Triage: multiple burrials and one rescuer

[eirikainersharp]

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).

Exactly, my point (well kind off). No work has been done to show triage would actually save lives, but no work hasnn't been done to show triage would not save save lives either. The avalanche comunity has a stigma about discussing the fact that in a this situation people are going to die. If you don't accept this then why would you look at triage. I think a paradime shift need to happen here.

Thanks for pointing out that data, it sumplements similar info on the CAA page, however in the form it is there is not enought info to decide wether or not triage would have made a difference: For example the 030106 slide at McBride:

"NAKUSP, B.C. (CP) - Two skiers are dead and another is injured after an
avalanche at McBride Mountain in the B.C. Interior on Friday afternoon.
RCMP said all three were caught in the slide but one managed to dig
himself out. He called for assistance and then set about locating the
other two, only to find they had perished. The avalanche came down about
three kilometres east of the community of Fauquier.
The skiers were part of a group of 12 staying at Valkyr Lodge in the
Selkirk Mountains, said a release from the Back Country Lodges of B.C.
Association
They were not accompanied by professional guides but were equipped with
avalanche beacons and other rescue equipment."

This is possibly a situation where tiriage could have helped, however there is not enough info about the fatalities to decide either way.

[eirikainersharp]

To change the direction this thread is going a bit though here is a question for you all?

If you were in a multiple burrial senario what information (if you had if would you use to triage the situation?

I think we can basically break thes factors into two categories based on the way people die in Avalaches: (category 1) factors that affect asphixiation, and (category 2) factors that affect trauma. The obvious one is burrial deapth (category 1). Another one that I think has to be whether the victimes are burried in woods vs open terrain (2).

[cj001f]

I think a paradime shift need to happen here.

Aside from making wonderful academic papers, why is a paradigm shift needed?

You've decided things need to change before you've proved there's a problem, and before you've figured out if your solution would actually work. Adding complexity without adding value is a NEGATIVE thing to do to rescuers

[eirikainersharp]

To quote myself:

The avalanche comunity has a stigma about discussing the fact that in a this situation people are going to die. ... I think a paradime shift need to happen here.

And I probably got ahead of myself here - what I'm talking about dosn't mean things getting more complicated. I think that if you were in this situation and you had one buddy burried 1m deep and the other 3ms deep you would triage the situation and resuce the shallower burrial first. This is an obivious call, why? because we know burrial deapth contributes to survival rates. Wouldn't it be usefull then if we knew if there were any other factors that contrute to survival rates - hence this thread.

[Tri-Ungulate]

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.

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.

cj's point of the scenario being a touch contrived are well taken, but if I had the presence of mind, I think I'd follow LeeLau's protocol in general. But if probing revealed my first victim to be very very deep (at or near the limit of my probe) I would probably at least consider going to #5 on eirik's protocol. However, I wouldn't keep repeating for each victim, then choose after flagging them all - I'd start digging at the very first victim I found where the probe indicated they might be close enough to the surface that I might get their airway cleared in a "reasonable" amount of time (say, as close to the "magic 15 minutes" as possible). How deep is that? I dunno, prolly depends on how set up the snow is, slope angle, etc. It's a dynamic situation and we can only hope that we make the correct decision. Thinking it through beforehand helps perhaps, so this thread is at least useful to spur the debate.

[Ermine]

Aside from making wonderful academic papers, why is a paradigm shift needed?

You've decided things need to change before you've proved there's a problem, and before you've figured out if your solution would actually work.

I tend to agree, I'm not sure triage would help in Multiple burials. Avalungs might give you more time to triage though? Some people die after 10 minutes of burial...not a lot of time to narrow the search, probe/flag, narrow the next one, etc. Unless you are breathing (air pocket, shallow burial), you're well into brain damage after 10 minutes as well (think drowning).

For the reasearch though, certainly look at ALL multiple burials, not just the ones w/ one rescuer on top. The bad winter in Canada a few years ago comes to mind (14 parished in two slides, two weeks apart).

