Suspension Trauma

[Bob Mehew]

Following discussion within the BCA's Training and Equipment Working Group, a poster plus back ground material has been produced on the topic of suspension trauma, see BCA News. (And for the pedants, trauma was chosen in favour of syncope being the medical term for fainting, that is the short term loss of consciousness; the concern here is the long term loss of consciousness.)

 

[georgenorth]

Following discussion within the BCA's Training and Equipment Working Group, a poster plus back ground material has been produced on the topic of suspension trauma, see BCA News. (And for the pedants, trauma was chosen in favour of syncope being the medical term for fainting, that is the short term loss of consciousness; the concern here is the long term loss of consciousness.)

Are there many examples of cavers having suffered from suspension trauma worldwide?

 

[mikem]

No, but then we are small fry compared to 80,000 members of BMC & "over 130,000 rope access technicians trained by IRATA,"

Still, it's worth being aware of.

 

[cap n chris]

Are there many examples of cavers having suffered from suspension trauma worldwide?

It has happened and there are accounts of it. Because it's relatively sudden in onset and brain death can occur alarmingly quickly, it's (IIRC) the reason why the CIC assessment(s) for mid rope rescue give you a 6 minute window to effectively and capably execute the rescue, be it traverse, ascent to descent, or descent to descent, past a deviation or rebelay (and if you can't do it in this time, you fail or get deferred for re-assessment ); sudden onset can result in death but I think the main reason for the time constraint(s) is to ensure an airway can be maintained in the event of unconsciousness on rope. In reality my guess/hunch is that most mid-rope emergencies wouldn't get solved in anything even remotely sub-six-minutes so the casualty would have to rely on good fortune/luck etc.. Mid rope rescue isn't something to entertain lightly as it can easily result in additional collateral. By the time cave rescue have turned up I would imagine it's a case of que sera, sera. I also recall it has other names/terms such as Harness Induced Pathology, Orthostatic Intolerance etc., but admittedly it has been a while since I re-upped on this topic. Despite its rarity it should be food for thought for all cavers doing SRT because my feeling is that many cavers believe that being able to progress on rope up/down/sideways equates to being an SRT caver whereas the full gamut of techniques including rigging/derigging/improvised and full rescue would be my preferred definition for being "able to do SRT".

 

[Badlad]

I wonder why trauma was chosen over syncope, intolerance, etc. This is the exact opposite conclusion that the rope access industry came to after extensive professional overview. The process is not a trauma or traumatic so the description was deemed to be misleading. There is good advice in the annex of the IRATA ICOP.

When I was a regular rope access trainer I struggled to find any real examples of the condition. Sure the symptoms can be produced under controlled circumstances but real life examples were impossible to find. There was one in America which involved a worker suspended in a fall arrest harness by dorsal attachment. Several caving/climbing incidents are thought to have involved the condition but I don't think any have been professionally proven.

I'd certainly like to hear of some examples if anyone has found any.

 

[mikem]

I expect it's simply because people recognise the word as being a bad thing... (& it's been in the public consciousness, which other terms haven't)

 

[georgenorth]

It has happened and there are accounts of it. Because it's relatively sudden in onset and brain death can occur alarmingly quickly, it's (IIRC) the reason why the CIC assessment(s) for mid rope rescue give you a 6 minute window to effectively and capably execute the rescue, be it traverse, ascent to descent, or descent to descent, past a deviation or rebelay (and if you can't do it in this time, you fail or get deferred for re-assessment ); sudden onset can result in death but I think the main reason for the time constraint(s) is to ensure an airway can be maintained in the event of unconsciousness on rope. In reality my guess/hunch is that most mid-rope emergencies wouldn't get solved in anything even remotely sub-six-minutes so the casualty would have to rely on good fortune/luck etc.. Mid rope rescue isn't something to entertain lightly as it can easily result in additional collateral. By the time cave rescue have turned up I would imagine it's a case of que sera, sera. I also recall it has other names/terms such as Harness Induced Pathology, Orthostatic Intolerance etc., but admittedly it has been a while since I re-upped on this topic. Despite its rarity it should be food for thought for all cavers doing SRT because my feeling is that many cavers believe that being able to progress on rope up/down/sideways equates to being an SRT caver whereas the full gamut of techniques including rigging/derigging/improvised and full rescue would be my preferred definition for being "able to do SRT".

I agree with everything you say about mid-rope rescue. For me, by far the most critical scenario is to deal with an unconscious casualty though.

I’d also be really interested to read any accounts of so called suspension trauma occurring in the real world. The combination of the casualty being conscious, suspended and unable to move certainly seems unlikely.

 

[Bob Mehew]

Are there many examples of cavers having suffered from suspension trauma worldwide?

