can have a very highly trained provider,but if their not trained for or comfortable in the environment their tasked to work in, they can be worse then useless, they can become a liability.
This is put forth as an honest question as I don't have much training or experience in caves (yet), but are there any unique conditions or potential scenarios that exist in caves that don't exist in say SAR or high angle rescue that would require specialized training and modification of existing wilderness protocols to allow the medic to render the best care available to their patient(s)?
Yes, BLS before ALS and the simplest solution if frequently the best solution.
Regards, Jim

[NZcaver]

This is put forth as an honest question as I don't have much training or experience in caves (yet), but are there any unique conditions or potential scenarios that exist in caves that don't exist in say SAR or high angle rescue that would require specialized training and modification of existing wilderness protocols to allow the medic to render the best care available to their patient(s)?

Great question! I won't go as far as to suggest modifications to wilderness protocols at this point, but...

One big issue that immediately springs to mind is not directly a medical one, but is nonetheless vital - communications. In most other situations, even in the wilderness, we take it for granted that using handheld radios - or even yelling across to someone - is a viable option. With few exceptions, this is simply impossible when underground. Specially-designed (and usually home-made) cave radios have been used with mixed success in some caves, and regular handhelds can sometimes be used line-of-sight. But generally cave rescue communications rely on runners (crawlers) who could take hours to pass a message, and/or by stringing an army-type field telephone system into the cave. Usually until field phones are set up and working, you're pretty much incommunicado - even with the IC and other teams that are also "on scene."

Medically-specific, the most common significant cave injuries I believe are fractures and sprains to lower extremities from slip-and-fall incidents. But just about anything is possible, and in the vast majority of caves hypothermia becomes an immediate risk - especially when a patient has limited mobility and/or is trapped in a tight passage or in water. Having to treat and free someone stuck in a tight passage may be something you don't often see outside the cave environment. I also doubt it's common in regular wilderness rescue to package a patient in a litter or SKED for transport, and later having to unpackage them just to fit through a constriction before repackaging again. You may also have to move them through water, up or down vertical drops, across tyroleans, and that kind of thing. Trying to avoid further damage to the patient, the responders, and the cave can sometimes be tough too.

[james huffaker]

Gents, Re comms, standing orders work when comms are down. Do any of the teams have an MD on them? This would allow for advanced practice protocols for the medics under the MD's license and also allow for on site medical control and going outside of protocol when the situation requires it. Also, if the doc has gone through the same training as the rest of the team, and is an experienced caver, he will be able to adapt the care to the specific realities faced in a cave rescue environment as mentioned above. Regards, Jim

[NZcaver]

Gents, Re comms, standing orders work when comms are down. Do any of the teams have an MD on them?

True, and sometimes an MD comes along (if you're lucky). There are a small but fairly active number of caver MDs scattered around, some of whom are on this forum. When you start talking about ideas for the addition/modification of wilderness protocols, they would probably be the best people to make educated suggestions.

Regarding comms - you're quite right about the medic operating independently on standing orders and protocols. Sorry I didn't make my last point clearer, but I'll try to clarify. As you probably know, cave rescues seldom (if ever) just involve one team of people to go find, stabilize, and transport a patient. You have the IC, operations, logistics, plans etc as required above ground, and an entrance control person on each cave entrance to track people going in and out. In the cave you could have 3 search teams (or task forces to use the new nomenclature) looking for the subject, plus a rigging team ready to go rig drops once they find out where the person is and what they need to rig. You may have a more advanced medical person/team ready to assume responsibly for the patient, and a transport team ready to help move them - who will hopefully be relieved by another team if/when the original team tires out.

These factors are not just peripheral to patient care, but integrated with it. Imagine trying to coordinate all this to make for as safe and efficient a rescue as possible, with limited or no communication below ground. That was my point.

[james huffaker]

Sir, Thank you very much for your patience in putting up with me and for your candor in answering my questions. I recognize that I'm new here as well as to caving in general and certainly to cave rescue and should probably shut up and learn before putting forth my opinions, I apologize to all. My enthusiasm for the subject overwhelmed my judgment. Regards, Jim

[fuzzy-hair-man]

.... but are there any unique conditions or potential scenarios that exist in caves that don't exist in say SAR or high angle rescue that would require specialized training and modification of existing wilderness protocols to allow the medic to render the best care available to their patient(s)?
Yes, BLS before ALS and the simplest solution if frequently the best solution.
Regards, Jim

I'm not very medically minded but I'll put a couple of suggestions:

Harness Hang Syndrome(HHS), OK this will exist in high angle rescue but above ground the common case would be that the victim is able to be removed from the rope quicker before harness hang becomes a serious issue. Medically the treatment for HHS conflicts with the HHS symptom of unconsiousness so in HHS documents it is often suggested that medical proffessionals will not be aware of HHS and therefore not treat it correctly.
Some HHS discussion here.

