/ Severe injury on Annapurna circuit

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jhsp - on 16 Jan 2013
Hello all,

Below is an account of an incident I was involved in. I'd appreciate opinions on what we might do differently in future, and any lessons it might have for others, and any questions you might have.

We were walking the Annapurna circuit, and my group of four friends had fallen in with a few other groups of trekkers, so that there were nine in the group. One of these had hired a guide. Otherwise, we were all trekking without guides or porters. On 5th January we were walking from Yak Kharka to Thorung Phedi, at roughly 4800m. A young man (28 years old??) who was part of the group stumbled on an eroded section of path at 3pm, and fell approx 30m down a steep (60 degree?) section of gravel/scree slope. He came to rest in sight, and appeared unconscious. One person remaining on the path, reported some movement after about 5 minutes.

I climbed down to him, which took me around 20 minutes. He was lying head downward on his right side. He had one open skull fracture of about 3 inches on the top right of his head, which I covered with a glove and applied pressure. I put my down jacket on him, and asked him to blink if he could hear me. This he did, but I could not get a verbal response or any movement from him. I continued to talk to him, cut his rucksack off, and tried to move him gently to a head up position, but couldn't - he was too heavy, and I didn't want to let go of his head. I carefully inspected his head, and found further large skull fractures on the top and back of his head. I tried to cover these and applied pressure. Unable to do much else, I waited for about 15 minutes, at which point four Nepalis from Thorung Phedi arrived.

They immediately lifted him and carried him rapidly down the last part of the slope to the flat river bed and set him down. I then asked them to retrieve his rucksack, remove as much clothing/sleeping bag etc as possible and put it on and under him. I again inspected his head more carefully, and found further injuries, maybe 4 large open fractures in total, one separate, the others joining to the presumed impact point at the back/top of his head. I removed my hat and tried to cover all of them with my hand. Bleeding was continuing, but not massively - I was more worried about hypothermia than blood loss at this point. (Later, in hospital they gave him 2 units of blood)

After an hour, he started to move his left leg in sporadic bicycle kick movements, and make groaning noises. He never moved his right side at all, and I assumed it was paralysed. Breathing seemed fine, and he started to move his head occasionally. At 4pm the valley came into shadow, and the temperature dropped rapidly. I noticed that his skull was easily depressed, and when he moved the bleeding tended to restart. I was concerned about not pressing his skull into his brain, but also wanted to stop the bleeding. He vomited once at about 4.00pm, and I didn't see any signs of blood. I cleared his airway. During this time I tried to keep talking to him, and reassuring him. Two members of our group arrived with more down clothing at 4.30pm. At 5.15pm, more Nepalis arrived from High Camp (above Thorung Phedi) with material for a stretcher. It was essentially dark by the time we got him on to it. I attempted to fix my hat and gloves over his head wounds with duct tape and some bandages for the stretcher journey.

Carrying him up to Thorung Phedi was very hard, and would have been almost impossible without the assistance of the locals who were many times stronger than any of us. Even so, they had to rest 2-3 times on the way. He vomited again while we were carrying him.

There was no power at Thorung Phedi, and the temperature dropped to -15c that night. We put him in a room and all 8 of us sat with him through the night. Our body heat was a very effective heater, and the room remained (slightly) above 0c all night. By now, he could answer yes/no questions, but continued kicking movements with his left leg, and some uncontrolled left arm movements. We checked pulse and temperature hourly. Pulse constant at 122 per minute, and temperature roughly constant around 36.0c.

We got him to swallow, and gave him water via a sponge into his mouth. At first he swallowed about 300ml in 2-3 hours but vomited it up again. We reduced the rate, and got him to retain about 250ml over the course of the night. I removed the hat/glove bandage and applied iodine soaked gauze, which we took turns holding in place by hand - he found pressure painful, and bleeding had pretty much stopped by now. And it helped keep us awake! We changed bandages maybe once or twice more over the night.