[LeeLau]

What a depressing topic. Still worth discussing though.

Thks for posting this topic and your thoughts on methodology eirik.

I think TriUngulate's post shows that the response might be highly situational.

[lemon boy]

another situational aspect is that the second(3rd/4th) burial might not be particularily close to your first. Might even be out of beacon range. It's one thing to triage 3 burials w/in 20-30m of one another and quite another to do so if you have to perform a full reaq/search etc.. that may carry you some distance (distance=time) from your original strike.

it might be better to do a simple triage based on whether or not strike one is deep or not

[eirikainersharp]

Good points all. Thanks!

[summit]

Aside from making wonderful academic papers, why is a paradigm shift needed?

You've decided things need to change before you've proved there's a problem, and before you've figured out if your solution would actually work. Adding complexity without adding value is a NEGATIVE thing to do to rescuers

How so? The change may not even add complexity! The change may add clarity if not simplicity. Perhaps the conclusion will be "if there are multiple burials, just start digging on the first one you find until they are unburied." just an hypothetical example...

The point is to clarify the situation so the rescuer is not faced with the complexity of trying to figure out how it should work as it happens.

[summit]

I couldn't find anything detailed that dealt with the questions posed here specifically. So, I wrote something.

WHAT IS TRIAGE AND WHEN IS IT NEEDED?

Triage literally means “sorting.” We use it as a way to best allocate resources. Triage is needed when there are multiple victims such that at least the initial rescuers or resources are overwhelmed.

WHAT IS OUT THERE NOW ON AVALANCHE TRIAGE?

As it stands now, there are no recommended methods for triaging buried victims, only for triaging unburied patients against buried victims and other unburied patients. As it was taught to me in Avi I: simply, locate and dig up each victim as they were found, perform minimal stabilization if they are breathing, move on to the next burial and repeat. It may not be discussed in Snow Sense, but it is being taught at the Avi I level, just perhaps not in every course.

A few books make mention of the order of action in multiple burials. Mountaineering 7th ed. states that you should dig up a located victim and, “Once you have determined that the rescued individual does not need urgent care, continue to search for the other buried victims” (358). That is what you would expect for companion and organized rescuers! Find, Unbury, Triage (treat)... Find, Unbury, Triage (treat)... (for the SAR types, remember LAST… Locate, Access, Stabilize… Locate, Access, Stabilize… ...Transport)

Very simple: Find, unbury, first aid - Move on

Methods for larger groups are found as well in that basic bible, The Avalanche Handbook (2nd ed.). "When more than one victim is buried, two persons concentrate on locating the first victim and the remainder continue searching" (McClung & Schaerer, 189). The rest is as you expect, recover the victim then, "first aid is rendered to the victim, and the search continues for other victims" (190). I'm not sure what they base their recommendation on, but likely 1975 publications from the Italians.

There are a few papers out there with guidlines for advanced triage of unburied patients by medical personnel. They usually involve methods that are not relevant to the lay rescuer here. The guidlines are actually not relevant to many professional rescuers due to equipment, training, and protocol issues. If anyone wants to know the ICAR/WMS guidelines for resuscitation efforts in avalanche victims, let me know. I haven’t seen any papers which go in depth about triage when dealing unburied AND still buried victims. The buried victims are in a black box which is why the books say what they do. I have not seen anything published on triaging buried victims for rescue priority based upon burial depth. Maybe someone else has read something and will mention it.

WHAT ABOUT THIS NEW IDEA OF TRIAGING BY BURIAL DEPTH?

As Redas points out, eirikainersharp's protocol of "locate all victims, determine who to dig out first by depth" has the potentially fatal flaw of time delays resulting from locating spaced out victims. Also, how many recreators carry flags to mark the burial positions, last seen points, signal peaks, and article finds? I've never met a recreator who carried flags that wasn’t a professional otherwise. If you have flags and a large group, like in an organized rescue, it makes sense for some people to continue searching for the next victim while the first group tries to unbury the first victim found.

