Abstract
Mountain Emergency Medicine (MEM) is ambitious and wide-ranging. The primary audience seems to be mountaineer physicians interested in mountain rescue, including those not trained in emergency medicine.
MEM is many things. It is an update and expansion of the International Commission for Alpine Rescue Medical Commission 2001 Consensus Guidelines on Mountain Emergency Medicine and Risk Reduction. It is a reference for the International Society of Mountain Medicine/International Commission for Alpine Rescue/International Climbing and Mountaineering Federation Diploma in Mountain Medicine courses. It is a comprehensive review of the current status of mountain emergency medicine. It provides some basic advice about adult education for training programs. It tells us how to design a very high-quality mountain rescue medical system. It relates heroic and instructive rescues in the Alps and the history of mountain rescue. It tells us what equipment we should carry for high-quality medical care during mountain rescue, although it does not teach us how to use this equipment.
MEM’s primary focus is on field care, but 3 chapters are devoted to in-hospital care. These read like a core curriculum on trauma management for emergency medicine residencies. Except for diagrams showing the operative management of liver injuries, for the most part, it lacks detailed explanations or graphics of how to perform the procedures it recommends.
MEM is Euro-centric, Alps-centric, and mountaineering-expedition centric. The chapter Envenomation by Bites and Stings has to do not with mountains but with getting to mountains in low-income areas, where bites and stings are common and advanced medical care is hard to come by. It features an extended discussion of treating venomous snakebite via pressure band immobilization, but no mention that pressure bandages are not recommended, and many say absolutely contraindicated, for North American pit viper bites. One chapter states: “Because there is a risk of neurovascular injury, joint reductions (excluding the hip) should be attempted in the field only by experienced physicians.” But in North America, we have long had wilderness EMT training, for which reduction of shoulder dislocations is a standard skill. Although there is a chapter on forensic medicine for deaths in the mountains, there is nothing on improvisation if you are in wild mountains with limited gear.
The 48 chapters read like independent highly-annotated review articles, with significant duplication. There are 3 separate reviews of scene safety and primary and secondary surveys, 3 of hypothermia management, 2 of helicopter operations, 2 of anaphylaxis, and 2 of Hannibal’s crossing of the Alps in 218 BC. This independence also leads to conflicting recommendations. One chapter says: “The possibility of hypersalivation and laryngospasm and the increased numbers of victims needing intubation especially limit the use of ketamine in mountain or high altitude medicine.” Another says: “Ketamine is a safe and effective sedative analgesic for remote environments.” In 2 chapters, traction splints are recommended for femur fractures, but another says: “Traction can reduce pain and spasm by decompressing the broken bone fragments and increasing arterial blood flow, but the rescuer must first exclude hip or pelvic fractures, supracondylar fracture of the distal femur, knee fractures or fractures of the ankle or foot, which are strict contraindications. Due to these contraindications and to their bulkiness, these splints have largely been abandoned in mountain rescue.”
There are errors of fact, such as: “Pre-hospital medical care began in urban areas in the 1980s, with the establishment of physician-staffed ambulances in Europe and paramedic-staffed ambulances in North America.” Emergency medical services in North America began in 1967 with the Freedom House paramedic program in Pittsburgh, Pennsylvania.
MEM states: “In mountain areas, at least one helicopter with a mountain-rescue-competent crew should be dedicated to HEMS [Helicopter Emergency Medical Services] within a region.... The appropriate financial model of the organisation will depend on local conditions, but the model should not compromise safety or the basic principle that the service is for everyone according to medical and rescue need, regardless of nationality, insurance, or other influences.” One hopes this does not mean that an underresourced country should reallocate scarce resources to provide such services primarily for visiting mountaineers. But many of MEM’s authors work in a collection of systems that do provide this sort of service in the Alps: an expensive, well-resourced system in a relatively-small mountain area. Therefore, you can get to a mountain casualty fast, and provide high-level emergency medical care, so that neurologically-intact survival is possible even after conditions such as cardiac arrest, including traumatic arrest. Such responses and results are the standard in the Alps, something that most other mountain ranges in North America and elsewhere can, at present, only aspire to.
Regardless of the rough spots, MEM provides a wealth of information; more importantly, it promotes intercontinental information exchange, and this North American mountain/cave rescue physician found portions of it fascinating. Especially in the mountains, we must often make our decisions based not on prospective, randomized, double-blind trials, but on anecdotes, case series, and expert opinion. This book provides many such expert opinions. Anyone involved in mountain emergency medicine or mountain emergency medical services—anywhere in the world—can learn quite a bit from it.