Scenario 4, Altitude Sickness

The Scene: Delap and a fellow guide are in the middle of a trip in the Sierras. Their clients are settling in at camp, preparing for the next day’s summit of Mount Whitney, when two climbers come down the mountain with bad news—a woman is unconscious on the saddle of Mount Whitney around 14,000 feet. Delap, who has worked in the emergency medical field for over a decade, sets out with a fellow guide.

“She was basically dead,” Delap remembers. “It was dark, she had not made it to the top, and was literally laying up there to die.”

When Delap and his partner reach the woman, she is unresponsive. They begin the slow and trying task of taking her down the mountain. When they get 1,500 feet below the saddle, she comes to, enough so that she can even walk on her own, albeit not very gracefully. Another 1,000 feet down and she improves even more to the point that Delap and the other guide don’t have to fully support her. But around 10,500 feet, the woman becomes combative. Instead of expressing gratitude to her rescuers, she refuses any further assistance. All of these developments, says Delap, are telltale signs of altitude sickness.

“I’ve seen this before in people where you bring them down and they’re like, ‘Oh I’m fine, I’ll go back up,’ and you have to say ,‘No you’re not fine,’” says Delap. “They’re fine now because they have oxygen in their head, but with altitude sickness, people don’t understand that.”

What not to do:

• Summit solo.

Ignore proper acclimatization. Above 8,000 feet, the Altitude Research Center recommends sleeping altitude should not increase more than 2,000 feet per day, and that climbers should take one rest day with no elevation change for every 4,000 feet of gain.

Ignore the signs of altitude sickness, in yourself, in your group, or in passing climbers—“If you see someone sleeping on the side of the trail at higher altitudes, or stumbling and falling around, ask them how they’re doing,” says Delap. “If they’re not giving you clear answers, encourage them to come down but be forewarned: they could be combative.” Signs of acute mountain sickness include headache, fatigue, dizziness, nausea, trouble sleeping, and poor decision-making. “It’s like being in a state of drunkenness without any of the good feeling and all of the bad decisions.”

What to do:

Descend immediately. It can take as little as 1,000 feet of elevation loss to improve conditions in a patient with altitude sickness.

In severe cases of altitude sickness, known as high altitude pulmonary edema (HAPE), breathing supplemental oxygen is recommended.

Karsten Delap

Scenario 5, Waterfall Accident

The Scene: It’s late in November 2016 and a 23-year-old man from Florida is with his friends visiting Moore Cove Falls in the Pisgah National Forest just outside of Brevard, N.C. Feeling bold, the man begins scrambling up the side of the 50-foot waterfall to the top. Suddenly he falls, at first just 10 feet. He lands on a ledge, but moments later, his lifeless body slides over the lip to the waterfall’s base.

“By the time we got the call out, got to the trailhead, and hiked in, we’re basically looking at an hour since the accident time,” Delap, who was one of the rescuers, says. “If he had been on the doorstep of the hospital, the likelihood [of survival] still would have been pretty slim.”

The man did not survive the attempted resuscitations. His death marked the eighth waterfall-related death in 2016 for Transylvania County, an area well known and beloved for its many waterfalls. Delap says the problem with tourists around waterfalls is that they misjudge their risk management.

“If he’d had a helmet on, he could possibly be alive, but people probably aren’t going to hike around a waterfall with a helmet on,” he says. “But the rocks are almost more slick than ice, because ice will melt and can freeze to your boot.”

What not to do:

• Ignore the warning signs near waterfalls.

In the event someone does ignore the warning signs, slips, and falls, do not make yourself a patient, too. “That’s happened a couple times this year. If you can’t hear them, can’t see them, can’t easily get to them, just call for help or go get help,” Delap says. “It sounds horrible to leave them, but if you rush in there and get hurt, too, that makes it twice as hard on the rescuers.”

What to do:

If you’ve determined it’s safe to get the victim, remove them from the water so they are not drowning or getting cold. Assess airway, breathing, and circulation, performing CPR when necessary.

If there is not a head injury, assume there is a spinal injury. Situate them in a position of comfort, “whatever that means for them,” says Delap. “We’re moving past the spinal immobilization devices. If they’re comfortable, their spine is probably not going to move, especially if it’s hurt.”

Remove wet layers, replace with dry clothes and other insulating materials, and treat patient for hypothermia, even in warm weather.

