Wilderness Medicine Case Study # 2: Rock Fall on Descent

This accident has been adapted from Accidents in North American Climbing 2021. The accident was real. The discussion of actions is a hypothetical exercise to review wilderness medicine practices and critical thinking in emergencies.

Throughout this case study, I’ll indicate the scene and what happen in italicsQuestions for the reader to consider before moving on are underlined. Everything else will be a discussion of wilderness medicine practices.

skip to the bottom of this post if you prefer to watch the video version of this case study discussion.

The Incident

In this incident, there are two people headed out to explore potential boulders to climb. It is March in the Pacific Northwest, so we can envision a lush, wooded area, with a fair bit of weather swings.  This was during the pandemic, and thus they were trying to be socially responsible by avoiding crowded areas.  In their exploration they used creek beds and erosion pathways to hike off trail.  The incident took place on their descent which was returning the same way they had hiked earlier.

A few things of note.  There were patches of snow on the ground and the weather had warmed significantly during the day.  The person in the back weighed more, and also was carrying more gear than the person in the front. All of these elements may have contributed to the incident.

Descending at the end of day…

“As I got to the steep section in the washout, I turned around to down climb, placing my hands on a block the size of my torso and stepping down to a smaller block. The foothold broke free when I weighted it, and then the larger block shifted and broke free.

 “I instinctively jumped back, pushing myself to the right of the fall line of the massive rock as it careened down the wash.” 

Ok, so we’ve got  some scene stuff going on now. And now there’s a medical problem.

“ However, it crushed my left hand against the adjacent rock slab as it crashed past.”

Scene Size Up

So, the first thing is always our scene size up and, in this situation, I would really like to know where the boulder was in relation to the other person? If this person was below, the boulder might have crashed towards them.


How stable is the environment?  Is there a chance of other stuff breaking loose? Is this location a gully that’s deep enough that you would have to be worried about more things falling down? Or, is that scene stable and the risk has passed-literally rolled by!


As the one responding, you should always be addressing those questions before rushing into the scene.

The patient (we’re going to call the injured person the patient now) who had their finger crushed says

“a moment later I noticed my pinky finger dangling, with the middle phalanx displaced and the fingernail hanging by a thread, and the white of the bones in my ring finger showing”

A pretty graphic description of what that crushing injury looked like to the hand.  They go on to say

“Then everything was swallowed in a red gush of blood.”

We should be able to assess this scene quickly.  If the location we are in isn’t good, quickly move to a better site out of more hazards.  In this case the other person isn’t injured as well (thank goodness) because they are needed to help.  Now, let’s get in there and address the fact that there is some significant bleeding.


Bleeding Control

Now remember where are places that we can bleed significantly from?

Our shorty wetsuit zones!  Up through the neck (carotid arteries), down each of our arms (to our elbows), our torso, and then down our legs to our knees.  Generally speaking, these are where we have large arteries that can expel large amounts of blood rather quickly. An exception to this rule can be amputations and based off that description it sounds like there’s a partial amputation going on.  We always want to consider amputations as a risk for significant bleeding.


In this case the patient

“…immediately wrapped my right hand in a fist around both fingers to apply pressure and held both hands above my head…”

The patient is doing exactly what we would hope- they are trying to stop the bleeding for themselves.   Wrapping around the wound generically is a common instinct, but how would we prefer to control our bleeding??


Well aimed direct pressure (WADP).  Ideally getting pressure onto the two digits that have been damaged.  If that isn’t working what’s our next step?


Tourniquet!  A tourniquet can feel big and scary to consider, but in cases like this it can be a great tool, especially if the scene is still hazardous.  Our patient could build a tourniquet and quickly stop the bleeding. Then we can move ourselves to somewhere safer, explore the wound and figure out how to provide better pressure directly.


