Survival Chance Optimized Procedures in Rescue
and How to Minimize Injuries During Excavation
Manuel Genswein, Switzerland
In companion rescue as well as in the start-up phase of organized rescue, shortage of rescue
resources are very likely if multiple buried subjects / patients are present. Therefore, not everyone can
be excavated or medically taken care of simultaneously. Triage strategies give advice on the most
survival change optimized sequence of actions in order to provide “greatest good for the greatest
number”. The remote reverse triage criteria give guidance on most likely areas of survival and the
sequence of excavation. The now proposed AvaLife strategy supports the rescuers concerning remote
and local triage, in particular the critical phase when some patients are already excavated while others
are still fully buried.
The last phase of rescue and excavation in immediate vicinity of the buried subject is often the most
time consuming part of the entire rescue effort. The combination of close proximity and the general
urgency of the situation may lead rescuers to overlook the potential for unnecessary stress for the
buried subject. During the excavation of a buried subject, mechanical impact to the body of the buried
person may lead to injuries, compromise a potential respiratory cavity, compromise breathing by
inhibiting thorax motion/decompression etc. Whereas the likelihood for the imposed impact to lead to
fatal consequences is marginal, precautions to limit the chance and extent of impact should be taken
as long as they do not compromise the goal of saving the life of the buried subject in a single burial
accident or saving as many lives as possible in a multiple burial event. This comprehensive summary
outlines the considerations to be taken into account for a wide range of influence factors such as burial
time, burial depth, snow hardness, availability of rescue resources as well as the interface to the first
medical assessment.
Keywords: AVALANCHE TRIAGE, EXCAVATION, INJURIES
The now proposed, more comprehensive
AvaLife strategy supports the rescuer
throughout the entire rescue in various aspects
of optimization decisions starting at the basic
question of “send someone for help or rescue
first”, the focus on buried subjects with higher
survival chances based on terrain and burial
depth criteria, the medical triage criteria as well
as the evacuation priorities. AvaLife helps to
make survival chance maximizing decisions
during the critical phase when some patients are
already excavated while others are still
completely buried. AvaLife only advises which
rescue techniques, medical treatments etc.
should be applied in which sequence, but does
not describe the individual techniques in detail.
Instructions on the individual rescue and
medical procedures and strategies, such as how
to search and excavate a buried subject, apply
CPR or the criteria for termination of CPR are
already widely taught and have been published
in previous ISSW Proceedings, ICAR
Introduction
In companion rescue as well as in the start-up
phase of organized rescue, shortage of rescue
resources are very likely if multiple buried
subjects / patients are present. Therefore, not
everyone can be excavated or medically taken
care of simultaneously. Triage strategies give
advice on the most survival chance optimized
sequence of actions in order to provide
“Greatest Good for the Greatest Number”. The
remote reverse triage criteria give guidance on
most likely areas of survival and the sequence
of excavation (Ref 20).
__________________________________
Corresponding author address:
Manuel Genswein
General Willestr. 375
CH-8706 Meilen
Switzerland
Mobile +41 79 236 36 76
E-Mail: manuel@genswein.com
1408
Recommendations and publications by
ICAR/UIAA Medcom in various medical journals.
The second part of the paper is not about
AvaLife, it describes an extension of the existing
“V-shaped Show-Conveyor Belt” excavation
strategy for advanced recreational and
organized rescue. Whereas saving burial time is
the most important optimization criterion for an
excavation strategy, measures to protect the
buried subject from unnecessary mechanical
impact should be taken in consideration when
sufficient rescue resources are available or
burial time has passed 35min.
subjects / patients in need. The procedures and
sequence of actions have to be systematically
analyzed and optimized in a strictly survival
chance oriented focus.
While the problem of shortage of rescue
resources persists, a reverse triage scheme has
to be followed. In reverse triage, the little
available rescue resources focus their efforts on
patients who have statistically good survival
chances and absorb only little rescue resources.
Rescue efforts for patients with statistically low
survival chances or for buried subjects who
absorb a lot of resources have to be postponed
until more resources become available.
In companion rescue, external help needs to be
alerted to provide additional resources. In case
communication networks allow calling for help
from the accident location, the emergency call
only absorbs limited time, but as soon as a
companion rescuer needs to leave the accident
site to go for help, the benefit of the action
needs to the carefully balanced against the loss
of resources on site. Whereas the drop of
survival chances is marginal within the first
18min of burial time, there is a very strong
decrease between 18 and 35min. For those
buried subjects who were able to survive the
first 35min of burial time, survival chances only
slowly decrease over time.