Diagnosing a fatality due to Suspension Trauma is not easy. The only UK circumstances which might just fit is the twin fatalities in Ireby Fell Cavern in 2001. A newspaper reported "A pathologist's report said the men were probably exhausted and suffered hypothermia when hit by the freezing water, losing consciousness and drowning." The Coroner recorded verdicts of death by misadventure on both men. However, the late Paul Seddon HSE report entitled "Harness suspension: review and evaluation of existing information" cites a major piece of work by the Medical Commission of the French Federation of Speleologists in the 1980s which includes several deaths.

Georgenorth also wrote "I’d also be really interested to read any accounts of so called suspension trauma occurring in the real world. The combination of the casualty being conscious, suspended and unable to move certainly seems unlikely."

One of the French descriptions was "the caver was freed quite quickly by his friends, but was in a very confused state. He was placed in the recovery position at the bottom of the shaft for 20 hours, but died."

 

[mikem]

You don't need to be conscious for it to become a potential problem. (Unless death is extremely traumatic then it's generally difficult to prove any single cause) https://fallarrest.com/suspension-trauma/suspension-trauma-fact-or-fiction

 

[cavetroll]

I suspect a larger cause of the lack of data for suspension syncope is that typically this does not happen in isolation: there is usually a reason why someone is not moving at all whilst on a rope. That could be hypothermia, could be head injury, could be a medical condition or could be simple exhaustion (etc). That condition may well be more obvious and may be mistaken for the cause of unconsciousness. I suppose the highlight for us is that there is evidence to support the idea that an immobile casualty may quickly become unconscious regardless of the reason for the immobility.

 

[georgenorth]

I suspect a larger cause of the lack of data for suspension syncope is that typically this does not happen in isolation: there is usually a reason why someone is not moving at all whilst on a rope. That could be hypothermia, could be head injury, could be a medical condition or could be simple exhaustion (etc). That condition may well be more obvious and may be mistaken for the cause of unconsciousness. I suppose the highlight for us is that there is evidence to support the idea that an immobile casualty may quickly become unconscious regardless of the reason for the immobility.

That makes sense. I guess the next question is: does that mean that suspension trauma is relevant as far as the rescuer is concerned? An event/injury that is sufficiently serious to *completely* immobilise the casualty is going to require rescue from the rope asap anyhow.

 

[Mark Wright]

There was a fatality a good few years back where a worker fell from the end of a crane jib they were building. He was wearing a harness with a dorsal attachment. He was shouting down to his workmates that he was OK but unfortunately they had no rescue plan for this scenario. He was eventually rescued by paramedics who used a telescopic crane with a rubbish skip on the end. The casualty was unconscious when they eventually got to him and had been for over 20 minutes. They immediately put him into the recovery position and that is what killed him!! He had a heart attack due to his heart being unable to cope with the fast flow of blood back to the heart. The recommendations in the IRATA ICOP suggests taking much more time over bringing the casualty into the recovery position.
A number of rescue systems were developed for industry after this incident allowing a casualty to be remotely clipped with a telescopic pole and lowered to safety. The Gotcha and Rescue Genie are two examples of the kits that were developed.

 

[Cavematt]

Whatever it's called (Suspension Trauma was the term back in 2006), it astonished me how quickly it could happen. I was at the top of the Bar Pot entrance pitch, assisting a novice, who had done all the club's usual training, up through the tight pitch-head. She was tired after a trip to the Main Chamber but I remember thinking we were 'home and dry' at this point. She struggled in the narrow section to get high enough to get off the rope. After what must have been only 5-10 minutes of struggling, with me providing the usual assistance from arms reach away, she started saying she was tired, and moments later, she was fully unconscious on the rope.

From first encountering issues that limited her movement, to becoming unconscious was probably around 15 minutes.

Thankfully I had the rope from the main pitch, and the guy below me had enough knowledge of how to do a cut rope rescue (and first aid training for once she was down there) to talk me through it from below, and the outcome was good.

At the time, I was under the belief that she had gone unconscious due to suspension trauma. Is this incorrect? Or is this just incorrect terminology these days? Either way, it was alarming how quickly a tired and stationary caver in a harness can succumb to this and I have always been surprised that it has never been a bigger issue in caving. Anyway, it can only be a good thing for BCA to be making cavers aware.

Interestingly, I believe the advice in 2006, when the above incident happened, was to position the casualty with their core body and head above their legs to prevent the potential sudden rush of poisoned, CO2-rich blood from the legs to the brain. This is what was done in our situation, but interesting to see that the advice has been updated to go against this previous advice.

 

[phizz4]

This theoretical scenario was covered on one of my first aid training courses (16 hour Outdoor FA) and the advice, after releasing the casualty, was to sit them upright with their legs stretched out in front of them. This was to stop the toxic blood rushing to the heart and other critical organs. Lots on the internet about this. The instructor used the term Suspension Trauma and we understood immediately what he meant, I'm not sure that we would have been so familiar with the other terms proposed.

