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Topic - Severe injury on Annapurna circuit

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.
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