The fact that loss of survival chances over time
is not linear, but includes periods where loss is
very dramatic and periods where survival
chances do not drop considerably over longer
periods of time strongly influences priorities and
procedures in a survival chance optimized
rescue algorithm. AvaLife is based on ICAR
Medcom procedures for the optimal treatment of
patients in snow avalanches. These existing
guidelines and recommendations assume that
there are sufficient rescue, medical and
transport resources available to treat everyone
in need of help simultaneously. However, in
companion rescue and in the start-up phase of
organized rescue, shortage of resources is very
likely in case of multiple buried
subjects/patients. As the verdict is set for a
majority of buried subjects within the first 18 to
35min after the accident, even in locations with
very good availability of rescue resources such
as in the European Alps, it is unlikely that all
organizational as well as rescue and medical
tasks can be simultaneously performed for
everyone in need of help. As soon as shortage
AvaLife - Survival Chance Optimized Decisions
and Procedures in Avalanche Rescue
AvaLife describes the rescue and medical
procedures for single and multiple burial
accidents. Concerning single burial events, it
describes the status quo, except for the
consideration on when to call/go for help vs.
rescuing first. Most of the new considerations
implemented in AvaLife show their effect in
multiple burial / multiple patient events. It
dynamically adapts to the changing balance
between available rescue resources and buried
subjects / patients in need of help. It therefore
dynamically optimizes the delicate balance
between reverse and normal triage:
- Reverse triage in case of shortage of
resources, often at the beginning of a rescue
operation
- Normal triage when the available resources
clearly overcome the extent of the rescue
problem
In reverse triage, the focus is on patients who
have good survival chances and require only a
moderate rescue effort. Normal triage allows to
treat everyone in need simultaneously and to
allocate all necessary resources - even to
patients who require a lot of rescue effort and/or
have only little survival chances.
Greatest Good for the Greatest Number
In case of shortage of resources during a rescue
operation for multiple buried subjects / patients,
the limited resources should try to optimize their
procedures in a way that provides “Greatest
Good for the Greatest Number”. The
optimization criterion is therefore the overall
outcome / survival rate for a group of buried
1409
of resources is an issue, the challenge is to
prioritize the tasks to achieve “Greatest Good for
the Greatest Number”. In order to optimize the
survival chances for multiple buried
subjects/patients, AvaLife compares survival
chances of the buried subjects and patients and
takes the ratio between amount of rescuers and
amount of buried subjects/patients into account.
Many rescuers and mountain rescue physicians
are emotionally strongly bound to the “in dubio
pro reo” principle and therefore it is a major
challenge for them - almost a change of
paradigm - to postpone a rescue effort or
medical treatment of a person with statistically
low, but not inexistent survival chances for the
benefit of another person in need with
considerably better survival chances. As much
as the “in dubio pro reo” paradigm is ethically
defendable for a single patient or when
resources are unlimited, the “Greatest Good for
the Greatest Number” paradigm is the most
ethical approach when there is more than one
person in need and rescue is short of resources.
Version 1.0 of AvaLife is the first tool which
advises in a clearly formalized algorithm on how
to proceed in order to achieve the “Greatest
Good for the Greatest Number” goal. The Basic
Version is recommended for basic level
companion rescuers, the Advanced Version for
advanced companion rescuers, mountain
guides, ski patrol, organized rescue etc.
AvaLife does not change the existing ICAR
Medcom recommendations and criteria for
termination of CPR for ALS and BLS trained
rescuers. It simply advises on the most survival
chance optimized use of the available
resources.
AvaLife Basic V1.0 (cc size when folded ones)
The most important and most prominent
example in this context clearly represents the
triage strategy for non-breathing patients.
Whereas all multiple patient triage algorithms for
non-avalanche settings immediate assign a very
low treatment priority (i.e. expectant / black) to
non-breathing patients after opening of the
airways, there is very much resistance to
postpone treatment for this category of
(normotherm) patients in avalanche rescue. This
is particularly problematic in the first 20min after
an avalanche where the statistical probability of
survival of a randomly chosen buried subject is
much greater than the probability for a positive
outcome for a non-breathing buried subject. In
AvaLife Triage Considerations
The comparison of triage criteria applied in
AvaLife with existing triage schemes for multiple
casualty accidents (START, ReSTART, Ref. 2125) clearly shows, that there is more resistance
in avalanche rescue to re-allocate resources
from patients with statistically low survival
chances towards patients with considerably
higher survival chances.
1410
rest of the
body as
required. Body
check, treat lifethreatening
injuries.
If unconscious,
put in recovery
position
YES
YES to all
CPR
YES
NO
Vital signs returned?
CPR for 5 min,
1 rescuer
NO
YES
CPR
buried subjects?