Scenario 6, Lower Leg Injury

The Scene: On a hot summer day at Looking Glass Rock near Brevard, N.C., a young man is out with his girlfriend climbing on the South Side. The man, who had taken a college course on rock climbing, isn’t the most experienced climber, but he knows some basic safety precautions. After scrambling to the top and setting up his anchor, he ties a BHK, or big honking knot, and prepares to rappel. Unbeknownst to him, he ties a slipknot instead, not a BHK, and he doesn’t back it up. When he leans back in his harness to begin the rappel, the slipknot fails, sending him over 60 feet to the ground.

“He landed on both feet resulting in a bilateral open tib-fib fracture,” says Delap, who was one of 23 rescue and EMS personnel on site. “Both bones in his lower legs were sticking out, and because of the way Looking Glass is, when he fell, his hands were scraping the rock on the way down. His hands were useless. They were down to the bone.”

That, on top of the already debilitating lower leg injuries, meant the man was entirely at the mercy of the climbers at the crag. Fortunately for him, two of those climbers happened to be Wilderness First Responders (WFRs). They made the call for help, gave the young man some water and kept him calm, took note of his allergies and medical history, and one of the WFRs even hiked to the trailhead to meet Delap. The whole rescue, from the time of the call to the time the young man was headed to a hospital, took just under four hours.

What not to do:

• Go climbing without proper training or a partner who is more knowledgeable.

What to do:

Stop bleeding through use of elevation, direct pressure, or tourniquet if hemorrhaging is severe. •Get patient in a position of comfort, being sure to protect the spine but not make it rigid.

Clean the wound with drinkable water. If patient is going into shock, this may not be the highest priority.

Fashion a splint, either with a SAM splint or something equally rigid like trekking poles or reasonably sized tree limbs. Even an empty pack could work in an emergency. If something rigid is not available, use plenty of layers and create bulk for stability. Fill layers and material around injury and wrap.

Scenario 7, Lightning

The Scene: An outdoor instructor is leading a course with his students at Table Rock in western North Carolina. Thunder rumbles in the distance. The instructor wisely splits up his group to reduce the potential for multiple victims in the event of a lightning strike. His students are well into their course by now, and take up the crouched lightning position in the parking lot.

Suddenly, there’s a loud BOOM. The instructor is blasted to the ground. His students scramble to get him to safety and check his pulse. There is none. Fortunately for the instructor, he had taught CPR earlier that week. The students started performing CPR immediately and resuscitated him on the spot.

“The reason it was so effective was that the heart that was stopped by the great defibrillator in the sky was a healthy heart,” says Padgett. “With CPR, his heart was able to start itself again,” and the instructor recovered just fine.

Padgett herself has been stuck high on ridgelines when storms roll in. She says that especially in North Carolina, a state that had the second highest number of lightning-related casualties between the years 1959-2007, afternoon storms should seriously factor into how and when a person decides to recreate.

“We encourage the groups we teach to make sure they summit early in the day because lightning storms are most common between 1 and 5 p.m.”

What not to do:

Ignore thunder. The National Oceanic and Atmospheric Administration suggests, “When thunder roars, go indoors!”

Camp on mossy balds or low-lying, treeless fields.

Assume your tent will protect you.

Take shelter beneath lone, tall objects, such as trees.

What to do:

Take shelter in forests with many similar medium-sized trees. “Imagine an apple orchard,” says Padgett. These also make safer campsites.

Begin seeking shelter and start descending at the first signs of a storm. Camp in areas where you are not the lowest or tallest point around.

If you’re paddling on the river and stuck in a storm, keep going. “Generally speaking, the fact that you’re on the water and moving downstream to your extrication point, probably the safer thing to do is keep on going,” says Padgett, though different river companies may have different policies.

If you are near your car, take shelter inside, but be sure to move it to a safer location first. “If you can’t avoid lightning, a vehicle is better than no shelter,” Padgett says. “The car could still get struck, so descend and get to a safer place with your vehicle rather than rely on it to protect you.”

Spread group out within earshot of each other and assume the lightning position, crouched down, hunched over, as small as you can make yourself.

If someone is struck by lightning, attempt to move them away from the site. “Lightning does like to strike in the same place twice,” says Padgett. “Check the scene for safety and drag or move the victim to a safer spot.”

Once the storm passes, continue descending if up high or seek better shelter. Storms in the Southeast in particular tend to cycle back around.