Stephen Hearns, specialist registrar in emergency medicine and medic for a Scottish mountain rescue team, outlines what is required to be an "action hero"

Mountain rescue teams in Britain undertake over 800 emergency rescues a year.¹ In Scotland these involve the care of 170 people with injuries and illnesses and over 30 deaths annually (preliminary data from my study of Scottish mountain rescue major trauma). The role of the 70 mountain rescue teams in Britain is to locate casualties, assess and treat their injuries, and evacuate them to hospital. Many teams enlist the help of a team doctor.² These doctors are involved in training and emergency rescues.

Background

A wide range of medical problems may befall mountaineers. Accidents result from slips, falls, and avalanches. They are often precipitated by navigational errors, lack of experience or equipment, and adverse weather conditions.

Accidents occurring in remote mountainous environments are complicated by many factors. Time to inform the emergency services may be prolonged, as may time for evacuation to hospital. The medical assessment and treatment of casualties is made more difficult by weather conditions, poor light, limited equipment, and limited assistance.

The commonest problems are, as one would expect, lower limb injuries. In Scotland almost 10% of mountain casualties are suffering from medical illnesses, and major trauma occurs in 5% (data from study of Scottish mountain rescue major trauma).

The role of the doctor

An appropriately experienced doctor can bring unique skills to mountain casualties. Patient assessment is likely to be more rapid and accurate when performed by a doctor. The doctor can administer effective analgesia intravenously and drugs for medical emergencies and can provide invasive skills such as cannulation and advanced airway management. Another important role for a doctor may be to decide to transport the casualty directly to the most appropriate facility for definitive care, rather than simply the nearest hospital, especially if a helicopter is being used for evacuation. It is often useful if the doctor travels with the patient during transfer to hospital in order to monitor the patient's condition and provide a face to face "hand over."

In the event of fatal incidents, doctors also have the ability to pronounce life extinct at the scene. This helps the work of the police and may remove the need for inappropriate resuscitative efforts being continued until the casualty arrives in hospital.

The mountain rescue doctor also plays an active part in medical training for other team members. This may involve organising formal training courses or less formal training during exercises. Doctors are also able to help with the medical aspects of debriefings after rescues and to follow a casualty's progress in hospital, thus allowing positive feedback for the team members involved in the rescue. The doctor may also be responsible for a rescue team's medical equipment.

Training

There are currently no requirements or guidelines as to what constitutes appropriate training and experience for mountain rescue team doctors. Even if there were they would be difficult to enforce as mountain rescue is a voluntary service and it is up to teams and team members to decide on their policies at a local level. Since 90% of casualties rescued are suffering from a traumatic injury, with 5% suffering from major trauma, it would seem appropriate that mountain rescue team doctors have experience and training in trauma and airway management. This would ideally include experience in an accident and emergency department. Suitable training courses are the advanced trauma life support course and the pre-hospital trauma life support course.

The British Association of Immediate Care runs several prehospital courses, some of which are intended for preparation for the examination for diploma in immediate medical care by the Royal College of Surgeons of Edinburgh. These courses cover aspects of management of medical emergencies and trauma applied to the prehospital environment. There is no course specifically for mountain rescue doctors in Britain. It is essential for mountain rescue team doctors to inform their medical defence union about their involvement in prehospital care of casualties.

All members of mountain rescue teams should be able to work independently and safely in the mountains. This requires skills in navigation, rope work, and movement on steep ground and in adverse winter conditions. A degree of physical fitness is also required. Mountain rescue involves lengthy searches and carrying heavy equipment and casualties on stretchers for prolonged periods, often in severe weather conditions. A good sense of humour is also essential.

Courses covering mountaineering and mountain rescue skills are run regularly at the Glenmore Lodge Training Centre near Aviemore and at Plas y Brenin in Wales. Most outdoor centres run "mountain leader" courses, which cover a wide range of mountaineering skills. Specific skills such as technical rescue, radio communications, and working with helicopters can be gained after joining a team.

All civilian members of mountain rescue teams, including doctors, are unpaid volunteers. Most teams use pager or telephone systems to call out team members, who carry pagers at all times and attend if they are available at the time of call out. The annual number of calls out varies from five to 100 for a few busy teams.

Appeal of mountain rescue medicine

Mountain rescue doctors face the challenge of using their medical skills in a uniquely testing and inhospitable environment, and the work provides an incentive to maintain your skills and physical fitness. Many experiences and skills can be gained while working and training for mountain rescue: mountaineering skills are constantly improved, and opportunities arise for training in advanced driving, off road driving, radio communications, and helicopter aeromedical evacuation. The importance of effective teamwork and the skills of good leadership can also be observed and slowly acquired. Being lowered down a mountainside to a casualty on a winter's night or being suspended 30 metres above a river on a Tyrollean traverse on a training exercise requires you to trust in your team mates' abilities and your team leader's decisions. Such skills are invaluable for the everyday medical practice of any doctor.

Drawbacks

Involvement with mountain rescue requires considerable commitment, which may not be compatible with a busy full time job, especially one with an on-call commitment. Most teams train for one day a month, and it is important to attend as many of these as possible. Accidents tend to happen at weekends, when the hills are busiest, and teams are often called out at night because people have become overdue or have fallen while trying to descend in the dark. This can put a strain on relationships and can be physically and mentally tiring.

Doctors who climb or walk in the mountains often do so to escape from stressful jobs and to get away from the strains of dealing with ill patients. This sense of escape and love of the mountains can be affected by seeing injury and death in this environment. There is also the potential risk of injury to team members during training and rescues. These include road traffic accidents, falls, and helicopter incidents.