≤ 27% More rescuers than
YES
~1 %
>>90%
YES
50%
CPR
~5 %
Postpone
full
excavation.
NO
CPR
YES
Burial time
~1 %
> 35min?
NO or ND
More rescuers than NO
buried subjects?
YES
2 or more rescuers
per remaining
buried subject?
NO
Were the airways YES
obstructed?
NO or ND
Other buried
subjects present?
NO
Breathing normally?
NO or ND
Other buried subjects present?
YES
NO
YES
Severe multiple trauma?
NO
Burial time < 20min?
YES
YES
Patient responsive, no life-threatening injuries?
NO to any
YES
Breathing normally?
NO or ND
Immediately clear airways.
Give five rescue breath(1).
Deep burial?
(Hard debris: > 1,5m; Soft debris > 2m)
NO
Excavate head and chest!
Are there non OR partially buried subjects?
NO
Search for buried subjects! Maximize probability of detection and minimize search time!
Prioritize unsearched terrain with increased probability of survival: No forest, no high cliffs, no seracs or crevasses.
Prioritize buried subjects with “increased survival chances” indicated by vital data capable search devices.
>75% Excavate
: not determinable
: expect hypothermia
: approx. survival rate
YES
Accident - Start here!
(1) If unfamiliar with rescue breath procedure or unacceptable to perform, only open airways and proceed.
YES
Still buried subjects?
NO
Fully excavate and treat patients not taken care of yet,
monitor status of existing patients, assist ongoing CPR
Rescue and Medical Care in Advanced Companion and Organized Rescue
Excavate rest of body, protect cervical spine, body check, treat injuries, treat patient gently, protect from further cooling. If in CPR, continue until ICAR MEDCOM criteria for
termination of CPR for BLS /ALS trained rescuers is reached. Notify rescue / medical staff about approx. burial time, status of airways at time of excavation and treatment on sight.
x%
ND
1411
YES
Prior to patient
leaving site:
Attach ICAR medical
status report sheet to
each patient.
If not available, attach
note with approx.
burial time, status of
airways at time of
excavation and CPR
status on site.
If multiple patients in
same priority, apply
second stage triage
based on urgency,
age and gender of
patients.
Assign transport
priority to this patient!
When transport capacities are very limited, flying times long or there is serious doubt that helicopter(s) may not come in for an extended period of time due to flying constraints,
reassess sequence of transport priority and/or postpone departure of helicopter if more buried subjects are expected to be excavated soon.
Tolerance for interruptions of CPR during evacuation: burial time < 35min: no tolerance; burial time >35min: short interruptions ~5min i.e. during hoist operation acceptable.
Breathing; life-threatening injuries?
NO
YES
Burial time > 35min, patent airways, in CPR, life-threatening injuries?
NO
YES
Breathing; unconscious OR somnolent?
NO
If rescue short on resources, only transport
YES
to closest medical infrastructure capable of
Burial time <35min, in CPR?
measuring serum potassium value. Assess
NO
patient
for asphyxiation and lethal injuries.
Burial time >35min, patent airways, in CPR?
YES
YES
Transport to medical clinic with CPB / ECMO capabilities.
NO
ECG asystole or unknown?
NO
YES
Remaining patients in CPR?
NO
YES
Conscious, injured patients?
NO
All remaining patients
Start here!
Evacuation Priority – Multiple Patients
Prioritize search means based on probability of detection. How likely is it based on the location and type of accident that the buried subjects are equipped with transceivers? Recco?
Prioritize fast search means and apply multiple search means at the same time if sufficient resources are available. If buried subjects are likely to be detectable with transceiver or Recco
and site access faster than 25min, do not considerably postpone search and rescue by picking up rescue dogs.
Maximize Probability of Detection and Minimize Search Time
Keep survival chances of buried subjects based on burial time and type of accident in mind: 15min: ~90%; 35min: ~35%; 60min: ~25%; 90min: ~20%; 180min: ~15%. Limit exposure by
limiting the amount of rescuers on ground, choice of mean of transport etc. Postpone rescue or mitigate danger if survival chances of the buried subjects are low compared to the risk of
the rescue mission. Keep in mind that the accumulative risk of the rescue mission increases with every additional rescuer who is exposed.
Risk Management in Avalanche Rescue
Strategic Organization and Evacuation in Professional Companion and Organized Rescue
Highest
Priority
Lowest
1412
companion rescue, there is the unique chance
to get physical access to the buried subject
within a very short period of time (Ref 26), even
for lay rescuers with minimal training (Ref 27).
