NPC Journal 4(1), Jan 1987, pp 61-65

TECHNIQUES AND EQUIPMENT

Caving Accidents

Management from site to surface. for those in the unfortunate
party or attending as rescuers - general guidelines

Dr. D. Gibson, MB, ChB(Leeds), DA(UK)

It appears from reading the recent CRO figures that fatal caving accidents are predominantly from drowning and long falls. The treatment of a very seriously injured person, or victim apparently drowned has an understandably poor chance of a successful outcome and so the prevention of these accidents is of prime importance. This can be achieved through the thorough checking of equipment prior to use, suitable training in the use of potentially dangerous techniques and sensible choice of cave in poor weather.

There are, however, many less serious injuries that may befall the unfortunate speleologist and it is for these that I wish to provide guidelines for expedient and safe evacuation, whether in the Dales or Darkest Jungle. Readers should note that some degree of medical experience is assumed, since injuries must be properly diagnosed before they can be treated. For basic background reading on the subject I have mentioned some useful books at the end of the article.

Lower Limb Injuries

These are frequent accompaniments of falls. If fractures are evident, the predominant deciding factors in mode of evacuation are the site of the accident and whether or not the fracture is compound (ie. associated with a surface wound).

Ankle

A severely sprained ankle can be as painful as a broken one. It will exhibit loss of stability and tenderness over bony prominences. The salient points are :
1) leave the boot on;
2) bathe in cold water to reduce swelling;
3) if possible, evacuate under the victim's own steam, often without a call-out.

Negotiation of pitches is the difficult part with these injuries, but a good lifeline does a lot to help. SRT is possible too.

Lower leg

Fractures to the tibia and fibula leave an unstable foot causing great pain on movement. Splinting the leg, either to the other leg or to a piece of wood, does a lot to alleviate pain on moving. A casualty may be evacuated in this way if the cave terrain allows it, but if a long or difficult series of passages in anticipated, a suitable (eg. Baycast-type plastic) support should be used. This requires some degree of skill and inevitably a call-out. If the fracture is compound (remember the tibia is just under the skin) dressings should be applied to the wound and antibiotics given.

Knee

A severely sprained knee will swell sufficiently to prevent much useful movement. It may need splinting and careful evacuation, although not always on a stretcher. A fractured or dislocated kneecap is similar. The latter may be involved with a laceration and should be suitably dressed with an antibiotic cover.

Upper Leg

A fractured femur is the result of a quite severe fall and one should seek evidence of other injuries, particularly of the spine, before moving the casualty. Again it is possible to splint the two legs together in order to evacuate the victim. The patient will be unable to stand or crawl very far due to the pain. The bones invariably overlap owing to the pull of the overlying muscles. The most appropriate means of reasonable stabilization is with a Thomas splint, particularly if much passage or many pitches are to be involved. A stretcher is therefore almost mandatory. Blood loss into the fracture site can be up to four pints or more, so the patient will often be shocked with a thready pulse, and be restless. A compound fractured femur may bleed very severely and firm dressings will thus be needed. The risk to life from this type of fracture may indeed be quite high and monitoring the welfare of the casualty throughout the evacuation is important. Consideration should be given to an intravenous infusion (drip), though this has not to my knowledge been resorted to in any CRO rescues so far.

Pelvis

These are often stable fractures by the nature of the anatomy and careful movement of the injured can allow self-evacuation. If very painful, a stretcher may be necessary. Passing blood instead of urine suggests rupture of the plumbing and nothing can be done before hospitalization. Again, spinal injury should be sought before risking movement of the patient.

Chest

Fractured ribs are painful. But again, the anatomy means that they are fairly stable fractures. The odd fracture without complications can often be helped out without a stretcher. The danger lies in possible puncture of the lungs producing a pneumothorax with difficulty in breathing. Again, careful movement out should avoid this complication but it may already have occurred at the time of the accident, particularly if there are compound fractures. Covering a wound helps, but occasionally a doctor may have to consider introducing a large needle into the chest wall. This is potentially dangerous and only in extreme cases should it be considered.

Abdomen

Any fall, whether causing multiple limb injuries, or perhaps only minor scratches, can cause rupture of internal organs. This is particularly likely if the fall was onto the side or front. Fractured ribs may give clues to this. A badly torn spleen can cause exsanguination in under an hour, but such injuries are the exception. Rapid evacuation to a hospital is of prime importance if abdominal injury is suspected. Abdominal pain and a shocked patient are warning signs. Again, an intravenous infusion, even if only set up on arrival at the surface, may be life saving. The use of a helicopter may be necessary with remote entrances to speed travel to a hospital. The use of strong painkillers (eg. morphine) can mask the signs of intra-abdominal trauma and thus care in the use of these agents is important.

Upper Limb Injuries

Hand and Fingers

Sprains or fractures should not usually require a call-out unless many pitches have to be negotiated. Fingers should be strapped to neighbouring fingers for splinting. Broken bones in the hand can be supported, prior to being bandaged, by a rolled pad in the palm.

Wrist

The fracture may be supported with a triangular bandage or a splint arranged to stabilize it. The caver may then often be able to go out under his own steam. Sprained wrists frequently benefit from strapping with firm bandaging.

Forearm

Breaks of the radius and ulna bones may frequently be compound. These require sterile dressings over the wound followed by splinting. If severely unstable, a plaster of Paris pot may have to be applied where long lengths of passage are to be negotiated. Given these precautions though, the caver may often exit with minimal help.

Elbow

Broken bones close to the elbow are often pulled out of alignment by their muscle attachments. One has to be careful that the pulse is palpable at the wrist in the position at which the elbow is splinted (usually at 90°). Support by a triangular bandage is useful.

