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Scottish Mountain Rescue

ICAR 2017

SMR Delegation Report

-

05 February2018

© Copyright – SMR, 2018

The information that is contained in this document is the property of Scottish Mountain Rescue. The contents of the document must not be reproduced or disclosed wholly or in part or used for purposes other than that for which it is supplied without the prior written permission of SMR.

ICAR 2017


Released: 05 February2017

© Copyright – SMR, 2018 UNCONTROLLED COPY ONCE PRINTED

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Document Details

General Detail

Abstract The 69th ICAR congress was held on in Andorra 18

th to 21

st October 2017. SMR

was represented at the congress by three ordinary members of Scottish mountain rescue teams. This report is an account of the meetings of the congress and the individual commissions.

Authors Ken Marsden, Naomi Dodds, Andy Ravenhill

Owner Scottish Mountain Rescue3

Document History

Ver Date Amendment

1 05/02/18 First Issue

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Table of Contents

1 Introduction ........................................................................................................ 5

1.1 Technical Commissions ....................................................................................... 5

1.2 SMR Delegation .................................................................................................. 5

2 Pre-Conference Workshop – Big Wall Rescue (Naomi Dodds, Andy Ravenhill) ............................................................................................................ 7

2.1 Suspension Syndrome (Dr John Ellerton, ICAR MedCom President) .................. 7

2.2 Splinting (Dr Natalie Hölzl, BExMed) ................................................................... 8

2.3 Andorran Search Dogs ........................................................................................ 8

2.4 Norwegian Big Wall Rescue by Helicopter ........................................................... 8

2.5 Mid-face Casualty Handling (Andorran MR) ......................................................... 9

2.6 Mid-Face Pickoff (Croatian MR) ........................................................................... 9

2.7 Mono Pole Edge Transition (USA MR) ................................................................ 9

2.8 Mid Face pick-off (Italian MR) ............................................................................ 10

2.9 Canyon Rescue / Counter balance haul (Italian MR) ......................................... 10

3 Avalanche Commission – Ken Marsden ........................................................ 11

3.1 Best Practice in Avalanche Rescue ................................................................... 11

3.2 Country Reports ................................................................................................ 11

3.2.1 Italy .................................................................................................................... 11

3.2.2 Switzerland ........................................................................................................ 12

3.2.3 Norway .............................................................................................................. 12

3.2.4 USA ................................................................................................................... 12

3.2.5 France ............................................................................................................... 13

3.2.6 Slovakia ............................................................................................................. 13

3.3 Mountain Guide Incidents in Slovakia ................................................................ 13

3.4 Buried Subjects Outside of the Visible Boundary ............................................... 13

3.5 UIAA Standards for Shovels and Probes ........................................................... 13

3.5.1 UIAA Standard 156 Avalanche Rescue Shovels .............................................. 14

3.5.2 UIAA Standard for Avalanche Probes ............................................................... 14

3.6 Pinpointing After a Search with Electronic Means .............................................. 14

3.7 Avalanche Safety and Education ....................................................................... 14

3.8 Avalanche Transceiver Developments ............................................................... 15

3.8.1 Mammut Pulse Barryvox ................................................................................... 15

3.9 Summary and Conclusions ................................................................................ 15

4 Medical Commission – Naomi Dodds ............................................................ 16

4.1 ICAR MedCom papers and projects in development.......................................... 16

4.1.1 Multiple trauma management in alpine environments (Peter Paal, Italy) ......... 16

4.1.2 ICAR MedCom recommendations on suspension syndrome (Hermann Brugger and Giacomo Strapazzon, EURAC) .................................................... 16

4.1.3 Psychosocial health of ski patrollers and mountain rescuers (Marie Nordgren, Sweden) ........................................................................................... 17

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4.1.4 Medical Resource Website (Natalie Hölzl, BExMed) ........................................ 18

4.1.5 ICAR Medcom recommendation on quality improvement for avalanche rescue missions (Alex Kottmann and Mathieu Pasquier, Switzerland) ............. 18

4.2 Short Presentations ........................................................................................... 18

4.2.1 Knowledge of avalanche checklist (Giacomo Strapazzon, EURAC) ................ 18

4.2.2 Mountain Registries (Monika Brodmann, EURAC) ........................................... 18

4.2.3 Survey of MR teams’ Management of Severe Hypothermia (Andreij Gorka, Poland) .............................................................................................................. 19

4.2.4 Snow density study: Effects of snow properties on humans breathing into an artificial air pocket (Giacomo Strappazon, EURAC) .................................... 19

4.2.5 Potassium cut off level in avalanche victims (Hermann Brugger, EURAC) ...... 19

4.2.6 Optimizing avalanche rescue strategies using a Monte Carlo simulation approach (Peter Paal and Manuel Genswein) .................................................. 19