Companion rescuers have therefore the chance
to reach the patient in a stadium where asphyxia
has only limited impact or severe, asphyxiainduced breathing suppression is present but
has not lead to cardiac arrest yet. A few
moments later in the timeline of rescue, these
patients may be considered to be part of the
“witnessed cardiac arrest” subgroup of the “CPR
on pre-hospital cardiac arrest patients” group
and therefore have approx. 8x better chances
for a positive outcome of CPR (Ref 10-12 ).
Another few moments later in the timeline of
rescue, these still normotherm patients (burial
time < 35min) do not belong anymore to the
subgroup of “witnessed cardiac arrest”, as the
rescuers reached them with a time delay of
several minutes after cardiac arrest. This last
group of normotherm patients only has very low
chances for a positive outcome in BLS CPR
(Ref 10-12) on an avalanche and therefore time
and resources invested for this category of
patients have to be very restricted in case there
are still buried subjects present. In version 1.0 of
AvaLife, the duration of CPR is limited to 5min
for normotherm patients without vital signs when
the rescue operation is short on resources. The
longer BLS CPR continues without visible
success, the lower the chance for a positive
outcome (Ref 12, 13, 18, 19, 28). These are the
considerations behind the 5min criteria. The
20min criteria may be seen as aggressive, but
simply leads to a sharper separation between
patients with a statistically good prognosis for a
positive outcome and patients with less positive
prognosis. The longer the time frame to judge
the quality of the outcome, the shorter this
duration has to be set, i.e. comparing status at
arrival in the ED with neurological outcome at
time of hospital discharge. Furthermore, early
triage decisions lead to shorter burial times for
the subsequently excavated patients and allow
head access times of <35min, for multiple buried
subjects (Ref. 26, 27).
Implications of “Greatest Good for the Greatest
Number”
Rescuers and mountain rescue physicians who
point out that they have seen positive surprises
with longer burial times and long-lasting,
companion rescue CPR should consider that
AvaLife does not imply any modifications to the
current ICAR Medcom recommendations and
guidelines in case there is only one patient or no
shortage of resources. In particular, AvaLife
does in no circumstance modify any of their
current recommendations and guidelines
concerning final termination of CPR. However,
as a tool with the goal to provide “Greatest Good
for the Greatest Number”, the AvaLife algorithm
strictly has to allocate resources to rescue tasks
which lead to the greatest overall survival
chances. This implies that rescue efforts and
medical treatments which absorb a considerable
percentage of the available resources over a
longer period of time have to be postponed. In
the practical application this leads i.e. to the
effect that buried subjects in high burial depth
will be excavated only after the partially buried
subjects and fully buried subjects in shallow
burial depth have been taken care of.
Concerning medical triage this implies i.e. that
treatment for a patient in traumatic
cardiorespiratory arrest has to be postponed
due to the very marginal chance for a positive
outcome in this category of patients (Ref. 16 p.
1420; Ref 1-7).
Considerations on rescue breath and
compression-only CPR
Based on the European Resuscitation Council
Guidelines for Resuscitation 2010 (Ref 14), chestcompression-only CPR is not as effective as
conventional CPR for cardiac arrests of noncardiac origin (e.g., drowning or suffocation) in
adults and children (Ref 15). Chest compression
combined with rescue breaths is, therefore, the
method of choice for CPR delivered by both
trained lay rescuers and professionals. Laypeople
should be encouraged to perform compressiononly CPR if they are unable or unwilling to provide
rescue breaths. These facts are reflected in
AvaLife as initial rescue breaths are included,
standard CPR is advised and the footnote (1)
specifically makes reference to only opening
airways and performing compression-only CPR.
1413
How to Minimize Injuries During Excavation
Practical implications and procedures
During the excavation of a buried subject,
mechanical impact to the body of the buried
person may lead to injuries, compromise a
potential respiratory cavity, compromise
breathing by inhibiting thorax
motion/decompression etc. Whereas the
likelihood for the imposed impact to lead to fatal
consequences is marginal, precautions to limit
the chance and extent of impact should be taken
as long as they do not compromise the goal of
saving the life of the buried subject in a single
burial accident or saving as many lives as
possible in a multiple burial event.
Based on a study carried on by Brugger et al
(Ref 28), many survivors of a full burial situation
describe the last phase of their excavation as
one of the most freighting moments of the entire
event. Looking at the significant number of Post
Stress Disorder problems reported by the above
quoted study, there is as well an interest of
reducing psychological stress and trauma by
taking precaution when getting in close proximity
to the buried subject.