Perhaps some of the respiratory problems caused by exposure to histo in guano?

There's rabies but you would be well and truely out of the cave before that becomes an issue.

[NZcaver]

Sir, Thank you very much for your patience in putting up with me and for your candor in answering my questions. I recognize that I'm new here as well as to caving in general and certainly to cave rescue and should probably shut up and learn before putting forth my opinions, I apologize to all. My enthusiasm for the subject overwhelmed my judgment. Regards, Jim

Please don't apologize!

This is a discussion board. If we all kept quiet instead of putting forward and discussing opinions and observations, this would just be another lame online newsgroup that only regurgitates caving-related tidbits from the media.

Don't give up posting because you might annoy someone or try their patience - I probably have that effect on people all the time. With your interests, I would even suggest attending a National Cave Rescue Commission weekend or weeklong seminar some time. More details on the website here, although not all courses are listed, and some information is not always kept updated.

[Stridergdm]

I would think access to the patient is perhaps one of the biggest differences. In one rescue I helped with, for the first 24 hours or so, the only access to the patient was his foot. He was trapped in a tight passage and that's about all the rescuers could see.

Now imagine trying to get vitals, assess the patient, etc when that's it.

As for doctors, the scary thing is I think I've met probably 1/3-1/2 of the active doctors in the caving community (at least the ones with advanced rescue experience). Ok, maybe that stat isn't scary.... but knowing who they ARE
(Seriously, all of them are great folks and seeing them peering over the litter at me would be reassuring, if a little embarrassing.

Actually that brings up an interesting legal issue (oh actually there's lots). In the aforementioned rescue, a doctor eventually entered the cave and was with the patient for a major portion of the rescue. He should have come out far sooner than he did, but there was question if under the existing protocols he could be replaced with someone less training.

Oh, that reminded me (and sorry for rambling) of another potential issue rarely encountered outside a cave (at least I think it's rare), low O2 levels. We had to pump air into the cave to combat this.

Thanks for the great discussion.

[james huffaker]

Gents, first thanks for the encouragement, though you may live to regret it.

As regards advanced providers (MD's, NP's, PA's etc.) offering their assistance in caring for your patient, unless they are part of the "system" in which you are functioning or are willing to assume total care and responsibility for the patient, I have in the past graciously or depending on how disruptive they are being, not so graciously declined their assistance. If they are not familiar with the existing protocols or the requirements of the operating environment, they can do more harm then good, and if they will not accept responsibility for the patient, you are still responsible for what you allow to be done to the patient while they are under your care. "Street side" credentialing can be problematic as well. Are they who they say they are, or did they sleep in a Holiday Inn last night.
I hear tell that some SWAT teams have doc's that are on their entry teams. An aggressive hands on medical director can be a very useful thing.
Re comms, Yes agreed, coordinating all of the various elements is integral to patient care, as we are all trying to accomplish the same thing but from different perspectives. My ignorance showing, but how do you establish reliable comms between all of the various elements?
Stridergdm, so how did you get your entrapment free? What can you do with a foot? Check peripheral pulses indicating perfusion, start an IV, do pulse ox's work on toes?
Regards, Jim

[james huffaker]

Gents, To reiterate, for those with interest in such things, http://www.remote,austere,wilderness, and third world medicine.com, a web site made up of MD's, PA's, RN's, medics, EMT's and farmers,plumbers and assorted John-Q's. The only requirement is an interest and the only dumb question is the one you don't ask. It is peer reviewed so the info on it is GTG.
Get off the X forums, Battlefield Medicine sub forum, ResQDoc (AKA Kieth Brown MD) principal of Global Medical and Rescue Services located in Belize, allot of their wilderness medicine (anything from WFA to expedition medicine) and rescue classes take place in caves. On Get off the x, a gent by the name of MikeG (one of ResQDoc's instructors) designed the Mike sack as a Med bag for cave rescue. Just thought you might want to know. Regards, Jim
PS, I cant seem to get the link to work, but I think your efforts in searching them out will be well worth it. Jim

[PaulSiegel]

http://medtech.syrene.net/forum/index.php

Is this what your trying to link to?

[kmstill]

Gents and Ladies(?) Good afternoon. I'm glad to see the thread still alive!

....or vet skills for the animals....

Regards, Jim

props for remebering us vets! now please just forward that to my CDR... Seriously, we say "train as you fight" (or rescue as the case may be) for a reason. great discussion

[james huffaker]

PaulSiegel, Yes and thank you. Also http://www.getofftheX.com Battlefield Medicine sub forum, and http://www.gmrsltd.com.
kmstill, I know they use dogs and sometimes horses in SAR and dogs in USAR, I don't know if you folks use dogs in cave rescue, but in any event, the "wilderness" (not being able to evac in a timely manner) applies to our four legged team members too, so we need to know how to care for their needs as well. Regards, Jim