Wilderness Medicine Case Study 1: Climber Fall
Leader Fall on rock
This accident has been adapted from Accidents in North American Climbing 2021.[i] The accident was real. The discussion of actions is a hypothetical exercise to review wilderness medicine practices and critical thinking in emergencies.
Throughout this case study, I’ll indicate the scene and what happen in italics. Questions for the reader to consider before moving on are underlined. Everything else is discussion of wilderness medicine practices.
A party of 3 climbing a trad route. The first pitch was climbed without incident and an anchor was built on the ledge system that fit all 3 members of the party. On the second pitch a few pieces of gear were placed until loose rock prevented the lead climber from placing anything. The next section of the climb involved a roof, and one small gear placement was found for protection. The lead climber attempted a high right step into the roof and found themselves upside down and falling.
As one of the two climbers on the ledge, you witness your friend take the high right step and then see the rock break under their feet. Your friend immediately flips upside down. Their head impacts the rock and the last small piece of gear placed pops free. Your friend then drops and slides approximately 20 feet before other gear stops the fall. They are barely above the belay ledge where you are now.
What are your first steps as the uninjured partners?
For many of us, the instinctual answer is to say you will see if your friend is awake and responsive, but first you must take care of safety and stabilizing the scene. Thankfully you have 2 uninjured people to support the fallen climber. A 2:1 ratio is a great help during an accident.
- Is the anchor still intact?
- Does the rope appear to still be whole and still attached to the climber?
- Is there a safe way to reach your friend without removing yourself from the protection of the systems and rope?
I would resist the urge to call 911 at this moment. It is far more important to stabilize the scene and assess your friend. They may be bruised and banged up but otherwise completely capable of descending the climb and getting back to the car.
The Incident: continued
The scene is safe.
The injured climber stood upright on their own after the fall.
What does that tell you about the primary assessment? Remember this is where we look for immediate life threats to the critical systems.
- You know they have a pulse if they are awake
- You do not know if they have any severe bleeding-
- quickly do a blood sweep, looking along the arms legs and torso in the ‘shorty wetsuit’ zone.
- Wear gloves or ask the patient to look for bleeding
- They have an airway
- And are breathing
- They are awake
Do you think this type of fall could be a mechanism of injury (MOI) to the spine??
Yes this is an MOI for a spine injury
You find no significant bleeding though there are cuts and some facial bleeding
The injured climber is able to stand on the belay ledge. You are now clear to move into a secondary assessment- in total, the above will only have taken you a few minutes.
Upon clearing the primary assessment you find…
Your friend reports that they have a vague memory of hitting their head.
They are having trouble speaking and begin to stabilize their own neck to support better breathing.
They want to lie down and support their own neck out of concern that they may have injured their spine.
Ok what can we safely conclude and take action on now?
I hope by now you are keenly aware of the signs and symptoms of a spine injury. So what do you do?
Resist the urge to do any stabilization. THEY ARE ALREADY DOING STABILIZATION on themselves. Instead support the request by the injured climber to place them in whatever position they find best for comfort and breathing (this is a part of PROP).
Is there spine injured? It appears so- based off their own self reporting of ‘feeling unstable’. Is it a worrisome area- yes! It’s along their cervical spine/neck- which is high up on the spinal cord and more vulnerable to injuries.
Despite all this, do not waste time and energy holding ‘c-spine’ (This means holding someone’s head from moving). Actions such as this are best left for front country ambulance responses where you have a team of people and resources helping. Along with a short time frame to the hospital.
For now, your patient is providing their own support and willingly restricting movement. If this changes and their mental status declines reevaluate hands on stabilization.
What should you be doing?
Now it’s time to call for help. This level of injury does warrant more resources to evacuate in a spine stable manner. The urgency is high, mostly because of the patient reporting difficulty breathing. The spine injury is a logistics concern, but the breathing is already a problem.
Thankfully there are two of you. Send your uninjured friend down to initiate a rescue (this is exactly what the party did).
Ok, the rescue was initiated. In this case it was by an emergency beacon.
Help is on their way…. It’s just going to take hours and hours and hours.
I should hope that your next instinct is to do a more thorough assessment of your friend’s injuries and looking for potential problems. Some things to consider:
- What are the vital sign trends?
- Take vitals and take them every 5-10 minutes until you get a clear picture of how they are trending.
- What would be one big concern after a big trauma like this?
- They could have internal damage that is hard to see- things like ruptured organs and internal bleeding.
- Watching how vitals change over time will be hugely important in catching early signs of these problems.
- You will also want to do a full physical exam- while still handling the patient in a spine stable manner.
- Do they have a traumatic brain injury (TBI)?
When you go through SAMPLE history you determine that the patient blacked out after their head was impacted- so yes they have a TBI!
Upon a physical exam you can see their helmet is severely cracked and it appears they have facial trauma. All signs of a high impact blow and a higher risk TBI that could lead to increasing intracranial pressure.
Phew! You aren’t done yet. There still are hours until the rescue team will arrive.
What other care should you provide to your patient?
- Insulating your friend on the ledge from the rock and adding layers to keep them warm
- Giving them food and water
- Assisting them with bathroom needs
- Continue to pay close attention to their ability to breath and mental status
- Continue to monitor vitals
Everything above highlights why ‘c-spine’ becomes impractical. In this report rescuers did not arrive until 9pm. How much harder would the above list of items be if your hands weren’t allowed to let go of the patient’s head?
So now you have done everything above, you are waiting and you have time, should you do a spine assessment? Can the patient pass?
If you have the luxury of time, and you have taken care of all the other more urgent needs then consider doing a spine assessment to gather more information about the severity of injury your patient has.
THIS SHOULD ONLY BE DONE IF THERE IS NOTHING ELSE MORE IMPORTANT. Keeping the patient warm, fed and breathing well are far more urgent problems that could kill your patient if ignored. Coordinating a rescue is far more important than a spine assessment. Thankfully, your other rescuer was able to do this for you. If you were alone, it could be that you would be too busy with other tasks to ever get the time to do a spine assessment.
As for results: Your patient WILL NOT BE ABLE TO PASS a spine assessment. They are already complaining of pain and instability along their neck. This means that the column/bone structure is damaged to some degree. But conducting the spine assessment can help you determine if the nerves have also been damaged.
OK- It’s 9pm and a helicopter has arrived, packaged your patient and flown them to the hospital. What a day!
- The medical results from this accident listed the following:
- Multiple fractures of the C1 vertebra
- Occipital skull fracture
- Multiple fractures to upper jaw, cheekbone and nose
- Broken molar
- Ligament tear on the left hand
- And partial tear of the MCL on left knee
Thankfully the patient has made a healthy recovery except for a slight loss of range of motion in neck and wrist.