4.2.7 Causes of death among avalanche fatalities in Colorado: a twenty-year review (Alison Sheets, USA) ............................................................................. 20

4.2.8 Emergency ultrasound in an alpine setting (Andrea Orlandini, Italy) ................ 20

4.2.9 The effect of body position on management of buried avalanche victims (Hermann Brugger, EURAC) ............................................................................. 21

4.2.10 Virtual Learning Environment (VLE) using Moodle (Mike Greene, MREW) ..... 21

4.3 Summary ........................................................................................................... 21

5 Terrestrial Rescue Commission – Andy Ravenhill ........................................ 23

5.1 Using Connector/Carabiner in Mountain Rescue Organizations ........................ 23

5.2 Static Rope Knots for Rope Extension or Rope Connections for Rope Extension. .......................................................................................................... 23

5.3 Redundancy for Lowering or Raising People with Fiber Ropes .......................... 23

5.4 Talks Lectures and Presentations on Big Wall Rescue ...................................... 23

5.5 Saturday General Lectures. Combined all commissions .................................... 26

5.6 Summary. .......................................................................................................... 27

6 Summary ........................................................................................................... 28

Appendix A - Future Congress ............................................................................... 29

Appendix B - Conference Programme ................................................................... 30

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1 Introduction

ICAR is the International Commission for Alpine Rescue. The commission membership is made up from 103 organisations from countries around the world. Recently there has been an increase in membership particularly from Asia. The commission is heavily dominated by the main European alpine countries in terms of membership and governance.

The commission is governed by a board made up of the presidents of the four technical commissions within ICAR, elected ‘assessors’ from the ICAR membership and is headed by an elected president. ICAR functions as a fully constituted, democratic, transparent and neutral organisation. The key principles of ICAR are as follows:

Focus must always be on the patient

ICAR lays down the basic principles for global mountain rescue

Mountain rescuers must be protected against overregulation

ICAR improves mountain rescue outcomes by exchanges of experiences and by recommendations

The working language of the commission is English with all documents also translated into French and German. During the congress meetings, all presentations are translated to/from English, French and German. The ICAR website is www.alpine-rescue.org

The 69th annual congress was held at the Sport Hotel, Soldeu, Andorra

The overall theme of this year’s congress was Big Wall Rescue

For further information on any particular topic please contact one of the individual delegates listed in Table 1-1.

1.1 Technical Commissions

ICAR is comprised of four individual technical commissions as follows

Avalanche

Terrestrial

Air

Medical

In addition to the four technical commissions there was a separate dog handler meeting.

1.2 SMR Delegation

Scottish Mountain Rescue was represented in the technical commissions as follows

Table 1-1. ICAR- 2017 SMR Technical Commission Representatives

Technical Commission SMR Delegate Rescue Team Contact

Avalanche Ken Marsden Glencoe [email protected]

Terrestrial Andy Ravenhill Oban [email protected]

Medical Naomi Dodds Aberdeen [email protected]

Air No delegate

The technical commissions meet in separate sessions at the beginning of the congress. Technical commission meetings comprise presentations of the latest rescue operations, lessons learnt, new equipment and rescue techniques. The results of these discussions can result in the production of specific ICAR recommendations, e.g. use of avalanche transceivers, knots in ropes, medical guidelines etc.

http://www.alpine-rescue.org/

mailto:[email protected]




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The avalanche and terrestrial commissions also meet jointly as there is much in common between the two. The final day of the congress is a joint meeting of all commissions with presentations and a final congress annual general meeting. The full programme for the 2017 congress can be found here .

http://www.alpine-rescue.org/ikar-cisa/documents/2017/ikar20170922004419.pdf

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2 Pre-Conference Workshop – Big Wall Rescue (Naomi Dodds, Andy Ravenhill)

The pre-conference workshop was held at two locations, close to the hotel and above the resort by chair lift access.

A number of demonstrations tried to show how to evacuate a belayed casualty from a steep cliff using various rope techniques, other demonstrations looked at the treatment of the casualty.

2.1 Suspension Syndrome (Dr John Ellerton, ICAR MedCom President)

This workshop covered the practical management of a suspended casualty in a climbing harness. The symptoms of suspension syndrome can be explained by vasovagal neurogenic syncope or ‘fainting’, due to a lack of blood returning from the legs back to the heart. It is recommended that a conscious suspended casualty should be encouraged to actively move their legs, and all casualties suspended should be rescued as quickly as possible. A casualty should be placed in a horizontal position to encourage blood flow back to the brain, and a primary survey performed to explore other reasons for symptoms or loss of consciousness. They should then be transported to hospital for further assessment.

