Triage: multiple burrials and one rescuer

[eirikainersharp]

Something that I feel is lacking in avalanche education for the backcountry recreationalist is a treatment of triage in a multiple burrial one rescuer senario.

After speaking with Steven Christy from BCA about his thought on multiple burrial education (a topic he recently presented a paper and poster on at ISSW) we came to the conclustion that the avalanche industry as a collective seems unwilling to accept the reality that when you factor in search and recovery times at least one victim is most likley going to die in a multiple burrial situation with a lone rescuer.

What this means then is at some point a rescuer is going to have to decide which victim to rescue first (and by implication who is probably not going to survive). Why then isn't triage given more importance in avalanche education?

As I understand the ciriculum here in Canada, (I'm nor sure about the states), the old on RAC course (US Level 1 equivalent) dosn't covere this at all and as far as I'm aware it still isn't part of the curriculum for the new AST courses.

Although mupltiple burial, lone rescuer situations are a worst case senario, I think it is still important issue. I'm interested in hearing what peoples thoughts are about this gap in education, and maybe even discussing some ideas for triage.

What factors are going to contribute to a persons chance of survival?

[Rednas]

This is an excellent topic and you are right: single searchers looking for more than one person are doomed (or I should probably say the other victims are doomed). I always chuckle when someone tells me how good their beacon is in a multple burial because it doesn't come down to the beacon. It comes down to how fast the searcher can search, probe, and then dig. If it's one searcher for more than one victim there is likely going to be someone dead. Now of course there will always be exceptions to the rule like if everyone is buried very shallowly. But who knows? Best not to get in that avalanche in the first place. But then imagine doing CPR on the guy you get out while everyone else is still buried under the snow. Harsh!

[LeeLau]

It's not covered either in AST 1 or 2. The old CAA Level 1 barely touches on it.

My wife is doing OEC. I'll look through the coursework but that isn't covered.

The ACMG book covers the topic but I don't have the book, am not a guide and don't recall what it said.

I hope to never get into that situation. One thing I haven't practised in a while is being incident commander and taking charge of a burial situation but then presumably this is taught in SAR and I have no SAR background. This is lightly taught in old ARAC; new AST 2.

I'll go through this exercise since it's useful to think it through

1. Assess safety of own person.

2. Assess safety of burial site - ie exposure to further avalanches, hangfire etc

3. Call for help if possible. Turn beacon to receive

4. Look for visible clues of victims on surface (gloves, hands sticking out, body parts, packs)

5. Following a zig-zag line ski down (with skins on) to the avalanche path. If I hear or detect signs of instability immediately seek a safe spot and reassess what to do.

6. Use visible clues, beacon to detect buried victims.

7. On getting first signal, take off skis, take off pack - anchor skis and pack to the side. Skis go tail first in the snow; pack goes around skis. Attempt to detect victim.

8. Victim detected. Assemble shovel. Assemble probe. Dig.

9. Clear airways. Turn off beacon (?? Should this be done??).

10. Attempt to detect next signal. Put on pack again. Put on skis again perhaps unless deposition zone is unskiable.

11. Repeat for next victim.


To sum it up I'd clear airways and move from victim to victim. I've got no illusions that any of this will happen quickly

[snoboy]

My first thought was that a quick airway check/clear and move on would be the way to go. I guess this comes from my OEC triage training, which basically says of they haven't got effective respirations, they get low priority...

Something to think about indeed. I have no illusions that I would be able to save multiple victims by myself. Hence, I try very hard to put only one at a time in the firing line.

[eirikainersharp]

7. On getting first signal, take off skis, take off pack - anchor skis and pack to the side. Skis go tail first in the snow; pack goes around skis. Attempt to detect victim.

8. Victim detected. Assemble shovel. Assemble probe. Dig.

9. Clear airways. Turn off beacon (?? Should this be done??).

10. Attempt to detect next signal. Put on pack again. Put on skis again perhaps unless deposition zone is unskiable.

11. Repeat for next victim.


To sum it up I'd clear airways and move from victim to victim. I've got no illusions that any of this will happen quickly

Lee, I was hoping someone would bring this up.

The propblem I see with this strategy is lets say that your first victim is a deep burial i.e. they are harder to pinpoint and harder and take a longer time to dig out and have a lower chance of survival. Lets also say that the second victim is just under the surface, just deep enought that they can't do a push up and push them selves out, i.e they have a far greater chance of survival. I think that if you followed this strategy your going to waste time trying to rescue someone who has a low chance of survival and ignoreing someone with a higher chance of survival untill it is too late. I think that a strategy along the lines of:

1. Identify the number of victims.
2. Coarse search
3. Pinpoint
4. Pobe (to get a depth)
5. Flag
6. Repeat 2-5 for each victim then choose who has the highest likleyhood of survival and start with them.