My personal thoughts on rescue triage based on burial depth: In our single companion rescuer scenario, if I were to find a victim… and they were deep… and I heard another transceiver *nearby* MAYBE… JUST MAYBE… I would locate and probe. If I did and they were shallower, of course I’d recover them first. If they were deeper, I’d have a sick feeling in my stomach if the first find died and I spent precious minutes locating and probing a second victim I didn’t start digging on (see more later). Would I go romping 250ft across the debris field to catalog burial depths of distant victims? Not likely, but it depends how many people in my group are available. If I have three rescuers? YES, someone is probably going over to at least locate and determine the depth the next victim while the first two dig. Maybe they’ll start digging up the second victim or maybe they will come back and help dig out the first guy. 1m of heavy debris can take three people a long time.

My opinions are open to change if someone has better information and arguments. Right now, I am not convinced that eirikainersharp’s protocol is the right one. What would need to be shown is that the time spent doing all the locations first leads to a statistically significant increase in positive outcome for victims versus having that time spent digging in with current method of “dig as you find them.” On the other hand, is there any evidence to show our current method, not triaging buried victims against each other, is much more effective? So maybe someone can convince people, logically, that the “find them all and triage by depth” method is the better way even if only for certain situations.

In reality, TRIAGE is USUALLY going to be based on THE UNBURIED PATIENT, not the buried victim.

It is somewhat strange to have this discussion about how the recreational backcountry enthusiast should perform avalanche triage when it is not a given that they know CPR, much less basic medical and triage knowledge. In reality, triaging buried victims doesn’t require any medical training. Triaging unburied patients, even against buried victims, does require knowledge. Can you perform CPR? For current basic avalanche triage, you need to know a few things from CPR training.

Scenario: Your two partners are buried. You locate the first beacon, probe the victim, and unbury her head and chest. She is unresponsive and pale. You look listen and feel. She is apneic. You open her airway. She is still apneic. You give a few rescue breaths. She is still apneic.

What do you do? Maybe you checked for a pulse when you were doing your look/listen/feel for breathing, maybe not. Maybe she had a pulse. Maybe she didn't. It doesn't matter. Guess what you are NOT going to do until ALL victims are recovered, stabilized, and removed from immediate danger? CPR You triage her as black (expectant/deceased). You perform a head-tilt/chin-lift to leave her airway open and you leave her lying there in the snow. You move on to locate and unbury your other partner.

If you are performing CPR or rescue breathing, guess what you can’t do? Help anyone else. While the previous scenario was somewhat clear cut, there are not always clear answers to every situation in avalanche triage. It is especially difficulty if there is only one rescuer and you end up with a critical patient while other victims are still buried. If YOU have to triage, any situation or type of triage, and somebody ends the day in a body bag, YOU are probably not going to be feeling very well even if you did everything right.

THE FUTURE OF BURIED TRIAGE: What about the new Barryvox Pulse (BP)?
It doesn't necessarily clarify things:

SCENARIO: You have a BP, your two partners have a BP and a Tracker. They get buried. One beacon shows a positive life signs, but you probe it to a depth of 2.4m... do you go see how deeply the other guy is buried or just start digging up the positive life signs? Did you walk over the other beacon to get to the one with life signs? After all, your other friend has no life signs detector (or if he had a BP it could even be a false negative (malfunctioning detector)) but he could be buried at .5m. If you don't remember if others have the BP or you come upon the rescue, can you really prioritize a signal showing life signs? Can you walk past others? What if the positive is buried deeply? It could even be a false positive. Quite the quandary, no?

It is a different world if everyone is wearing the detectors and they are compatible and reliable. I think this is the future. It could be easily argued that any reliable information beats the black box we are dealing with now.