Figure 2-1. Suspension syndrome workshop. Photo: Naomi Dodds, Oct 2017

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2.2 Splinting (Dr Natalie Hölzl, BExMed)

A practical workshop focussing on the management of pelvic and lower leg injuries. The anatomy and pathophysiology of pelvic injury were discussed, and the application of a pelvic splint demonstrated using both commercial and improvised devices. Lower leg splinting was additionally demonstrated using a box splint and emphasis was made on how important it was to reduce a fracture putting it into normal alignment as early as possible by the rescue team.

2.3 Andorran Search Dogs

Quick demo by the Croatian Dog handlers on Dog training. It was pretty wet by the time we saw this and it was our last workshop so they weren’t that keen anymore. But it was good to see the contrast between the young dog and the fully trained search dog.

Figure 2-2. Andorra search dog demonstration. Photo: Naomi Dodds, Oct 2017

2.4 Norwegian Big Wall Rescue by Helicopter

On the big Norwegian walls 100m + they get HC dropped on the face then go down to the casualty with a long line which is clipped onto the fully extended winch line (80m) The longest line they have used was 230m once the lines are clipped the HC fly’s away from the wall. The winch line in hauled in then the rope is hauled up by a neat technique using a pro traction and a rescucender. (Pics & Video)

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Figure 2-3. Norwegian big wall rescue workshop. Photo: Naomi Dodds, Oct 2017

2.5 Mid-face Casualty Handling (Andorran MR)

Difficult access casualty handling: 1 suspended casualty two rescuers. Two Rescuers abseil down with a collar and flexible clip back board. Collar fitted and then back board clipped round the casualty. The casualty then transferred to the rescuers rope and lowered to the ground.

Flexible back board was fairly easy to use even with just two handlers, three were better. One on head one lift and one to slid in the back board. Pretty slick (Pictures)

2.6 Mid-Face Pickoff (Croatian MR)

Casualty placed mid face hanging on a rope. Rescuer abseiled down with a pulley rig set up on a Jumar clamp on the rope above his attachment point. On reaching the casualty he clipped the 3 : 1 pulley to the casualty and used a foot loop to haul the casualty up and unload his rope. Casualty then clipped onto the system and his rope removed (untied or cut). Rescuer and casualty the abseiled down to the floor.

OK demo I didn't like the use of a toothed rope clamp on the tensioned Rescue line and the rope setup was basic and clumsy. Seen a lot slicker systems. (Photos to the system)

2.7 Mono Pole Edge Transition (USA MR)

Very slick demo by the Americans of a mono pole edge transition system. MP was anchored by four tensioned lines as close to the edge as possible (safe) Angle of line are important for stability. Plenty of attachment points on top and button. Twin rope lower with one rope high and one rope height adjustable to secure transition. Plenty of photos and video clips.

Weight of pole 7kg, a new lightweight pole 3 kg out soon. (PMI brochure)

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Figure 2-4. Mono pole edge transition workshop

2.8 Mid Face pick-off (Italian MR)

The Italian version one a mid-face pickoff with some interesting knots (pics and video) One easily adjustable for passing knots, the other just a version of a prussic plus a W munter, basically a munter with an extra turn (Monster Munter is better)

2.9 Canyon Rescue / Counter balance haul (Italian MR)

A demo of a floating Kong stretcher and a waterproof cas-bag. Setup was simple Jumar at the head and fixed tie in at the foot. This was a counter balance haul using a pull-up on the edge and a rescuer counter balance king the stretcher. After the haul another rope was clipped onto their head to aid the edge transition. Interesting belay using a non-fixed belay using 1 man per rope and the friction of a car tire and they edge. As no hauling was need it worked well. Extra rope to lift the stretcher nose over the edge. Tail rope under the stretcher. (Pics + video)

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3 Avalanche Commission – Ken Marsden

President Dominique Létang (France)

Vice President Vacant position

Secretary & Translation Manuel Genswein (Switzerland)

The Avalanche Commission meeting was made up in two parts. The morning session starts with a minutes silence and then continues with administrative matters and a summary of progress over the last year. Country reports then follow. The afternoon session comprises more detailed presentations and discussions on specific topics.

3.1 Best Practice in Avalanche Rescue

Considerable progress has been made in the development of the Best Practice in Avalanche Rescue. This is a suite of 160 annotated illustrations depicting the latest proven techniques for avalanche rescue. The annotations have been translated in to 18 languages using common terminology. This has been a huge task taking into account regional differences in say French and German between different European countries.

The illustrations have now been finalised with the recognition that sooner or later they had to stop. The enemy of good is better. Some work is still required to refine the annotations in all the different languages. Posters will be available to download in the future on a subscription basis.

Figure 3-1.Example Illustration Best Practice in Avalanche Rescue

3.2 Country Reports

Representatives present data regarding the number of avalanches, victims and fatalities for the year. Further explanation may be offered regarding snow conditions for the season, impact of education and information campaigns. Worrying trends are identified backed up by data. A consistent topic raised from many speakers was the number of incidents involving guides or ski instructors.