We had some oral painkiller - possibly tramadol, but it was a German brand name if so (lent by another trekker). We applied the maximum dose (30 drops every 6 hours, something like that), which appeared to have only slight effect, but the patient asked for more, so it must have done something!

We kept him awake and answering questions all night. As his alertness slowly improved, so did his apparent discomfort. He often contradicted himself with the yes/no answers, so it was hard to find out the areas of pain/discomfort. We had reached a telephone in Ledar (below us) at around 4.00pm, and were promised a helicopter at 6.30 am the next day - first light. In the end, the chopper arrived at 9.45am - a very frustrating wait, with a fear it might not come at all for some reason!

We again stretchered him to to landing zone and loaded him on. This time I found a triangular bandage and did a slightly better job of fixing his dressings to his head! Two young American women he had been travelling with also went into the chopper to help with arrangements at the other end.

Result
---------

He reached Kathmandu on the 6th, and his mother in Canada was contacted 2-3hrs later. She agreed to immediate surgery. Fragments of bone had entered his brain. These were removed, and his skull stapled (48 staples, I think he told me!). Amazingly, no other injuries beyond a large bruise over his eye, and small cuts.

I saw the patient on 14th Jan. He was still paralysed on the right hand side, and seemed to have quite bad pain for an unknown reason in his left shoulder. He could form short sentences, but still had speech problems. He was cheerful, laughed at our cruel jokes, and seemed to be doing pretty well, considering. Apparently CAT scans showed some dead brain tissue, but that's 3rd hand information, so should be taken with caution.

My thoughts:

He was an experienced hill walker, and the section he fell off, while slightly tricky, was nothing that gave any one pause or concern.

I probably should have paid more attention to cleaning the wound. I don't know why I didn't think to make an iodine solution and wash it.

At 3pm it was warm and sunny. I wasn't expecting to be there holding his head for 2.5hrs. I should have taken my own sleeping bag, and a head torch. (We ended up stretchering him in the dark, with only one or two torches between all of us available)I also got scarily cold without my hat/gloves/down, and was starting to contemplate taking my jacket back by the end!

Put more proper wound dressings in my first aid kit (I only had one). The gauze bandages stick to the wound, and the material caught caught up in bone fragments. Messy.

Any thoughts or questions very welcome. The doctors in Kathmandu were somewhat surprised he survived the night!

P.S. His medical insurance was excellent, they never queried any cost, and have also paid out for much greater nursing care than is standard in the hospital.
Simon_Sheff - on 16 Jan 2013
In reply to jhsp:

He fell off a path in the middle of nowhere and received a head injury. You helped him. Well done. Apart from publishing medical information about him without his permission, what exactly do you want people to comment on?
Caralynh - on 16 Jan 2013
In reply to jhsp:

Hard to comment too much without you being there but first, never apply direct pressure to a skull fracture.
Secondly, 2 people should have been sent for help immediately, to arrange heli evacuation.
Finally, SOME attempt should have been made to stabilise his c-spine, especially since he had signs of altered level of consciousness and later altered sensation and reflexes.
On the plus side, at least you got him out, and as said before, no-one who wasn't there should be passing judgement.
John Rushby - on 16 Jan 2013
In reply to Simon_Sheff:

Maybe he/she wants someone with medical training to comment on whether what he did was appropriate and given his injuries would not be unusual in a clmbing environment we could then learn something

The bloke was not named so there' no permission needed

You need more bran in your diet
jhsp - on 16 Jan 2013
In reply to Simon_Sheff:

1) I have his permission
2) I was thinking maybe others with more medical knowledge could comment
3) I'll grant you it was all probably more interesting if you were there. Luckily you didn't have to pay a penny for my thrilling account of this exciting incident, so don't feel too bad.
jhsp - on 16 Jan 2013
In reply to Caralynh:

Mmmm, I wondered about the whole applying pressure thing - now I know! Yes, two people were sent towards a phone immediately, and others were sent towards a nearer (but phoneless) source of help.