In the generic design of the V-shaped snow
conveyor belt, several strategies have been
taken into account to ensure a good balance
between reduction of excavation volume / burial
time and reduction of mechanical impact to the
buried subject. First, the probing spiral is applied
in most cases perpendicular to the slope angle,
which makes that the rescuers access the
buried subject not from straight above, but cave
in along the probe. Second, in case of a very
shallow burial depth (<50cm, in very soft snow
more) the starting point of the “V” is 1m below
the probe with two rescuers in the tip of the “V”
from the start of the excavation procedure.
Third, in difference to improvised excavation
techniques or BCA’s “strategic shoveling”,
access to the buried subject applying the Vshaped snow conveyor belt is purposely kept in
a narrow, approx. 30 to 40 degree angle. The
relatively narrow tip of the “V” minimizes the
likelihood of impact to the buried subject and
keeps the required excavation volume as low as
possible until the first visual contact of the
patient is established. Only at this point, two
rescuers work in immediate proximity of the
patient and adapt the shape of the “V” to the
visual outline of the patient.
No compromise against survival chances
In despite of the interest to access the buried
subject as gently as possible, NO compromise
may be made between “saving lives” and “limiting
potential for mechanical impact” in the first 35min
of burial time where survival chances in the
asphyxia phase drop very rapidly and every single
minute spent on a more gentle approach may lead
to severe, irreversible brain damage or death.
1414
Probing spiral with multiple probe hits
Deep burials
As a new, additional measure to avoid
mechanical impact during excavation, a probing
spiral with multiple probe hits should be applied
when burial time has passed 35min or when
many rescuers are available. While one rescuer
proceeds on the probing spiral to achieve
multiple probe hits, the remaining rescuers start
the “V” already 1 to 1,5m downslope. Ones
several probe hits have been made, set the lead
probe for the excavation crew in the middle of
the probe hit pattern to avoid reaching an
extremity of the buried subject first. In case the
probe hit pattern indicates that the body is
parallel to the fall line, place the lead probe in
half of the height of the probe hit pattern, very
slightly offset sidewise so that the flank of the
“V” is adjacent, but not directly overlapping the
expected position of the buried subject.
The above outlined strategies get applied in the
moment when the remaining burial depth is
smaller than the length of the probe and
therefore a probe hit is possible. In case of
burial depth greater than the probe length, the
lead probe for the V-shaped snow conveyor belt
is placed uphill of the spot where electronic
search means show the lowest distance
indication or highest amplitude of sound. The
upper layers of the debris are first removed
above the buried subject until the remaining
burial depth allows a probe hit. Initiate at this
point a secondary phase of fine search and
pinpointing (probing spiral) in the already
lowered tip of the “V”. As the rescuers get now
in close proximity of the buried subject, the
same consideration on minimizing potential
damage to the buried subject as outlined above
come in to play.
Influence factor “hardness of debris”
Acknowledgements
Fortunately, very hard debris are statistically
seldom. As hard debris require more invasive
snow removal techniques such as the cutting
snow blocks in half moons to effectively access
the buried subject, the potential for a more
severe mechanical impact increases. In
particular because hard debris compromise the
ability of the rescuer to quickly detect a change
in consistence when touching the buried subject
for the first time with the shovel, additional
measures should be considered. In very hard
debris, apply a probing spiral with multiple probe
hits already earlier than recommended by the
“burial time” criteria as a suboptimal alignment
of the access point / access angle of the
excavation crew may lead to severe
complication in close proximity to the buried
subject and therefore to a strong increase of
head access time.
The harder the debris, the more difficult it is to
feel subtle changes in consistence of the probed
debris which may indicate a probe strike as the
force required to penetrate the probe into hard
debris compromises the tactile feeling. In
despite of this problem, apply a probing spiral
with multiple probe hits.
The author would like to thank the many
organizations, colleges, friends and course
participants who have with their advice
contributed to the development of this paper, the
AvaLife algorithm and the development for the
procedures for a better protection of buried
subjects during excavation. In particular I would
like to mention concerning the development of
AvaLife: MD Peter Paal, MD Herman Brugger,
MD Anna Brunello and MD Melanie Kuhnke. For
the procedures for a better protection of the
buried subject: MD Alessandro Calderoli of
Servizio Valanghe Italiano SVI for his
determined role as an advocate for the buried
subjects and to Angelo Panza, Gianni Perelli
and the national instructors of Scuola Centrale
di Scialpinismo CAI for their effort, contribution
and extensive testing for the further optimization
of the V-shaped snow conveyor belt.
AvaLife Version 1.0 will be further optimized and
updated in collaboration with ICAR Medcom,
mountain rescue physicians, rescue
organizations, etc. If you have a suggestion on
how to further optimize AvaLife, please do not
hesitate to contact the author.
1415
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