European avalanche incidents tend to occur in the high mountains above the tree line. Generally for the main alpine countries the fatality rates this last year were below the long term averages

3.2.1 Italy

20 fatalities in the mountains

29 fatalities in the Rigopiano Hotel with 11 survivors

A number of key points were raised from the Italian delegate. During the Rigopiano Hotel rescue effort there were over 100 rescuers from many different agencies, e.g. fire, police, military as well as mountain rescue. Many of the agencies did not equip themselves with avalanche transceivers despite

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the risks. Special intelligence tools usually used against terrorism were deployed to locate buried mobile phones.

In two different incidents, two victims in each incident were found using Recco. All four were dead but the use of Recco at least found the bodies detecting electronic devices carried by the victims.

Other incidents highlighted the problems of multiple unrelated groups skiing in the same hazardous areas. As well as being unrelated group members spoke different languages making it difficult for rescuers to gain accurate on scene information. Many people are still not trained in companion rescue. It was highlighted that some guides are making very poor or irrational decisions, taking clients into hazardous terrain or with objectives beyond the clients technical abilities. Poor group management is also a problem with clients either not obeying safety instructions e.g. to travel spread out, or guides not enforcing good group management. 35% of avalanche incidents involved a guide, many are foreign including UK.

There is a law in Italy were by triggering an avalanche can lead to prosecution, irrespective of the consequences. It is believed that this leads to under reporting of avalanches and also people not engaging in the rescue effort but leaving the scene for fear of the legal consequences.

3.2.2 Switzerland

All fatalities were off piste skiers in the last few years

25 fatalities per year over 80 years, 23 fatalities per year over the last 20 years but more recreational use of the mountains

2016/17 8 fatalities, 2015/16 21 fatalities

No incidents with more than one fatality suggesting more defensive behaviour

The winter in Switzerland arrived late this last season with very poor winter conditions. This may have reduced the numbers in the mountains or improved defensive behaviours. Airbags were involved in some incidents. One in particular saw

A buried victim with no airbag

A partial burial with a deployed airbag

A partial burial were the airbag failed to deploy, the trigger handle was zipped away

3.2.3 Norway

2 fatalities, long term average is 5 fatalities per year.

Problem of foreign tourists not pronouncing mountain names correctly can lead to initial search in wrong area. The lack of snow and a poor ski season may well have contributed to the drop in fatalities.

3.2.4 USA

12 fatalities in 2016/17 is half of the long term average

Snow mobile users followed by back country skiers are the main victims

2016/17 saw 200% of the normal snow fall with 12 avalanche fatalities, 2015/16 saw 25% of normal snow fall but 11 avalanche fatalities.

Although the numbers are statistically small it highlights that the number of expected fatalities maybe independent of the overall snow fall despite increased numbers of recreationalists. This may be down to

1 Improved equipment

2 Social media

3 Better training and safety awareness

4 Better advisory and forecasting services

It was noted that had the fatality rate stayed the same with increasing recreational numbers, the expected number of fatalities would be more than 200 per year

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3.2.5 France

22 fatalities in 2016/17 compared to the long term average of 30

10 ski tourers

9 off piste

3 alpinists

114 people caught in avalanches

13 fatal incidents

2016/17 saw a warm autumn with no real snow pack before mid-January followed by early melting, hence a very short season.

A number of the incidents were multi burial with many involving guides or ski instructors.

3.2.6 Slovakia

10 incidents mostly during avalanche hazard level considerable (3)

Long term average 3-4 fatalities per year

2016/17 no fatalities

The 2016/17 season was a ‘very snow rich’ season in Slovakia

3.3 Mountain Guide Incidents in Slovakia

Four case studies of incidents involving guides since 1998 were presented. The conclusions were that

Guides have more exposure days and therefore greater risk

Client motivation pushes guides to increase risk

Client ‘disobedience’, not following guides instructions leads to higher risk

Most incidents occur in March and during an avalanche hazard level of considerable (3)

The comment was made that guides may be more inclined to criticise clients for their behaviour rather than admit to poor group control.

3.4 Buried Subjects Outside of the Visible Boundary

There are some rare cases where the buried avalanche victim has been found outside of the visible debris boundary, typically beyond the toe of the avalanche. The question was raised as to whether the flagging of the avalanche site should include the area beyond the visible boundary. This raised a number of questions.

1 Where exactly to place the yellow boundary flags?

2 How do we assess the distance beyond the boundary?

3 Could fresh snow beyond the boundary (the toe) be elevated by the debris driven below?

4 Could probing the fresh snow reveal buried debris?

5 Could this probing reveal the ‘real toe’ and the ‘apparent toe’

6 Are the number of victims buried beyond the boundary statistically significant

7 Data from Switzerland has 1 case in 80 years of one victim 10m outside of the visible boundary

A brief discussion followed to try and evaluate how big a problem this is. I believe that so long as the visible boundary is correctly marked, a decision can be made whether to search beyond the boundary. This would be marked in the usual way with red flags.