Since it's my second bit of serious-ish mountain first aid in 6 months I'm starting to think I should either learn more, or stay away from others ;-)

Caralynh - on 16 Jan 2013
In reply to jhsp:

You have no idea if your actions worsened his injuries (head and nervous system) or whether the initial impact caused all the harm. What you DO know is that you and your mates got him out and he is alive. People, including me, can post on here all they like about textbook management of this sort of incident, but no one who wasn't there can say exactly what they would have done in reality.
Best wishes to your mate for a full and speedy recovery.
John Rushby - on 16 Jan 2013
In reply to Caralynh:
> (In reply to jhsp)
>
> Hard to comment too much without you being there but first, never apply direct pressure to a skull fracture.
>
As someone who regularly uses his head as a brake, that useful to know
Simon_Sheff - on 16 Jan 2013
In reply to John Rushby:
> (In reply to Caralynh)
> [...]
> As someone who regularly uses his head as a brake, that useful to know


Ah the great knowledge of ukc

Depends on the circumstances. People can die from scalp lacerations and sub-dural artery bleeds. Direct pressure would save your life, perhaps at the risk of worsening your head injury.

Also the majority of skull fractures aren't diagnosed until scan. if they are grossly obvious there will probaly be a significant bleed, requiring direct pressure.

So to proclaim sweeping statements 'never apply direct pressure' to skull fractures, is bollocks :-)
John Rushby - on 16 Jan 2013
In reply to Simon_Sheff:

shall we summarise it as:

put a hat on

ring for an ambliance
Simon_Sheff - on 16 Jan 2013
In reply to John Rushby:
> (In reply to Simon_Sheff)
>
> shall we summarise it as:
>
> put a hat on
>
> ring for an ambliance

Beanie best :-)

PontiusPirate on 16 Jan 2013
In reply to Simon_Sheff:

It's worth pointing out that Caralynh is a paramedic.

@ Rubbishy - "As someone who regularly uses his head as a brake" - I reckon you should have your head covered in a metallic sintered compound - less stopping power in the wet, but at least it's more durable! ;-)

PP.
Caralynh - on 16 Jan 2013
In reply to PontiusPirate:

Thanks PP. It is also worth adding that yes, in case of catastrophic haemorrhage then that will take priority. Other than that my advice stands, especially since the OP did mention obviously depressed skull fractures.
Anyway, off to work in a bit, to see if I can apply my particular brand of "bollox" to my patients tonight ;-)
Simon_Sheff - on 16 Jan 2013
In reply to Caralynh:
> (In reply to PontiusPirate)
>
> Thanks PP. It is also worth adding that yes, in case of catastrophic haemorrhage then that will take priority. Other than that my advice stands, especially since the OP did mention obviously depressed skull fractures.
> Anyway, off to work in a bit, to see if I can apply my particular brand of "bollox" to my patients tonight ;-)

Doesn;t have to be catastrophic, just consistent oozing over time.

Don;t apply your bollox to any of my patients :-(

John Rushby - on 16 Jan 2013
In reply to PontiusPirate:

I was hit by a falling vacuum cleaner over Xmas, and spent the morning at Walsall Manor A&E. I have another nice scar now

I looked the part as I went for dinner that evening at some swanky country house hotel, and bled all over the sommelier.
lummox - on 16 Jan 2013
In reply to Simon_Sheff: I hope you have a better bedside manner than your online one.
John Rushby - on 16 Jan 2013
In reply to Simon_Sheff:

If you're in A&E at the Hallam - give Mikey Stockton as clip round the ear from me.
jonnie3430 - on 16 Jan 2013
In reply to Simon_Sheff:
> (In reply to jhsp)
>
> He fell off a path in the middle of nowhere and received a head injury. You helped him. Well done. Apart from publishing medical information about him without his permission, what exactly do you want people to comment on?