Upper Arm

Breaks to the humerus less frequently result in a compound fracture. They may often be managed by the hand being supported by a sling around the wrist and neck (collar and cuff). The weight of the arm reduces the bones to a good position. As usual, the patient will have most difficulty in ascending pitches, and in long crawls or tight constrictions.

Shoulder

Dislocation of the shoulder in some folk is a frequent and distressing occurrence. When recurrent, this may occur at the slightest provocation. If the pain is not extreme, with much muscle spasm, an experienced person may be able to relocate the shoulder, especially if the patient has experience of the process. However, in many cases it is better to immobilise the arm by strapping it to the chest. There have been incidents where the injury has been worsened by over-enthusiastic attempts at relocation while still underground.

Collar bone

This is the most commonly broken bone, occurring when falling onto an outstretched arm. The loss of stability of the arm can make crawling and pitches difficult, but over a short distance, self-evacuation is frequently possible. Supporting the arm with slings helps, as does a figure-of-eight arrangement over the back pulling the shoulders backwards.

Back

The possibility of back injuries can be inferred from the position of the caver; for example, if he has landed on his back on boulders; or by major fractures, for example of the femur. If conscious, he should be asked if he can move his legs or if he has any pain in the back. A patient with a suspected spinal injury shouldnot be moved until plenty of assistance is available. If a stretcher is to be used, he should then be carefully secured to it, lifted by at least four people. If difficult cave is to be traversed, the use of a spinal splint, fitted by an expert with the rescue team, is often better, since it allows the injured caver to help himself.

Feeling down the curve of the vertebral column for loss of continuity or tenderness is useful as an indicator of possible problems. Fractures may be of the bony prominences of the vertebrae, when the risk of spinal cord damage is low. However, this is difficult to be sure of underground and care should be taken in any case. Loss of movement may only be temporary (spinal shock): further damage must be avoided at all costs. In the event of a potential spinal injury beyond difficult or tight crawls, the risk of further damage is very high. If neck injuries are suspected, a cervical collar may be used, and one person holds the head steady whilst this is fitted.

Head Injuries

This broad category ranges from a few minutes unconsciousness following a bang on the head, to severe compound skull fractures with deep coma or semi-consciousness. No-one can save brain damage already done but further complications should be minimised. Open fractures and wounds must be covered. If talking, the patient should be talked to, ensuring that he doesn't become unconscious unbeknown to the rescuers. If unconscious, the airway is liable to become blocked by the tongue falling into the back of the throat. Insertion of an airway prevents this, as does the adoption of the recovery position, with the face downwards. If breathing stops, the airway should be checked and artificial respiration commenced, once every five seconds. Remember to pinch the nose and extend the head backwards, looking for chest movement. If no pulse is present, external cardiac massage can be begun compressing the lower breastbone firmly with the heel of the hand once a second. No further treatment of head injuries may usefully be offered underground except observation and care of the airway. If much blood is coming from the mouth, evacuation of the casualty face-down is desirable, although the standard Neil-Robertson stretcher is poorly designed for this.

Hypothermia

This ever-present danger may occur as the single problem in a tired individual or in addition to other injuries, in themselves not fatal. Waiting for a rescue team can allow a fall of body temperature to begin. If the temperature drops sufficiently (ie. to less than 30°C) the heart contracts incoordinately, and death ensues. Wet, windy areas in a cave, such as near pitches, are the most dangerous. If an injured caver cannot make his own way out until help arrives, consideration should be given as to whether a different position will reduce the tendency to lose heat. If spinal injury is suspected, then the relative risks of exposure and further damage must be assessed.

The warmth of companions huddled together, sitting on tackle bags, or the use of 'space' blankets are all useful. When available, a neoprene casualty bag should be used at the first opportunity, possibly with heated inspired air or oxygen. If dry clothing is available, it is well worth while removing wet garments and replacing them with dry, providing they can be kept dry afterwards. One should keep an eye on the rest of the team to ensure that hypothermia is not creeping up on them, impairing judgement in difficult circumstances.

On reaching the surface, the patient should again be as well insulated as possible and allowed to warm up slowly by his own body heat. The use of a hot bath is very controversial and should never be attempted without medical supervision. The sudden rush of blood through cold outer tissues may lead to further cooling of the core, with potentially fatal results.

It can be very difficult to decide if a very cold patient is still alive, as pallor; fixed, dilated (large) pupils; apparently absent pulse; and very shallow breathing may be found in people still alive. If in any doubt, one should continue to treat the patient as alive until someone experienced can declare that he has expired.

Death

To decide if this has supervened, either soon after the accident or during evacuation, can be difficult. The nature and severity of the injuries can give clues, but as stated above, if cold is an important part of the patient's condition it can be very hard to determine. If in doubt, the advice of a doctor must be sought. Absence of pulse and breathing, and fixed, dilated pupils are the classic features to be found.

Drownings

One should persist with artificial respiration and external cardiac massage for at least 45 minutes, although if the caver was underwater for long enough, no-one can revive him. However, success has been achieved and one must always try.

Acid or Alkali Burns

These should be washed liberally with water and dressed with gauze if possible.

Medical Problems

Heart attacks, appendicitis, diabetic comas and so on can all occur whilst caving. It is beyond the scope of this article to mention everything, but general supportive measures should be taken and evacuation out of the cave begun at the earliest opportunity.

Useful reading :

St. John Ambulance First Aid Manual

Several books on first aid for Hillwalkers or Mountaineers are available and the principles apply equally to the caving situation.

Medicine for Mountaineering - Wilkerson. A comprehensive guide for doctors and lay persons alike.

Following are a number of helpful illustrations and a guide to equipment that may be carried. It is not intended to be exhaustive and additions or omissions can be made depending on the situations to be faced.

Happy Caving !

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