This was mentioned on snowheads <http://snowheads.com/ski-forum/viewtopic.php?t=72110> but I thought I would raise it here.

First of all, even if you are skiing with a guide, have an idea of where you are in terms of the Run (eg: Vallonnets), Sector (Fornet), Resort (Val d’Isere) and altitude and slope aspect if possible.

Going back to the incident in the Vallonnets incident this week, in this instance I would call first, search after.

There are number of reasons for this:-

i. The incident was very close to Fornet where there are pisteurs who can come to help.
ii. Val d’Isere has a helicopter which could get additional resources including dogs to the scene within 5 minutes. Dogs are very quick to find avalanche victims under the snow.
iii. The PGHM from Courchevel could be at the scene in 15 minutes with a doctor, defibrillator - once you’ve dug someone out what are you going to do next? CPR is great while you wait for medical help.
iv. there were two people left, one could call while the other starts a primary search
v. The avalanche was vast with the victims maybe hundreds of meters down hill, it would take considerable time to reach them and one person would not be able to find and dig out people quickly
vi. there may be other victims that you have not seen on the slope

Dominique Letang, head of the ANENA and a guide and former head of a PGHM unit says that in off piste areas the priority should be on contacting the rescue services first. Obviously you should not leave the area or waist time if there is no signal but you can at least be dialling (112 or the local PGHM/CRS number) while getting out your shovel, probe and beacon.

http://pistehors.com/news/ski/comments/1001-backcountry-and-off-piste-rescue-operations-and-methods/
http://pistehors.com/backcountry/wiki/Avalanches/French-Emergency-Services-Numbers
http://pistehors.com/backcountry/wiki/Avalanches/Piste-Patrol-Telephone-Numbers

Obviously a lot depends on circumstances and the area where you are skiing.

davidof - 13 January 2011 12:00 PM

This was mentioned on snowheads <http://snowheads.com/ski-forum/viewtopic.php?t=72110> but I thought I would raise it here.

First of all, even if you are skiing with a guide, have an idea of where you are in terms of the Run (eg: Vallonnets), Sector (Fornet), Resort (Val d’Isere) and altitude and slope aspect if possible.

Going back to the incident in the Vallonnets incident this week, in this instance I would call first, search after.

There are number of reasons for this:-

i. The incident was very close to Fornet where there are pisteurs who can come to help.
ii. Val d’Isere has a helicopter which could get additional resources including dogs to the scene within 5 minutes. Dogs are very quick to find avalanche victims under the snow.
iii. The PGHM from Courchevel could be at the scene in 15 minutes with a doctor, defibrillator - once you’ve dug someone out what are you going to do next? CPR is great while you wait for medical help.
iv. there were two people left, one could call while the other starts a primary search
v. The avalanche was vast with the victims maybe hundreds of meters down hill, it would take considerable time to reach them and one person would not be able to find and dig out people quickly
vi. there may be other victims that you have not seen on the slope

Dominique Letang, head of the ANENA and a guide and former head of a PGHM unit says that in off piste areas the priority should be on contacting the rescue services first. Obviously you should not leave the area or waist time if there is no signal but you can at least be dialling (112 or the local PGHM/CRS number) while getting out your shovel, probe and beacon.

http://pistehors.com/news/ski/comments/1001-backcountry-and-off-piste-rescue-operations-and-methods/
http://pistehors.com/backcountry/wiki/Avalanches/French-Emergency-Services-Numbers
http://pistehors.com/backcountry/wiki/Avalanches/Piste-Patrol-Telephone-Numbers

Obviously a lot depends on circumstances and the area where you are skiing.

I also just read that on there as well, I’d be surprised (to put it mildly) if anyone actually got told anything other than to call first on the courses they mention.

The reasons you cite are all good but I think a major one is (iii) that’s the requirement for advanced life support. The act of digging of someone out, while obviously saving them from potential suffocation, hypercarbia etc can push them into cardia arrhythmia such as V-fib for example plus the considerations of any trauma injuries. You know the figures for trauma so the likelihood is that some medical help is required. The helicopter will be coming with primary or field support such as defibrillators and be able to evacuate the victim to the advanced life support in hospitals.

There’s never really a case where you’re not going to need hospitalisation, you’re simply not going to be planning to dig someone out, stick their skis back on and pop back to the village for a beer and a lie down.

The actual procedure to follow is to call, locate using transceivers, probe, shovel and then clear airways. The first (call) and last (clear airways) are vital. The obvious implication here is that you always need to be able to accurately describe your position.

I’m not surprised that someone from ANENA states the priority is to call for help, it would reflect what’s in the syllabus for guides and others right now (and for some time).