He probably wants to get an idea of the best practise way of dealing with the incident so he can learn for the future and improve his skills. I'd be interested too as I applied direct pressure to a heavily bleeding head injury once and would be interested in alternatives to stopping the bleeding without pressure.
NottsRich on 16 Jan 2013
An idle question to no one in particular: As the OP mentioned, is applying an iodine solution to an open skull fracture (in this sort of remote situation) a good idea or not? I have no idea whatsoever but would be interested to hear any suggestions.
PontiusPirate on 16 Jan 2013
In reply to John Rushby:

> I was hit by a falling vacuum cleaner over Xmas, and spent the morning at

I'd forgotten about seeing that incident reported on the other channel!
I nearly choked on my Ovaltine - hang on, why does that sound dubious?

Simon_Sheff - can you state your medical position? The OP is attempting to learn, and hopefully from real outdoor medical practitioners. I strongly suspect he is not wishing to be condescended to, patronised, or witness a petty argument! :-)

To the OP, I know of at least one expedition and mountain medicine specialist, if I can do so in a timely manner, I'll make her aware of your account and see if she has anything to add.

PP.
ads.ukclimbing.com
Simon_Sheff - on 16 Jan 2013
In reply to PontiusPirate:
> (In reply to John Rushby)
>
> [...]
>
>
>
> Simon_Sheff - can you state your medical position? The OP is attempting to learn, and hopefully from real outdoor medical practitioners. I strongly suspect he is not wishing to be condescended to, patronised, or witness a petty argument! :-)
>
> To the OP, I know of at least one expedition and mountain medicine specialist, if I can do so in a timely manner, I'll make her aware of your account and see if she has anything to add.
>
> PP.
I'm a consultant trauma surgeon, and ATLS examiner at the Royal College of Surgeons
I don't know Mike Stockerton, but A&E is at the Northern General and not the Hallamshire.

I haven't patronised the OP, I think he has done a good job. i was slightly irritated by the 'broad' statement that you shouldn't put pressure on skull fractures. ABC comes first. Also as said earlier, only grossly displaced skull fractures are evident 'in the field', it is often a diagnosis made after imaging, so changing your management when you can see is a bit daft. . Its probaly common sense to most people that if there was a glaring hole in someone's head and no bleeding, best to give a wide berth,versus significant oozing - apply pressure

As for iodine don't worry. Its a dirty wound and the injured party has more pressing things to worry about, especially as its likely a dirty wound. Apart from bleeding, shock, neurological injury, meningitis is the sub-acute issue in the days and weeks following, and iodine isn;t going to sort that.

ta-rah! if anyone has any pressing questions fell free to email, but I spending too much time here already!
wibb20 - on 16 Jan 2013
In reply to Simon_Sheff: Agreed. You were giving first aid, and with first aid you treat what you can see/find and you treat it in the order that it will affect your casualty at. You will die if you lose too much blood, so you needed to stem the bleeding - you would not normally apply pressure directly to a fractured skull, but then the treatment is taught without the added complication of bleeding. You should apply pressure around the wound - http://www.sja.org.uk/sja/first-aid-advice/head-injuries-and-seizures/head-injuries/skull-fracture.a...

You did well. In that circumstance, I doubt that there was much more you could have done to improve the prognosis - but none of us were with you to be able to comment 100%!
cuppatea on 16 Jan 2013
In reply to jhsp:

Head (brain) injuries are complicated things, with possible far reaching long term symptoms BUT you have to be alive to experience such symptoms.
SAF - on 17 Jan 2013
In reply to jhsp: You clearly did an excellent job in circumstances that were beyond your control, well done.

The only things that I would say is in the case of open skull fractures, or any wound for that matter, once the dressing is applied you are best to leave it, if it soaks through, apply a second dressing, if that soaks through, only then consider changing the dressing. Everytime the wound is exposed there is a possible route of infection.
The argument of direct pressure, ideally no, but if the bleeding is presenting a life threatening problem then you need to deal with that as a priority.
Personally I would have held back on giving the tramadol to someone with a head injury and reduced level of conciousness, but I wasn't there to see the distress the guy was in.