3.5 UIAA Standards for Shovels and Probes

UIAA standards are the only globally recognised standards for mountaineering equipment.

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3.5.1 UIAA Standard 156 Avalanche Rescue Shovels

Following much laboratory and field testing over the last two years, UIAA standard 156 ‘Avalanche Rescue Shovels’ was published in July 2017. This standard seeks to ensure that all shovels complying to the standard would withstand the loads generated in rescue activities. Tests have been designed to simulate the failure modes found in the field due to tension and bending. Some manufacturers are already compliant with the standard. The full standard is embedded below, a degree in mechanical engineering is recommended.

UIAA_avalanche_resc

ue_shovels_156_final.pdf

3.5.2 UIAA Standard for Avalanche Probes

Work is now underway to define standards for avalanche probes. Three categories of probes have been identified.

1 Racing

2 Companion

3 Search & Rescue

It is believed that a lower standard is appropriate for racing since this is a controlled activity and hence less robust equipment is required since additional help would never be far away in a properly managed race. The standard would look at all likely failure modes

1 Racing, 10 probing spirals to 1m depth 1m radius

2 Companion, 10 probing spirals to 1.5m depth 1m radius, 15 minutes slalom probing to 1.5m

3 Search & Rescue, as for companion probes but also 15minutes probing 2 holes per step to 2.5m depth in hard debris

All probes should have a printed metric scale 10cm intervals It was also proposed that probe be clearly marked at 1.5m and 2.5m to assist in easily identifying probing depths

Many other mechanical parameters were proposed but these are in the realms of detailed mechanical engineering relating to forces and bending moments. The intention is to develop laboratory tests which mimic actual use in the field.

3.6 Pinpointing After a Search with Electronic Means

A presentation was made regarding pinpoint probing following the fine search. The method presented was for a transceiver searcher to perform a very basic fine search, forwards & backwards to find the minimum distance to the buried victim. If the device gave a distance of 1.4m, then the victim could be buried anywhere within an arc of radius 1.4m.

This simplified fine search which only looks for a distance minimum on a single axis leads to the pinpoint probing not necessarily starting in the optimum location. This method of fine transceiver search was discussed with some delegates. In the Scottish mountain rescue avalanche courses, the full fine search method is taught first since this is the most difficult skill for participants to master. The issues raised by the presenter hence do not arise.

3.7 Avalanche Safety and Education

Three presentations from France, Andorra and the USA were given devoted to different education and information programmes.

All three programmes gather data from Q&A surveys of mountain users, typically skiers. Data is gathered regarding age, sex, experience, levels of training, equipment carried. This helps the local (not for profit) agencies to target appropriate education and information material to different user groups. Surveys reveal that people still go out off-piste and ski touring without transceiver, probe and shovel.

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www.Chamoniarde.com are finalising a very good video demonstrating and avalanche transceiver search and rescue. It is hoped that this will be available to use in SMR avalanche training courses in 2018.

3.8 Avalanche Transceiver Developments

Pieps, BCA and AVA were displaying their transceivers this year but no new models or significant advances.

3.8.1 Mammut Pulse Barryvox

Mammut are about to release the latest version of the Pulse Barryvox and Pulse Element avalanche transceivers. Unless a serious issue is identified, there will be no software development of old Pulse Barryvox, used by many Scottish mountain rescue teams. Servicing and repairs will continue to be supported for some time yet. The statement below is from the Mammut website.

For operators where having a homogeneous fleet is important, we'll do our best to accommodate your needs. We are no longer able to supply new Pulse or Element beacons, but we have a limited supply of dedicated warranty-replacement beacons should we need to replace one of your beacons under our 5-year warranty. At some point over the next couple years we will run out of these. After that time, any replacement under warranty will need to be with the new BarryvoxS and Barryvox beacons. We know this isn't a perfect solution so if you have concerns please give us a call and we will do our best to accommodate your needs.

The new Pulse Barryvox has a bigger screen and a slightly more compact case. The search displays and functional menus have been completely redesigned to offer a more intuitive user interface. Inside the device, advances in electronics and software mean that it is much less vulnerable to interference from external electronic devices. That said, it is still best practice to keep all sources of interference well away from avalanche transceivers.

Other advances mean that the new Barryvox can better keep track of other transceivers during the fine search phase of a multi-burial incident. The Barryvox uses timings between signal rising edges, some frequency and amplitude analysis to identify individual transceivers. There are also slight differences in pulse spacing between transceivers so that if two transceivers are turned on coincidentally, the pulses will eventually separate out and not continually overlap.