I am not a mountain professional but I am a medical professional. Irrecoverable hypoxic brain injury sets in 5-7 minutes after you stop breathing. So if you pull someone out lets say in the 15 minutes that we read about and successfully perform CPR and resuscitate your buddy the chances are they will have permanent brain damage. Even in the best case scenario it will take at least 2 minutes to make that call and that lost 2 minutes will not be made up by the arrival of a rescue team; no matter how quickly help arrives they will not dig my buddy out in the GOLDEN 5-7 minutes, and that is why I would dig first in single burial scenario, and I would like that to be done for me if I am under the snow.

Having said that when faced with a crisis situation such as the recent avalanches we all have to do what we feel is right under the circumstances, but I think there is little place for making sweeping statements that under all circumstances you should call for help first.

ps It would be a good study for someone interested in this field to look into the long term consequences of those who were successfully pulled out of avalanches. The current survival data (AFAIA) does not tell us how many live with long term debilities.

ace1 - 16 January 2011 05:38 PM

I am not a mountain professional but I am a medical professional. Irrecoverable hypoxic brain injury sets in 5-7 minutes after you stop breathing. So if you pull someone out lets say in the 15 minutes that we read about and successfully perform CPR and resuscitate your buddy the chances are they will have permanent brain damage. Even in the best case scenario it will take at least 2 minutes to make that call and that lost 2 minutes will not be made up by the arrival of a rescue team; no matter how quickly help arrives they will not dig my buddy out in the GOLDEN 5-7 minutes, and that is why I would dig first in single burial scenario, and I would like that to be done for me if I am under the snow.

Looking back to the source of the comments that David mentioned you should realise that there’s not an entirely realistic estimate of how long it does actually take to locate and partly recover someone. If you take a good point of measurement as being the time at which you’ve reached a person and cleared their airways then you’ll be extremely lucky (in anything other than a near surface burial) to recover someone in 10 or 15 minutes. People really, really need to try and move over avalanche debris and dig in it because they’re entirely failing to appreciate the difficulties. I can locate a couple of transceivers in a couple of minutes or a single one in less than 1min30s but I don’t conclude from that I can actually dig a couple of people out in anything like that time. People should think about the most unfavourable scenario, a large avalanche above them, trying to move up through the debris and then digging.

You’ve probably hit the nail on the head though, if I really thought a client could repeatedly dig me out in under 10 minutes after a slide then I’d probably/possibly say they ought to get on with it. But, I don’t think that, I think I want the experts in the air right away.

The golden figures about survival are more quoted than understood it seems to me sometimes. Your survival chances may well be higher if recovered in 10 or 15 minutes but 90-odd percent of a small number remains a small number.

ace1 - 16 January 2011 05:38 PM

Having said that when faced with a crisis situation such as the recent avalanches we all have to do what we feel is right under the circumstances, but I think there is little place for making sweeping statements that under all circumstances you should call for help first.

I think the medical profession really rather like protocols. The medical consultants that come in and do training for us, and I was with one just last week, do tell us we need to get help and to do that right away and that’s pitched at people who do know what they’re doing and do have first aid skills.

I’d also point out that you or I might be able to do CPR, and have a range of other skills for that matter, but it’s far from commonplace in UK skiers particularly. Here in Switzerland young people would actually tend to have those skills, either as part of military training or their basic driving training. In fact, just reading this thread again three things leap out at me :

1. If skiers think they’re going to do “companion rescue” then practicing with a transceiver just doesn’t cut it. They’re going to need some first aid skills. So the money spent on some new fat skis might be better spent on a first aid course (for example http://www.recfirstaid.net/cms/index.php but there are others)

2. They need to be able to describe where they are. We’ve a word (in professional circles) when you can’t describe where you are, it’s “LOST” so maps and an idea how to use them (some courses like http://www.nnas.org.uk/ and I’ve heard the Swiss guy is particularly good )

3. Try and move (up a hill) in avalanche debris and dig in it and then understand whipping out that flash transceiver and getting a probe return is the easier bit. It’s worth being blindingly quick at it so you can move quickly to the real work.

There isn’t a whole load of doubt about this, the first thing you need to do is call for help if there’s a signal. If you’re going to turn round and say that’s not optimum if there’s two of you one of whom is buried then take a second and recall that’s why we think that safest method of travel is a small group, say four people, travelling at safe distances and not exposing the whole group to danger. If you’re not in the configuration then you’re already a step or two down the accident chain before the avalanche even starts.

I don’t claim to be an expert on the causes of hypoxic brain injury, but I did ask a consultant anaesthetist about this at work today, as of all doctors, anaesthetists are the ones who deal the most with patients in respiratory arrest.

I asked about the likelihood of permanent hypoxic brain injury in an avalanche victim who’s airway was blocked with snow during the avalanche.