 

[Cantclimbtom]

I'm getting schooled reading this thread, I'd have aimed to get them down asap and put them straight into recovery position asap and not have known the risks here. (Edit: and I don't remember any mention of that in IRATA2, although that was a long! time ago for me)

Cavematt, Interesting you mention Bar Pot. I went down Bar Pot in late Summer as a solo trip but ran into some other cavers and we ended up a combined group (to avoid double rigging etc, I'd got there first). One of the party had considerable difficulty on exit, about 40 minute struggle. I was going last (derig my ropes) and he was second from last, so I was watching from below. For the first 10 minutes I was in silent tears of laughter and only just managed to retrain myself from shouting "helpful" comments. Actually as it progressed I got very worried and there was considerable relief when his companions managed to haul him from above. Without doubt, we were getting close to it being a rescue rather than self-rescue by his 2 companions (Edit or me jugging up to pick him down). It could've very easily have gone the way of your story, but in my ignorance I'd have put him straight into recovery. Glad I read this thread!

 

[mikem]

Useful summary here:

Ask a Pro: What is Suspension Trauma (aka Harness Hang Syndrome)?

orthostatic intolerance hypotension hang syndrome suspension trauma

www.dynamicrescue.com

Whilst hanging in the harness may have contributed to Cavematt's incident, it sounds like there were underlying blood pressure issues too:

Syncope (Fainting)

Syncope is also called fainting or "passing out.

www.heart.org

Interestingly, I believe the advice in 2006, when the above incident happened, was to position the casualty with their core body and head above their legs to prevent the potential sudden rush of poisoned, CO2-rich blood from the legs to the brain. This is what was done in our situation, but interesting to see that the advice has been updated to go against this previous advice.

You always treat for the most serious threat & aren't always close enough to know exactly what happened.

 

[ChrisB]

I'd have aimed to get them down asap and put them straight into recovery position asap and not have known the risks here.

@Cantclimbtom, that is the current BCA advice in the first link.

The 2009 HSE report (and the discussion in mikem's first link, which references it) says there's no scientific evidence for Reflow Syndrome following suspension and that all subjects recovered in a supine position. Mark Wright's account that it did occur is anecdotal not scientific but I don't see how a scientific study could address such incidents.

On a recent CNCC first aid course we were advised that in a crush incident, such a leg trapped beneath a boulder, if the casualty could be freed within 15 minutes reflow would not be an issue, but after 15 minutes it was better to leave them trapped until paramedics were present to treat them for reflow when released. Perhaps the length of time suspended unconscious is significant in whether reflow may be an issue?

 

[Bob Mehew]

On a recent CNCC first aid course we were advised that in a crush incident, such a leg trapped beneath a boulder, if the casualty could be freed within 15 minutes reflow would not be an issue, but after 15 minutes it was better to leave them trapped until paramedics were present to treat them for reflow when released. Perhaps the length of time suspended unconscious is significant in whether reflow may be an issue?

The latest advice to use a supine position is by the Medical Commission (MEDCOM) of the International Commission of Alpine Rescue (ICAR), see S Rauch, “Suspension syndrome”, ICAR MEDCOM RECOMMENDATION MED-REC-2021-0036 Ver 4, 2021; at the ICAR MEDCOM web site . The crush injury advice is apparently contary to the suspension trauma. In producing the advice on the BCA web site, we decided to avoid opening up a debate on this topic by making a cross reference to crush injury care.

 

[ChrisB]

Thanks Bob. To clarify, the BCA advice is to place in the recovery position following rescue if unconscious; would BCA advise a supine position if conscious?

 

[andrewmcleod]

On a recent CNCC first aid course we were advised that in a crush incident, such a leg trapped beneath a boulder, if the casualty could be freed within 15 minutes reflow would not be an issue, but after 15 minutes it was better to leave them trapped until paramedics were present to treat them for reflow when released. Perhaps the length of time suspended unconscious is significant in whether reflow may be an issue?

This is definitely not the current standard as I understand it (having been in the room while this was discussed with a number of HART paramedics yesterday although I am not medical). Remove the boulder as soon as possible. MREW cas-carers don't give fluids anyway (AFAIK) so waiting for fluid loading before removing a boulder might be pointless.

Crush Injury — REAL First Aid

Crush Injury and Crush Syndrome: Rhabdomyolysis, Compartment Syndrome and pre-hospital recognition and treatment.

www.realfirstaid.co.uk

"The likelihood of developing acute crush syndrome is directly related to the compression time, therefore victims should be released as quickly as possible, irrespective of how long they have been trapped."

(warning, has pictures of injuries)

https://www.insarag.org/wp-content/uploads/2023/03/Attachment-C-MWG-The-Medical-Management-of-the-Entrapped-Patient-with-Crush-Syndrome-final-draft-March-2023.pdf

"The removal of the compressive force is one of the most critical phases of the extrication. Therefore, the method and timing of the removal of the compressive force should be closely coordinated between the rescue technicians and the medical personnel.
At the same time, removal of the compressive force should not be unnecessarily delayed as the severity of crush syndrome is proportional to the duration of compression."