[nesta]

Lots of good stuff here Summit. The only part I'm questioning is when you said "how many recreationists are carrying flags" for marking- you're right, probably zero, but you can use a ski pole, tree branch, your hat, anything you can think of that's not going to move. Forget about marking signal peaks etc, mark only a probed body. Now I agree that there are a lot of variables which makes this quandary of if he/she is buried to a depth where statistically the chances of survival are slim at best, do I leave him/her to locate the other signals which could be a great distance away ?, or do I spend that time digging and rendering the necessary first aid, all the while hoping the others aren't buried at significantly shallower depths?, a FREAKIN Nightmare! Since each potential situation like this, one which cj001f feels is extremely rare to begin with, is unique, I'm not so sure a standard protocol can be developed, while at the same time I'm not so sure some of the examples you've brought up are necessarily the correct way to proceed. In other words, it is entirely situation dependent. One thing I thought of as you were mentioning the distance between victims being a nagging factor, is that if you were the lone rescuer, don't you think you would have a fair idea where those victims were buried to begin with based on LSP's, surface clues etc.? ( or at least how far apart they were relative to one another) Then you would have an overall picture in your mind how to proceed in terms of your decision whether to uncover or not based on the burial depth as you began to pinpoint your touring partners. Triage... first rule of...do the greatest good for the greatest number.

[Jer]

Good points all. Thanks!

No. Mine was not a good point.

[summit]

NESTA: one thing you said I thought should be repeated: "significantly shallower"
It is a term to think about. How much shallower does a person have to be to make up for the lost time? That is key to the idea of burial triage by depth. I'm also thinking debris density probably plays a huge factor since debris density can vary from 200kg/m^3 to 1000kg/m^3! Obviously, it is easier to dig through a small dry powder sluff than a slush flow.

As far as distance being a factor... yes you may have general idea of where your companions are buried for the reasons you said, but there is still searching and pinpointing to consider. I was thinking that if they are farther arpart, the burial depth difference would have to be greater for depth triage to trend towards a positive difference. There is vertical vs horizontal distance to consider. Additionally, the debris field terrain makes distance more or less of a factor. Supportive flat debris is much easier to travel on than huge chunks of slab that break apart. Consider that if you may be walking all the way back to the first victim you found under depth triage.

If victims are close together, isn't there a better chance that they are at similar depths? (Paging someone who has read a lot more case studies than I have)

Unless you are breathing (air pocket, shallow burial), you're well into brain damage after 10 minutes as well (think drowning).

If you aren't breathing at all due to pressure, occluded airway, or no airspace, you could start your brain damage in 4 minutes! 10 minutes and your are most likely a vegetable.

If you are breathing, you still most likely to die of asphyxiation except it will be from hypoxemia secondary to hypercapnia (ie CO2 toxicity).

even if they where under for say 2 hours when help gets there the flight nurse is going to say start CPR.

Not always... or at least not always for very long... helicopters have monitors and thermometers, thankfully, and flight nurses/medics usually have protocols for field pronouncement. Victims may even meet obvious signs criteria. It all depends...

[nesta]

NESTA: one thing you said I thought should be repeated: "significantly shallower"
It is a term to think about. How much shallower does a person have to be to make up for the lost time? That is key to the idea of burial triage by depth. I'm also thinking debris density probably plays a huge factor since debris density can vary from 200kg/sqm to 1000kg/sqm! Obviously, it is easier to dig through a small dry powder sluff than a slush flow.

As far as distance being a factor... yes you may have general idea of where your companions are buried for the reasons you said, but there is still searching and pinpointing to consider. I was thinking that if they are farther arpart, the burial depth difference would have to greater for depth triage to trend towards a positive difference. There is vertical vs horizontal distance to consider. Additionally, the debris field terrain makes distance more or less of a factor. Supportive flat debris is much easier to travel on than huge chunks of slab that break apart. Consider that if you may be walking all the way back to the first victim you found under depth triage.

If victims are close together, isn't there a better chance that they are at similar depths? (Paging someone who has read a lot more case studies than I have)



If you aren't breathing at all due to pressure, occluded airway, or no airspace, you could start your brain damage in 4 minutes! 10 minutes and your are most likely a vegetable.