He said that it is difficult to give precise figures due to the variables involved, but that given that avalanche victims are usually fit and healthy, and that the cooling effect of being buried in snow would work to protect the brain, he would not be surprised if an avalanche victim buried for 20 mins escaped with no long term brain injury.

I didn’t ask about the consequences of respiratory arrest progressing to cardiac arrest, but Ise’s point about cardiac arrest resulting from rough handling of the severely hypoxic victim during the digging out phase sounds very credible to me.

If a victim was to suffer a cardiac arrest while being dug out, then a helicopter with drugs and a defib would represent their only chance of survival to discharge from hospital, so I’m going to continue to encourage the phone before searching approach amongst my friends.

We were fortunate enough to have a consultant anaesthetist give a lecture last week at the EAS professional course and he mentioned the cooling effect of hypothermia as your colleague did.

It’s a good point about victims being fit and healthy but this *may* be negated by trauma. There’s some publications (Brugger, Etter et al) that suggest, if I recall it correctly, that victims that succumb to early onset of asphyxia would be those suffering more extensive trauma in the avalanche. My memory of the data is that it’s hard to say in Europe as avalanche victims aren’t regularly autopsied compared to Canada where they are. One output of this work is that we ought to wear helmets for off-piste and touring more than we do, personally I skied alpine/piste at Les Deux Alpes and Métabief in the last 10 days with a helmet then didn’t bother skiing with a helmet at La Grave for a week so I ought to review that personally.

If your starting scenario is a safe group size observing some spacing then it’s hard to conclude you would do anything other than call if there’s signal. If there’s only two of you then you’re in adverse position from the very start. It’s not surprising that Munter includes group size and management in both the knowledge based 3x3 and cybernetic RM/synthesis.

The Wilderness & Environmental Medicine Journal has a few good papers if you’re looking to read more.

I’ve been told the same, that the cold greatly increases the time for brain damage to occur. If the victim has his airways clear he will probably be able to breath for some time, until he has exhausted the surrounding oxygen/CO2 builds up in the snow/breath freezes the snow around the victims head (this is the idea of the avalung - it expels breath away from the victim’s head).

Obviously the exhaustion of the air supply takes some minutes and seems to account for the rapid drop of in survivability after 15 minutes. There is then a period of stability as those survivors with an air supply succumb to hypothermia.

So I agree with Ise that you want expert medical help on the scene once / during the extraction phase but obviously everything is a judgement call. The main problem I’ve seen (and I organized an exercise yesterday with my club group) is controlling individual personalities without a clear leader; everyone wants to head of and search with their beacon rather than getting probes and shovels at the ready, you then get people turning their beacons back onto transmit prematurely and walking around the site, bystanders arriving etc.

davidof - 17 January 2011 11:07 PM

I’ve been told the same, that the cold greatly increases the time for brain damage to occur. If the victim has his airways clear he will probably be able to breath for some time, until he has exhausted the surrounding oxygen/CO2 builds up in the snow/breath freezes the snow around the victims head (this is the idea of the avalung - it expels breath away from the victim’s head).

Obviously the exhaustion of the air supply takes some minutes and seems to account for the rapid drop of in survivability after 15 minutes. There is then a period of stability as those survivors with an air supply succumb to hypothermia.

Quite, that’s why the survival curve is being massively over-interpreted in the thread you pointed at. It simply doesn’t support the analysis they’re making at all, without distribution it’s a good example about how not knowing sums could kill you.

As it happens, in Switzerland a study of 20 year figures give a median burial of 60 minutes. The raw data could tell you what proportion of the population was recovered in under 15 minutes but it (ought) to be clear it’s a fairly normal distribution, ie recoveries are in mid values and not at extreme low or high times. The median burial time for companion rescue is a lot better at around 20 minutes.

In fact, the source of that data is a paper from SLF titled ”AVALANCHE RESCUE SYSTEMS IN SWITZERLAND: EXPERIENCE AND LIMITATIONS” which offers as one conclusion that better outcomes for organised rescue are, in part, due to mobiles phones and being able to call for rescue.

davidof - 17 January 2011 11:07 PM

The main problem I’ve seen (and I organized an exercise yesterday with my club group) is controlling individual personalities without a clear leader; everyone wants to head of and search with their beacon rather than getting probes and shovels at the ready, you then get people turning their beacons back onto transmit prematurely and walking around the site, bystanders arriving etc.

So we arrive at a point where human factors play the greatest role in outcomes and not the amount of gear you just bought off ebay In this case, group management and having a plan. When I’ve tried to make this point to people in the field I’ve let them run aimlessly around for one exercise then reviewed it asking what could be improved and where time could be saved, it’s quickly identified you need a plan, a coordinator and communication. The next run normally knocks a few minutes off.