Would increase survival rates in this senario. How then do we choose who has the hightes likleyhood of survival?

What I think would make this a lot easier is if there was some statistical analysis into what sort of burrial characteristics increase survival likleyhoods. I havn't been able to find any literature about this though - has anybody else heard of any?

Now to addmit my alterior motives for starting this thread - I'm currently working as a reasearch assistant with the UBC Avalanche Research Group, and I think this might be a problem that I could work on under their guidance.

[taz]

My first thought was that a quick airway check/clear and move on would be the way to go. I guess this comes from my OEC triage training, which basically says of they haven't got effective respirations, they get low priority..

thats how I was thinking but yeah, Erik makes a damn good point with a deep burial. It really has me thinking. if you say flag the first victim and then go to the next, whos to say those other haven't all ready expired due to trauma and the first was the one you could have save or the other way around. i can see why the S1 has so much intrest with it. being about to "see" the vitals of the victims and making a call that way. I think i need to drink some gin and think about this more.

[cj001f]

How often does this scenario occur in real life? Once a year?

[Jer]

In the case where you are the single searcher and there are multiple deep burials, the wisest course of action is to get the hell out of there and pretend you weren't with that group of retards.

[Magnoe]

In the case where you are the single searcher and there are multiple deep burials, the wisest course of action is to get the hell out of there and pretend you weren't with that group of retards.

Was it intentional irony that your avatar is known for burying it's head in the sand?

[nesta]

I think I already alluded to this in the Caution Pieps DSP transceiver.....thread when replying to the Suit who was told in beacon manufacturer's manuals to turn off each beacon as they were found. I advised him that this was not a good practice to get into especially in a real life lone rescuer scenario. cj001f wonders how often this happens in reality, and I can tell him that avalanche rescue dog handlers are trained and validated ( in Canada) on the assumption that the dog team are the only trained rescuers arriving at an avalanche accident and must be a one man (and dog) hasty search/accident site commander/rescue leader until further help arrives. On many callouts this is exactly what they are faced with after being the first flown into a scene. But at the same time actual triage of multiple victims is not part of the curriculum. I think common sense prevails. I do agree this is a topic that should be covered in Avalanche courses, particularly AST courses, where the participants have no aspirations of becoming professionals, but are backcountry enthusiasts who are interested in companion rescue, where the possibility does exist for a multiple burial/single rescuer scenario.

[eirikainersharp]

How often does this scenario occur in real life? Once a year?

If that.... but I think a little thought could make these rare cases have beter outcomes.

[Rednas]

1. Identify the number of victims.
2. Coarse search
3. Pinpoint
4. Pobe (to get a depth)
5. Flag
6. Repeat 2-5 for each victim then choose who has the highest likleyhood of survival and start with them.

The problem with this is that in order to identify the number of victims a single searcher must cover the whole search area if he/she does not know how many victims there are (like if it's someone elses avalanche and not yours!). Maybe some vicitms are at the top, maybe some are at the bottom, maybe some are dead, maybe some are alive, etc. Identifying the number of victims in a slide that you did not see could be very difficult, especially if it's a large slide. This has me very concerned all of a sudden. I like to think that with proper travel technique never more than one person would be caught in an avalanche. I guess CMH and Wiegele are pretty exposed though when they ski 10 or 12 at a time on a slope.

[Rednas]

I think I already alluded to this in the Caution Pieps DSP transceiver.....thread when replying to the Suit who was told in beacon manufacturer's manuals to turn off each beacon as they were found. I advised him that this was not a good practice to get into especially in a real life lone rescuer scenario. cj001f wonders how often this happens in reality, and I can tell him that avalanche rescue dog handlers are trained and validated ( in Canada) on the assumption that the dog team are the only trained rescuers arriving at an avalanche accident and must be a one man (and dog) hasty search/accident site commander/rescue leader until further help arrives. On many callouts this is exactly what they are faced with after being the first flown into a scene. But at the same time actual triage of multiple victims is not part of the curriculum. I think common sense prevails. I do agree this is a topic that should be covered in Avalanche courses, particularly AST courses, where the participants have no aspirations of becoming professionals, but are backcountry enthusiasts who are interested in companion rescue, where the possibility does exist for a multiple burial/single rescuer scenario.