If you are breathing, you still most likely to die of asphyxiation except it will be from hypoxemia secondary to hypercapnia (ie CO2 toxicity).


Not always... or at least not always for very long... helicopters have monitors and thermometers, thankfully, and flight nurses/medics usually have protocols for field pronouncement. Victims may even meet obvious signs criteria. It all depends...

Some more good points to ponder... I hope Eirikainersharp is taking all this in. You're probably correct about burials close together being at reasonably same depths, although that depends on terrain ( benches, gullies, obstructions etc) and also how you define closeness or distance. I was thinking if they were +/- 50 m apart to use an arbitrary figure, where that would not necessarily mean same depth of burial, and the sort of distance that would really pose a dilemma in the mind of the lone rescuer, as he/she could probably manage that type of distance no matter the debris type and/or any type of terrain features. Whereas shovelling time of the first pinpointed victim would be very dependent on depth and density of the debris as you've said. Also, if correct travelling or skiing techniques were being employed in the first place prior to the accident, I suppose the distance between burials would rarely be close enough that you would not even need to use the pinpoint in a circle method to go to the 2nd beacon, and again, you would hopefully have picked up a fair bit of information as to the approximate location of your buried comrades by watching the avalanche from a safe location.
A small point but I think you meant kg/m cubed for your density units, not kg/m squared ( never know someone might learn something from all this discussion). Perhaps your last few words of your post sums this whole thread up... it all depends!

[eirikainersharp]

Thanks so much guys - these last couple of posts have really given me some good ideas.

One question raised was: If victims are close together, isn't there a better chance that they are at similar depths?

I think that this question has differnt answers depending on if you are talking about displacement across the deposit or displacement along it.

For displacement across the run out - although older dynamics models assumed that avalanches had a turbulent component modern dynamics models have decided to assume a more laminar flow - this would suggest that if victims are close togtheger there is a good chance that they are burried at similar depths.

However what will have a significant impact on burrial depth though is where about in the runnout the victims are located. Avlanches deposits do not have a uniform dept along the runout but have a distribution dependent on the distance from the beta point (where the slope angle first decreses to 10 degrees). Thus I think two victims burried relativley close down the runout could have a large variance in their burrial depth.

These statistic (if I can find evidence of it - which I think I can) might be a very usefull way of triaging without having to find and flag (and when I say flag - I simply mean mark - with a glove pole whatever) multiple beacons.

I think the issue Nesta raised of scale is an important one, in terms of debris field and in terms of burrial depth. I think one thing I am going to have to look at is under what scale is it worth considering triage. The standard for a CAA level 1 (basic professional, competent recreationalist) is to be able to find 2 beacons burried in 50m by 50m search area in under 5 minutes and I was thinking on using these parameters as the base assumtions for my research.

[eirikainersharp]

By the way Summit I really appreciated the thought and time you put into your post - you gave me lots to think about you two Nesta. Do you mind if I ask you guys what your background's are?

[nesta]

don't mind at all. i'll PM you.

[summit]

I think the issue Nesta raised of scale is an important one, in terms of debris field and in terms of burrial depth. I think one thing I am going to have to look at is under what scale is it worth considering triage. The standard for a CAA level 1 (basic professional, competent recreationalist) is to be able to find 2 beacons burried in 50m by 50m search area in under 5 minutes and I was thinking on using these parameters as the base assumtions for my research.

The issue of scale is indeed important. I questioned it as well when asking at proximity should I consider determining the depth of a second beacon before digging... right now I"m thinking VERY close by for the single rescuer.

I still think that there is a better way than trying to determine the depth of ALL beacons before digging. Something that addresses the issues of scale both of victims and deposition size and consistency.

See below for one based on your pointer (although it is hampered by large avalanches)

However what will have a significant impact on burrial depth though is where about in the runnout the victims are located. Avlanches deposits do not have a uniform dept along the runout but have a distribution dependent on the distance from the beta point (where the slope angle first decreses to 10 degrees).

