Abstract
The introductory discussions focused on the epidemiology and treatment of cardiovascular emergencies, cold injuries, and trauma; however, the challenges of reporting on the epidemiology of pathologies in remote settings stems from a paucity of field-specific data, and for this reason we hosted a discussion on the technical and logistical aspects of creating transnational data collection systems. Until such registries accumulate sufficient entries, an epidemiological overview of alpine accidents and treatment outcomes is preliminary and the field remains at the mercy of primarily case reports and case series. This fact motivated discussions on the feasibility and ethical considerations of conducting field-specific research and the applicability of existing treatment guidelines in adverse conditions. A final consensus was formulated regarding the most urgent topics and the research strategies required in order to reach the next milestones in the field.
Throughout the discussions it was reiterated that mountain emergency medicine can be differentiated from emergency medicine in other settings in a number of aspects. There are specific pathologies, for example, frostbite (Cauchy et al, 2011), suspension trauma (Mortimer, 2011), the triple H syndrome (hypothermia, hypercapnia, and hypoxia) (Brugger et al, 2003), and high-altitude illness (Basnyat and Murdoch, 2003) that are not seen in other environments. Furthermore, trauma accounts for up to 90% of all cases in mountain rescue operations (Marsigny et al, 1999; McIntosh et al, 2010), and although the incidence of trauma is higher in urban areas, the relative mortality may be higher in rural cases (Fatovich et al, 2011). In this setting, patient outcome ultimately depends on innumerable factors (e.g., type and severity of injury, accident location, environmental conditions), but two factors seem to unavoidably play a major role: the time granted by the specific situation and the skills of the medical and rescue team in extreme conditions. Without extensive training and practice in adverse conditions the emergency physician is not adequately prepared to make case-specific decisions and lacks the flexibility required of emergency situations. Thus, it is crucial that in-field decisions are supported by existing treatment guidelines (Brugger and Durrer, 2002; Durrer et al, 2003; Ellerton et al, 2009; Elsensohn et al, 2006; Morrison et al, 2010; Paal et al, 2007; Soar et al, 2010; Sumann et al, 2009; Tomazin et al, 2003; and Zafren et al, 2005). However, as these are based primarily on data from in-hospital settings and expert consensus with a low level of evidence, whether these guidelines are always applicable in an adverse, prehospital environment is a matter of debate.
The collection of data specific to a prehospital setting by means of multicenter data registries clearly emerges as one of the most urgent issues requiring immediate attention. The International Hypothermia Registry (https://www.hypothermia-registry.org/) and International Alpine Trauma Registry (http://traumaregistry.eurac.edu/) are transnational platforms for the collection and storage of hypothermia and trauma data, respectively, and aim to identify potential prognostic factors in the pre- and in-hospital management of patients exposed to environmental factors. A continued focus on international comparisons, as recently exemplified by the differences in avalanche survival curves in a Canadian and Swiss sample (Haegeli et al, 2011), and a better understanding of different environmental conditions and rescue processes will enable tailoring of treatment recommendations and rescue operations to specific cases.
Prehospital data collection is not without limitations and inherent ethical challenges. Studies in the emergency setting require special attention to the impossibility of obtaining informed consent from patients in an unconscious or life-threatening state and, as more recently highlighted, to the possibility of increasing risk in some situations where informed consent regulations create a delay of treatment (Roberts et al, 2011). In the case of animal testing, one must be aware of the impact of public opinion on research feasibility (Brugger et al, 2010; Paal et al, 2010), even if animal welfare models have been respected. The “three Rs” principle for animal testing is a reminder to continue to seek out new research models and techniques to replace animal with non-animal designs, reduce the number of animals in a test, and refine the experimental design to enhance animal welfare for those animals still tested (Russell and Burch, 2007). The idea of establishing a laboratory that could simulate standardized and reproducible adverse weather conditions was discussed as an innovative testing alternative for scientific investigations in the field of mountain emergency medicine.
With a focus on the future, the expert consensus stated that the most urgent single topics in the field at present include: (i) trauma care, (ii) optimal treatment of severe hypothermic patients without cardiac arrest, (iii) management of cardiovascular emergencies in relation to their incidence, and (iv) treatment cessation recommendations; however, a more or less unanimous declaration underlined again the need for further experimental studies and clinical data collection, and this stands out as the key element for establishing evidence-based medicine in mountain areas.
The field of mountain emergency medicine can be traced back to somewhat rudimentary origins in a pioneering group of doctors with mountaineering skills trying to introduce urban medical standards in mountain rescue situations. A milestone for the field was the establishment of the International Commission for Mountain Emergency Medicine (ICAR MEDCOM) in 1948, who made a transition in the 1990s from a simple platform for the exchange of knowledge to a structured working group with a focus on evidence-based recommendations. The Institute of Mountain Emergency Medicine was founded in October 2009 at the European Academy of Bolzano, Italy, and works in close cooperation with the ICAR MEDCOM to strive towards an internationally recognized, evidence-based scientific standard in the field of mountain emergency medicine.