On another note: elevation, for bleeding control, is really falling by the wayside. It’s not effective in controlling severe bleeds.  There’s no amount of lifting that will take our limbs out of the range of our heartbeat.  Instead, elevation comes in handy for post injury as a way to reduce swelling, throbbing and pain.


Continue Your patient Assessment

So, we control the obvious bleeding- now let’s make sure they aren’t bleeding from anywhere else.  The rest of our Primary Assessment was handled in the witnessing of the event.   We have confirmed they have:


Airway, Breathing

Pulse, Bleeding (now under control)

Awake and no reason to consider this a risk for spine injury.


We Can Move on to the Secondary Assessment

What is the full picture of this patient? Is there anything else that is injured, or other things to consider?

I mean, if you see two of your fingers nearly ripped off are you paying attention to whether you also rolled your ankle or tweaked your knee? Everyone in this scene should take a few deep breaths. Accidents are stressful.  It doesn’t have to take a long time, but we do need to cast a big net and figure out the entirety of the problems.  This will help in coming up with a well thought out treatment and plan.


Logistics and Rescue Plan

The area had no cell signal.  They did not own any kind of satellite communication device and they had not passed anyone all day long.  Given that the sun was setting and the patient could still walk, they decided that they were going to self-rescue.

Fancy that! We can’t always call for help. They are out remote, which is great.  There’s nothing wrong with that decision.  It just means that when something went wrong, they didn’t have as many resources, and getting to resources was  going to be harder.   I think self rescue was also an excellent decision!! Sending one person out and trying to call for help would create unnecessary delays.   It’s in the patient’s best interest to hike themself out.


They dropped some of their equipment so they could descend quicker.


Yes, yes, yes!  It’s so great to recognize that our equipment is replaceable but our fingers are not!   This is a huge sticking point for me with outdoor climbers that don’t want to leave two pieces of gear for a rappel station. Saving $8 at the risk of huge falls or even death! Don’t get me started!  Prioritize yourself! Please!


The patient continued down the creek still clutching their hand. The encountered many downed logs on the return and mention having difficulty navigating obstacles.


Here’s my plug again for bleeding control with a pressure dressing.  This would have gotten the patient hands free.  Which would have helped a lot with balance.


In about a half an hour they made it back to the car!  Fifteen minutes down the road they got cell service, but decided to continue to drive to the hospital instead of arranging an intercept.  It took about an hour more to reach the emergency room and a couple hours later they were transferred to another hospital for surgery.


Think about that.  With a little bit of grit, they were at the car in thirty freaking minutes!  Yes, there were challenges, but 30 minutes and they are now able to get the patient way closer to the care they need. Now if there had been cell service part way down the trail ,they might have called an ambulance to meet them at the trailhead, and that would have been a great, but at this point their own vehicle is the fastest option to get to care.


Take Aways

  • Bleeding control! Learn how to build a pressure dressing and tourniquets.
  • Consider buying a manufactured tourniquet for your first aid kit.
  • Self-rescue is often the fastest and most effective way to get to the help you need.


The patient wrote this case study report and noted that they now own and carry a GPS location device.


I understand how this seems like a simple solution  given having been in a situation where something bad happened and you wanted to be able to call for help- but couldn’t.   But I’d like to pose this question back-  Would having pressed the SOS button have made things any faster or better?


I think not. In fact I think the opposite.  In this situation, they got themselves to the car in 30 minutes and to a hospital in under 2 hours.  If they had called out for help, it would take quite a lot of time for any rescue to be organized, likely hours.   It’s doubtful a helicopter could have landed in a heavily wooded area.  So, pressing the button would likely have resulted in a much longer delay to surgery.


I point this out because I don’t want the takeaway to be- have a GPS locator beacon, but rather, be prepared and as self sufficient as possible.  You and whomever is with you are always your BEST resource in an emergency.


Below is a video version of this case study:

You can read more by ordering the Accidents in North American Climbing 2021. Direct quotes were taken from Jamie Sookprasong.





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