3.9 Summary and Conclusions

The most interesting development in recent years is the ‘Best Practice in Avalanche Rescue’ project. The illustrations and guidance text are a valuable resource to ensure the consistency and continued improvement in avalanche rescue training. It is hoped that Scottish Mountain Rescue will be able to subscribe to the project and have access to the illustrative materials.

Initiatives around the world trying to assess and improve the level of avalanche awareness are very worthwhile but outside the scope of Scottish Mountain Rescue.

There are currently no new significant technological leaps in avalanche transceiver technology. The new Pulse Barryvox is still a three antenna device GUI although the underlying electronics, processing and GUI have all imporved. Teams using the now obsolete Pulse Barryvox should consider how they will manage their stock in the future.

http://www.chamoniarde.com/

http://www.mammutavalanchesafety.com/2017/03/new-mammut-barryvox-and-barryvoxs.html

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4 Medical Commission – Naomi Dodds

President Fidel Elsensohn (Austria)

President Elect John Ellerton (England)

ICAR MedCom is the abbreviation of the Medical Commission of ICAR. ICAR MedCom meets twice a year in order exchange experience and knowledge of mountain emergency medicine, as a result of these meetings publications and recommendations are produced for distribution.

The ICAR MedCom Autumn 2017 meeting took place over two days and welcomed 69 members, representing many different academic, rescue and mountain emergency medicine organisations around the world. ICAR MedCom was extremely pleased to have SMR represented again this year. Scotland is unique in terms of its environment and remoteness, with non-health care professionals delivering casualty care on a voluntary basis. This provides additional medical challenges not encountered in other countries, and therefore the commission expressed that input from SMR is highly valued.

The meeting started with introductions, apologies and approval of minutes from the Spring 2017 meeting which took place in Liguria, Italy. The first day was spent discussing ICAR MedCom papers and projects currently in development. The second day consisted of short communications from ICAR members about research projects recently undertaken. During the meeting John Ellerton was elected as the next ICAR MedCom President and a big thank you was given to Fidel Elsensohn for his dedication to the role over the past 8 years.

4.1 ICAR MedCom papers and projects in development

4.1.1 Multiple trauma management in alpine environments (Peter Paal, Italy)

ICAR MedCom recognises that updated recommendations should be developed for the management of multiple trauma casualties. These guidelines will build on the previous 2009 paper regarding fluid management in mountain rescue.

It was decided that all ICAR MedCom publications moving forward should be Open Access so they can be viewed by everyone without charge.

4.1.2 ICAR MedCom recommendations on suspension syndrome (Hermann Brugger and Giacomo Strapazzon, EURAC)

The pathophysiological mechanism of suspension syndrome has been debated for decades.

Partial results of a new Italian study at the EURAC Institute of Mountain Emergency Medicine (IMEM) in collaboration with the Medical University of Innsbruck were presented by Giacomo Strapazzon.

Methods: 20 young male subjects were suspended either after resting or after climbing on a climbing wall. Parameters to be measured were hemodynamics, echocardiography, venous pooling by ultrasound and venous O2 content by NIRS. The subjects were instructed to stay as still as possible.

Results: Presyncope (dizziness) occurred in 30% of subjects. There were marked increases in venous pooling, and decreases in heart rate and blood pressure in the subjects with presnycope.

Conclusion: The most likely cause of presyncope in suspended subjects is neurally mediated.

Recommendations; Syncope (loss of consciousness) can be avoided by active movement. Victims of suspension syndrome should be rescued as rapidly as possible and placed in the horizontal position. There is no evidence in favour of a semi-recumbent position or ‘W’ position which was previous practice.

In addition to the IMEM study, there is a recently study from New Mexico. The New Mexico study showed no increase in potassium or creatine kinase in subjects with presyncope. The IMEM used standard climbing harnesses, while the New Mexico study used industrial harnesses. Both studies had similar results.

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Additionally there are case reports to consider, in one the victim had been hanging from a paraglider for 45 minutes and was in no apparent distress, but then had a sudden syncope and was rescued a few minutes later in cardiac arrest.

Hermann and Giacamo will work on the ICAR MedCom recommendations and present their work for ICAR MedCom approval in autumn 2018.

Figure 4-1. Suspension syndrome. Photo: Naomi Dodds, Oct 2017

4.1.3 Psychosocial health of ski patrollers and mountain rescuers (Marie Nordgren, Sweden)

Marie first gave an update from the hypothermia incident she presented last year, in which three 14 year old boys fell into cold water whilst canoeing a mountain lake in Sweden. Two of the boys had no vital signs when rescued and the nearest ECMO centre was 30 minutes away.

One of the boys had a core temperature was 14.5°C and his potassium was 5.2 mmol/L after he arrived at the hospital in Trondheim. He now has a hard time with short time memory, some problems with his hands and right leg, but he can jog and ride a motorbike. He is now in high school on an engineering program. The other had a core temperature was 18°C. He now has a hard time with his hands due to tendon instability and muscle fatigue, but is also doing well in high school.

