Terrestrial rescue teams usually work in poor weather conditions and at night or when the air-bound intervention teams need technical assistance. During rescue operations medical rescue personnel is frequently facing a hostile environment with cold, wet, windy, and low visibility conditions. In addition, the patient’s condition can already deteriorate by delayed arrival time.

These circumstances complicate the initial assessment and diagnosis and limit medical treatment and outcome. Terrestrial rescue operations require extended activation time, high physical exertion, and environmental hazards during access to the site of the accident and prolonged evacuation time (Fig. 8.2).

Medical and technical management must be adapted to the conditions in order not to increase risk to the patient and the rescue team and to improve outcome. Monitoring may be restricted or not possible because devices are not always available and sometimes the weather conditions (freezing monitors), darkness, or certain injuries of the patient, for example, hypothermia, set limits for a continuous monitoring. All injured and sick persons in the mountains are considered hypothermic until the contrary is proved [3]. Further drop of body temperature should be avoided and assessment and treatment should avoid unnecessary undressing and provide proper insulation as soon as possible [4]. Physicians working in the mountains or mountainous environment must be comfortable in exposed situations, conscious of their own and the patient’s safety, and being able to work under extreme conditions. Technical mountain knowledge and experience as well as theoretical and practical skill of climbing in steep terrain in summer and winter conditions are mandatory. Training for doctors must basically include the same technical skills like self-belaying and other rescue maneuvers, transport and management of avalanche victims, canyoning rescues, and other specific emergencies like regular training for all rescuers. Physicians as part of a helicopter crew frequently may be supported by a single (air) rescuer. Thus they must be trained in performing long-line or winch operations without the support of a team. In case of bad weather conditions, the physician must be able to move safely and descend by himself when necessary [5, 6] (Fig. 8.3).

Overall he should consider and accept that medical treatment may be limited and injuries usually survived in urban areas may lead to death in this setting. Despite intensive training, alpine emergency physicians constantly face the situation that mountain rescue personnel does not show the same high level of medical education as in urban emergency medical system, where usually professional staff provides emergency medical assistance [7]. In an urban setting different tasks are performed by professional health-care providers. In mountain rescue operations, emergency physicians must perform usually delegated measures by themselves. Nevertheless, they should not lose track of the overall situation and adapt medical care to the specific situation of the mission. Unnecessary and excessive medical measure (“stay and play”) may delay the entire rescue operation unnecessarily and expose the patient and all team members to additional danger. In rescue operations risk assessment and management is one of the main tasks of the team leader. However, the emergency physician must adjust his actions to the situation and include the objective risk into his considerations. Emergency physician working in the mountains must adapt medical measures to existing human and technical resources. Optimized therapy should have priority over maximized treatment causing delay. Rapid evacuation may be an effective form of treatment. Every therapy, once begun, must be carried out until the patient is handed over to the following team. Adequate supply of medical or technical equipment, drugs, and oxygen is either not possible in reasonable time or might delay the entire rescue operation. Often the entire recovery cannot be brought later to the scene without delaying. In addition changing environmental factors and/or the patient’s condition may force the emergency physician to employ alternative medical strategies or evacuation procedures in cooperation with the team leader. In extreme weather situations, it may be appropriate to stay with a medically stable patient in a safe place (hut or bivouac), until the situation allows terrestrial or air-bound evacuation. In mountain rescue the emergency physician is frequently not the first on the scene either because no doctor was available from the beginning or the first message about the severity of the injury or illness was not correct. In this situation the key question arises: can the patient be treated by first responders sufficiently and transported to the doctor? Or must the emergency physician ascend to the location of the accident? Assessment of symptoms and signs of injury severity can be performed by trained rescuers who act as first responders, and initial steps of treatment can be prioritized by radio or mobile phone. Evacuation time may be shortened, hazards reduced, and medical treatment will start earlier. Increasing numbers of mountaineers seek recreation in mountain regions where the existing rescue resources are far less and the problems much greater than in the situations as described above. Commonly rescuers reach the scene of the accident hours or days later, apart from the fact whether there are any technical and medical options for professional mountain rescue. Expedition medicine in high altitudes or in very remote mountainous areas is beyond the scope of this disquisition.