I have never heard of dog handlers or search and rescue getting live victims out of avalanches. Have you? I think we are in deep trouble the more we explore this. Like I know that when multiples happen at huts they try to fly in some CMH guys to help via a radio but they are just a few minutes away. If you are at Rogers and there's a big slide it's going to take a helluva lot of time to get other help there. This is not good! We are doomed. I am thinking about this and we are doomed. Travel one at a time, that is the solution.

[cj001f]

Was it intentional irony that your avatar is known for burying it's head in the sand?

The OP specifically said

avalanche education for the backcountry recreationalist

not professionals. There's much more efficient things to spend time on in the average BC class, like drilling proper procedure and staying the fuck out of a slide, than training for a rare subset of what should be a rare event.

Isn't the first question to ask - is there a problem? How many situations like this arrive a year? If this is some rising cause, or a significant problem, by all means solve it. If you look at the data first you might find other problems which will help people and make a nice paper.

[eirikainersharp]

The problem with this is that in order to identify the number of victims a single searcher must cover the whole search area if he/she does not know how many victims there are (like if it's someone elses avalanche and not yours!). Maybe some vicitms are at the top, maybe some are at the bottom, maybe some are dead, maybe some are alive, etc. Identifying the number of victims in a slide that you did not see could be very difficult, especially if it's a large slide. This has me very concerned all of a sudden. I like to think that with proper travel technique never more than one person would be caught in an avalanche. I guess CMH and Wiegele are pretty exposed though when they ski 10 or 12 at a time on a slope.

I guess this is the advantage of some of the older analogue beacons F2 and M2 as well as the Baryvox on analogue. With these beacons you can pick up and count singnals from up to 80 m.

The problem with a big deposit as I see it is wasting time moving around it from one victim to the next if they are spread out. However again if there was some statistical relationship (my thinking of the possibility for research again) between where in the deposit people were burried and their survival rates this could help the rescuer 'localize their search'.

[eirikainersharp]

Isn't the first question to ask - is there a problem? How many situations like this arrive a year? If this is some rising cause, or a significant problem, by all means solve it. If you look at the data first you might find other problems which will help people and make a nice paper.

Good point. Although with modern transievers survival rates in single burrials senarios are getting better every year. I think it is starting to become worth while to look at these rare cases. This is problem especially interesting since most avalanche courses for recreationals focus heavily on a single rescuer finding (as opposed to recovering) multiple beacons with out any treatment of organizing your rescue to be as effective as possible.

[cj001f]

Good point. Although with modern transievers survival rates in single burrials senarios are getting better every year. I think it is starting to become worth while to look at these rare cases.

So what are you going to cut from a standard course to teach your triage technique? Based on my experience the "average" person requires explanation and some field practice to get the grasp. Say 2-4hrs of class time. Is it really worth that? I get it, the problems interesting..... that doesn't mean the solution is useful.

[eirikainersharp]

So what are you going to cut from a standard course to teach your triage technique? Based on my experience the "average" person requires explanation and some field practice to get the grasp. Say 2-4hrs of class time. Is it really worth that? I get it, the problems interesting..... that doesn't mean the solution is useful.

A simple statistical analysis could give some rules of thumb as to what type of victim is more likley to survive. For example deep burrials have lower survival rates than shallow burrials, people pushed into wooded areas have lower survival rated due to trauma than peole burried in open snow fields. I'm a mathematician, it wouldn't be that hard for me to analyize all these variable and then come up with a simple general matrix; something like: rescue the shallowest burrial first, rescue people in open areas before people in wooded areas.

[taz]

I have never heard of dog handlers or search and rescue getting live victims out of avalanches. Have you? I think we are in deep trouble the more we explore this. Like I know that when multiples happen at huts they try to fly in some CMH guys to help via a radio but they are just a few minutes away. If you are at Rogers and there's a big slide it's going to take a helluva lot of time to get other help there. This is not good! We are doomed. I am thinking about this and we are doomed. Travel one at a time, that is the solution.

in canada, 1, a fernie dog called Kino. The dogs in say switzerland have a better living victim rate (as I put it down to) the shit hits the fan you dial 1414 and you have a dog and handler and/or if not that a medic team (paramedic, ACLS and such) trained in SAR on it's way. you are right, if it hits the fan in say rodgers it is hard to get the help in the time frame needed. and Yes if the terrain and pack suggests that its ify then 100% go one at a time but how many people that are backcountry users and don't have any idea are out there? (I'm off track sorry blame that half botttle of gin) I've thought about it and I'm with Erik that probe, see depth and flag move to next, yes it would be a hard call but so is not going out to save a friend when there is hangfire, its a fucking hard call. if it a big mother fucker you gotta think well, the pressure inforced on the vitcim is going to be huge thats with out trauma in the ride to deposit. It's a luck thing. if god forbid any of us are ever place in such a spot in time we know we DID do all we could when we could. but it would be ( I feel) a great thing to add to the course, it's better to have some form of training for this type of events, you can't perpare for it with out some form of training even if it is only a small about. it still adds up.