“He was the most dead person of all the dead persons I had seen” said one of the rescuers following the accident.

This led to Marie Nordgren and Ulrika Tranaeus initiating a qualitative research project interviewing ski patrollers and mountain rescuers to explore the impact of these accidents on their psychosocial health. The mean age of participants was 37.5 years. Ski patrollers in Sweden are paid full-time professionals, Mountain rescuers are volunteers although they are paid for some rescues. A literature review of PTSD had been carried out. Swedish, Italian and UK studies found that volunteer rescuers coped better than professional rescuers, possibly due to a sense that they were performing a worthwhile service. Professionals usually had other duties that were not related to rescue. A study of French mountain rescuers on prevalence and factors leading to PTSD exists but does not seem to be available on PubMed.

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There was an interesting discussion following the presentation regarding how rescue members are debriefed following an incident, some professional teams have clinical psychologists working with them and some have no formal provisions for psychosocial health. In the UK we have adopted a TRiM (Trauma Risk Management) model for secondary prevention for PTSD and SMR provides members with training to become an MR TRiM Practitioner.

It was proposed that this work on psychosocial health is extremely valuable and should be developed into a ICAR MedCom paper, with the view to raise awareness and publish the recommendations.

4.1.4 Medical Resource Website (Natalie Hölzl, BExMed)

It has been recognised that there is a need for an internet-based library for ICAR MedCom resources. The ICAR website which has limited capacity and does not allow continuous edits. The new site should be user-friendly for the contributors as well for those accessing the knowledge base, work will be done over the next year to develop this idea further.

4.1.5 ICAR Medcom recommendation on quality improvement for avalanche rescue missions (Alex Kottmann and Mathieu Pasquier, Switzerland)

Alex and Mathieu reviewed the last 15 years of avalanche rescues for REGA and established that there is a lack of adherence to guidelines. This has also been highlighted in two recent papers -

Strapazzon G, MIgliaccio D, Fontana D. et al. Knowledge of the Avalanche Victim Resuscitation Checklist and utility of a standardized lecture in Italy. Wilderness Environ Med 2017 [epub ahead of print].

Kottmann A, Blancher M, Pasquier M, Brugger H. Avalanche Victim Resuscitation Checklist adaptation to the 2015 ERC Resuscitation Guidelines. Resuscitation 2017 [epub ahead of print].

It was proposed that an ICAR Medcom recommendation should try to answer the question: ‘What do we do during avalanche rescue missions and how well do we do it?’

The recommendation should communicate data, interpret information and help rescuers to make decisions, adopting the most useful quality indicators for avalanche rescue missions.

The quality indicators will be developed by literature search, expert agreement and a consensus meeting. An update would be presented at the ICAR MedCom Spring 2018 meeting.

4.2 Short Presentations

4.2.1 Knowledge of avalanche checklist (Giacomo Strapazzon, EURAC)

Strapazzon G, Miglaccio D, Fontana D. Knowledge of the Avalanche Victim Resuscitation Checklist and Utility of a Standardized Lecture in Italy. Wilderness Environ Med 2017 [epub ahead of print].

This was a retrospective study to assess knowledge of the ICAR Avalanche Checklist amongst professional mountain rescue personnel in Italy. Rescue personnel were asked to complete a questionnaire pre and post avalanche lecture as part of a mountain rescue course. In the pre-lecture survey, 65% of participants had never taken an avalanche course, 76% had no avalanche rescue experience and 34% had heard of the ICAR Avalanche Checklist. Prior to the course 36% of the participants knew the correct burial time cut off for withholding CPR in a completely buried victim with an obstructed airway. This increased to 84% after the course.

4.2.2 Mountain Registries (Monika Brodmann, EURAC)

For low incidence high impact incidents, registries can be extremely useful in collecting data and improving outcomes.

In an attempt to increase the number of cases in mountain registries, three international registries Hypothermia Registry (IHR), Alpine Trauma Registry (IATR), and the Avalanche Registry (IAVAR) will be accessible from a single site: www.mountain-registries.org.

http://www.mountain-registries.org/

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4.2.3 Survey of MR teams’ Management of Severe Hypothermia (Andreij Gorka, Poland)

Podsiadio P, Darocha T, Kosinki S, et al. Severe hypothermia management in mountain rescue: a survey study. High Alt Med Biol 2017 [epub ahead of print].

Aim: To assess whether mountain rescue teams (MRTS) are able to follow guidelines.

Methods: A questionnaire was sent to 123 MRTs in 27 countries.

Results: There was a low rate of return of questionnaires and a low incidence of severe hypothermia.