But again, good job, the guys alive and by the sounds of it making a good recovery :-)
Clint86 - on 17 Jan 2013
In reply to jhsp: Thanks for sharing that. Quite an experience.
Simon4 - on 17 Jan 2013
In reply to SAF:

> Personally I would have held back on giving the tramadol to someone with a head injury and reduced level of conciousness, but I wasn't there to see the distress the guy was in.

That was what I always understood to be the correct course of action.

Will Legon - on 17 Jan 2013
In reply to jhsp: Really interesting account and thanks for posting it. I've led a team on that trek and I train people in outdoor first aid. If I'd have done as you did I'd be pleased with myself. You gave (really good) first aid and you organised an evacuation.

One thing on the 1st aid front to note is the difference between being in an urban environment and out in the wilds. I can see why a UK paramedic might say never apply pressure to a skull injury - they're essentially minutes away from a trauma team with bags of plasma. You weren't.

Lessons for next time - yes better and more 1st aid kit. And all of you should always know or have a note of each other's insurance company with 24hr tel no. the person's address and DoB so that there's no quibbling over money when the call goes out.

Really really well done.
Got a job rob - on 17 Jan 2013
In reply to jhsp: I am a nurse. Not a A+E nurse just an adult nurse. Well done. You did some good first aid, you are now trying to learn what you did well and what you did badly. Thats the greatest thing you have done. Next time, you will now do even better. thank you on behalf of this patients family!
mypyrex - on 17 Jan 2013
In reply to jhsp: As a first aider myself I'd first like to say that you seem to have handled the situation well. I've got a vague idea of where it happened having been there last October and I do not envy the situation you were in.

Also, I think it's worth remembering that when we have to do first aid "for real" we are bound to look back and ask our selves if we could have made a better job of it or done things differently. A few years ag I had to do CPR "in anger". Sadly the chap did not make it. Many times since I have asked myself if there was anything else I could have done. That said, I was told by the paramedic that he was probably dead before I got to him.
gavinj - on 17 Jan 2013
In reply to jhsp:

Good effort!!! You undoubtedly saved his life. Your not a professional, and I think just keeping your shit together and managing the situation as well as you did was a great achievement. Your own self-analysis seems to cover it pretty well.
damowilk on 18 Jan 2013
In reply to jhsp:
Hi, I would add my support to the others that you did a good job.
One point I'd add is in the case of accidents in the wilderness, first priority is safety to you and others, don't create any more casualties. Make sure your own warmth, hydration and safety are taken care of as well as the casualties.

In these situations you work to your level of competence. Its probably not much use telling you the ATLS standard for trained health care professionals. In a nutshell take care of airway, breathing and circulation including stopping bleeding, in that order. Try to fix the neck/spine as best you can after an injury, maybe a cut up bit of ground mat and some tape, and move the head minimally, but trying to keep this in place through a long, complicated rescue in this situation can be very difficult.
I'd agree don't worry too much about infection, that is a down the line problem, unless you were going to be days stuck somewhere. Just try not to make a wound dirtier, and once covered, keep it covered.

You did well.If you wanted to learn more, maybe look into a specific wilderness first aid course, like the ones geared for SML awards.
Hannes on 18 Jan 2013
In reply to jhsp: I would also like to chime in with good job! Obviously there are minor nitpicks and most of them you noticed yourself like gauze straight on a wound isn't a great idea, holding the bandage on wasn't ideal but taping it would have been better and like someone else said tramadol might not be ideal as opiod type drug can depress respiration.

Did you ever check him over properly to make sure he didn't have further fractures or something else?

I'm guessing his depressed skull fracture saved him as the brain had space to swell and he basically gave himself a craniotomy.
jhsp - on 18 Jan 2013
In reply to Will Legon:

You are completely correct about the insurance details. Mine were neatly folded at the top of my rucksack, and no-one had a copy. Pretty useless if I'm half way down a cliff. It never even occurred to me to share them around - it will now! We were lucky that he'd been more sensible, and his friends had copies of it all.

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