This is very interesting point, but is it relevant to avalanche triage? If you are locating and marking, aren't you going to determine the burial depth with a probe?

On the other hand... those very skilled with their beacons and with vizualizing locations in their head could proceed to what might be deepest point on the runout of a smaller slide and then be able to discern the general direction and range to multiple victims locations and then choose one to unbury first based on the range and bearing indicating that burial to be in an area of the runout that is likely to be shallower.

This offers a great increase in speed over the "locate and mark all" method because there is no pinpointing and probing of each beacon... indeed one need not go that near each buried beacon. Only a little extra time would be spent before pickign one based on probablitliy of shallower burial!

The longer the range of the searching beacon, the better this (very imprecise) technique will work.

Caveat: obviously range can be way off depending on the buried beacon's orientation. The bearing could also be way off depending how the flux lines are going. The probability of a serious bearing discrepency increases with range.

This technique will be FAR easier with an S1 or Pulse I think...

CONS:
Requires an Ortovox S1 or Barryvox Pulse beacon otherwise requires well above average beacon skills and very good visualization skills under stress
May be confusing to the reacreationalist
Time to start of digging is great than simply going after the first signal acquried
Speed and effectivness badly impaired by large deposition areas and short ranged beacons

PROS:
Much faster time-to-start-of-digging than locate-all-then-dig triage
Likely improved chances of choosing a shallower buried victim to dig on than by choosing based on first signal encountered

EDIT: I have a different idea... I'll post tomorrow... including some sample protocols...

[eirikainersharp]

ohh the suspense... I can't wait summit!

[Jer]

You know, maybe it is time for a mathematical analysis of avalanche rescue strategies. My gut feeling is that the important variables (time to find, time to dig up, airspace, trauma, etc.) will be so stochastic that their variance will overwhelm the expected effects of modestly different strategies, which means that all reasonable strategies will yield (on average) equally bad results. But maybe such an analysis would identify parts of the problem where additional effort might yield significant payoffs.

Has anyone done any such research and published it? It'd be titled "Models of avalanche rescue and recovery" or something like that.

Seriously, you guys who know the literature. Anybody seen it?

[eirikainersharp]

No, I havn't seen anything like that. I don't know if I agree with you though, just on a gut feeling. I'm going to go do a little digging.

[Ermine]

... My gut feeling is that the important variables (time to find, time to dig up, airspace, trauma, etc.) will be so stochastic that their variance will overwhelm the expected effects of modestly different strategies, which means that all reasonable strategies will yield (on average) equally bad results.

Errr, yea. I'm wondering if in a few years...maybe a decade, technology might help w/ a multiple burial triage strategy (avalungs, fancy new beacons). Dogs might still be your best way to know which one to dig up first? Time is of the essence, so it's just a F'ed up situation to begin with...and digging in solidified avalanche debris (where's the backhoe)?

Still might be a good research topic? Unless there is an easy checklist, the basic avie classes would still rather teach avoidance than some flowchart. We're supposed to be skiing one-at-a-time anyway and making good trerrain choices on the uptrack?

[Ermine]

A couple dismal examples. I've skied near these accidents. Friends came in a week after the second one and saw the holes in the snow. I'd love to read some conclusions from research...but even w/ multiple rescuers who are on the ball:

http://www.avalanche.org/proc-show.php3?OID=17534

http://www.avalanche.org/proc-show.php3?OID=17414

[summit]

A couple dismal examples. I've skied near these accidents. Friends came in a week after the second one and saw the holes in the snow. I'd love to read some conclusions from research...but even w/ multiple rescuers who are on the ball:

http://www.avalanche.org/proc-show.php3?OID=17534

http://www.avalanche.org/proc-show.php3?OID=17414

It is hard to tell anything becaues there is no information on the order of rescue and burial depths and times... etc...