[Rednas]

TAZ! Party on! Dude you are right though, a lot of it comes down to luck in mulitple burials. Harsh but true.

[nesta]

I have never heard of dog handlers or search and rescue getting live victims out of avalanches. Have you? I think we are in deep trouble the more we explore this. Like I know that when multiples happen at huts they try to fly in some CMH guys to help via a radio but they are just a few minutes away. If you are at Rogers and there's a big slide it's going to take a helluva lot of time to get other help there. This is not good! We are doomed. I am thinking about this and we are doomed. Travel one at a time, that is the solution.

Nice effort on the solution, but you better go read some case histories, because accidents have obviously happened and will continue to happen, no matter what, guaranteed. Travelling one at a time does not automatically mean only one person in a group is going to be buried in an avalanche should one occur. There have been numerous cases where touring parties have been practising safe travel and yet there have been multiple burials. I merely used the dog example to show that even with professional rescues there is a need for triage sometimes and a strategy for finding multiple burials in all cases where that is the reality. While it's true that dogs usually locate corpses, the handler is always optimistic that he will save somebody's life, for that is his/her mission. The reason they usually find dead avalanche victims is, as somebody else mentioned, the response and travel time to the accident. Some dogs, were they to be at the scene as the avalanche occurred would be able to locate a victim quicker than you could with your beacon. But I'm getting sidetracked here... the point is the dog handler still beacon searches as he works his dog on the site, the dog is mainly there to scent the unlucky victim that is not wearing a transceiver, and there are quite a number of those. So the lone rescuer (the dog handler) could be, and often is, called out to a scene with multiple burials wearing transceivers, frantic, useless witnesses, and before additional help arrives, be faced with the triage situation under discussion in this thread. ( my apologies for the run on sentence) True, quite often other rescuers are there first, which is even better for a dog handler in that he can go about solely working the dog on the site, but as I said before, he/she is trained for the worst case scenario of being the lone rescuer. But back to this thread....It is even more likely a scenario with a recreational back- or side- country touring party consisting of 3 or more people that have been involved in an avalanche where there are 2 or more full burials. I would basically follow Erik's advice on locating, probing, marking and/or uncovering based on burial depth in regards to which victim should be uncovered first. You gotta play the odds and you have to use common sense and logic. No two situations are going to be identical- do your best with what you have.
As for your first question, yes I have and so has taz ( it's Keno BTW, but that was only a single burial)

[cj001f]

You gotta play the odds

So what are the odds of this occurring and triage making a difference.

You guys are putting the cart before the horse.

[nesta]

So what are the odds of this occurring

and you are quoting me out of context.

[cj001f]

and you are quoting me out of context.

To make a point that keeps getting glossed over here - no work has been done to show triage would actually save lives!

I did a quick gloss over the incident reports at
http://www.avalanche.org/accidnt1.htm
I couldn't find an accident in the past 4 seasons that matched the scenario described where triage would have made a difference (based on outcome/injuries).

[taz]

but have some form of triage training WOULD better perpare people for this type of thing. it's like shutting the stable door after the horse has bolted. yes, no work has been done to prove this (yet)would save lives. but think of it this way say victim 1 is under 1m of snow and no vitals, victim 3 may be under say the 60cm but with some form of vitals. so can you point out to me what is the point in working your arse off digging thru avi deposit (say for vic no 1) for half an hour ( say it was slab ). even if they where under for say 2 hours when help gets there the flight nurse is going to say start CPR. the odds are this can and will happen. when you are under you can hardly breath the pressure is that great. snow is fucking every where, under your eye lids and breathing holy shit if you do have a small air pocket it's really fucking hard all you think is fuck I'm stuck, I'm dead. the pressure around you body is some thing you simply can not relate to unless you've been there. there is not a day gone by I'm not thankful for the chance to be alive MY BEST friend is the one who saved me and he was taken by the very same thing 3 years later. have you ever tried to dig thru avi deposit????? 1m deep is fucking alot and hard for one person. think about it in a human form avi deposit freezes it's nothing like digging a pit.