Conclusions: Many teams were not equipped with electrocardiographic (ECG) monitoring, automated external defibrillators (AEDs) or low-reading thermometers. Some patients were sent to local hospitals rather than to hospitals capable of extracorporeal rewarming (ECLS). The majority of MRTs are not equipped to provide Advanced Life Support (ALS) especially in victims who are in cardiac arrest.

4.2.4 Snow density study: Effects of snow properties on humans breathing into an artificial air pocket (Giacomo Strappazon, EURAC)

Introduction: Beyond 35 minutes there is no reported survival with a blocked airway. This study aimed to explore the impact of air pockets and snow density further.

Methods: Subjects breathed into artificial air pockets except for subjects in the control group, who had no air pockets. There were multiple measurements including snow density and permeability. There were 3 levels of snow density.

Results: There was a high rate of early trial termination in the highest snow density group. Only snow density was correlated with air pocket gas values.

Conclusion: A rapid decline in SpO2 occurred without an air pocket and in the highest density snow.

4.2.5 Potassium cut off level in avalanche victims (Hermann Brugger, EURAC)

Introduction: The highest recorded serum potassium in an avalanche survivor is 6.4mmol/L. ICAR MEDCOM and the European Resuscitation Council (ERC) propose potassium >8 mmol/L and core temperature (Tc) >30°C as cut offs for not using extracorporeal life support (ECLS) in avalanche victims. Sensitivity and specificity of these cut offs, confidence intervals and receiver operating curve (ROC) analysis have never been estimated.

This was a retrospective study of avalanche victims with out-of-hospital cardiac arrest (OHCA). The hypothesis was that serum potassium is useful to determine the chance of survival. The null hypothesis was that serum potassium is not related to the chance success of extracorporeal rewarming. Estimating the false positive rate can be used to improve the selection for use of extracorporeal life support (ECLS) of avalanche victims with reversible OHCA from hypothermia.

Methods: Avalanche victims with OHCA admitted for ECLS 1995-2016 were included. Although centres in Europe and North America were invited, all responses came from Europe. Data was collected using the Utstein form. Prehospital parameters included duration of complete burial and airway status. In-hospital data include the initial core temperature, cardiac rhythm and serum potassium.

Results: Burial duration did not distinguish survivors from non-survivors. Non-survivors had higher mean serum potassium, and the difference in serum potassium between non-survivors and survivors was statistically significant. Survivors had lower Tc than non-survivors.

4.2.6 Optimizing avalanche rescue strategies using a Monte Carlo simulation approach (Peter Paal and Manuel Genswein)

Peter Paal began by giving an introduction to avalanche rescue, presenting data from relevant literature on resuscitation.

Reynolds JC, Frisch A, Rittenberger JC, Callaway CW. Duration of resuscitation efforts and functional outcome after out-of-hospital cardiac arrest: when should we change to novel therapies? Circulation 2013; 128(23):2488-94.

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In casualties with a normal temperature brain damage begins within 3-5 minutes of cardiac arrest if CPR is not performed. The above study showed that longer CPR time increased survival but resulted in worse neurological outcome due to brain damage.

Moroder, L, Mair B, Brugger H et al. Outcome of avalanche victims with out-of-hospital cardiac arrest. Resuscitation 2015; 89:114-118.

This study demonstrated that of 55 avalanche victims in cardiac arrest, only two survived with good neurological outcome. Both of these casualties had a short burial and received immediate bystander CPR.

Lexow K. Severe accidental hypothermia survival after 6 hours 30 minutes of cardiopulmonary resuscitation. Arctic Med Res. 1991; 50 Suppl 6:112-4.

There are cases in the literature demonstrating that hypothermic patients can survive very long durations of cardiac arrest if hypothermia precedes hypoxia. However, avalanche related cardiac arrest is often due to asphyxia and this is associated with a very low chance of neurologically good outcome.

Monte Carlo simulation is a computer model which uses repeated random sampling of input variables, to calculate the distribution of expected outputs. It can potentially predict survival in various avalanche situations,

An interesting discussion then took place regarding triage of avalanche casualties given the data Peter Paal presented and the output from the Monte Carlo simulation. If there is only one rescuer and two buried casualties do you commence CPR on one and continue for 20 minutes according to the avalanche resuscitation guidelines, whilst the other receives no CPR? It was suggested by the Monte Carlo simulation that CPR should be performed for 5-7 minutes on one before moving to the next, unless the casualty was in VF a shockable rhythm in which is associated with good outcome. However, further work is need to develop more comprehensive medical parameters for avalanche victims to confirm this theory.

4.2.7 Causes of death among avalanche fatalities in Colorado: a twenty-year review (Alison Sheets, USA)

The aim was to explore the cause of death among avalanche fatalities in Colorado. All avalanche fatalities between 1995-2015 were included and the cause of death for each fatality was determined by the county coroner. The injury severity score (ISS) was calculated for all patients with autopsies. Of the 110 deaths 65% were due to asphyxia and 29 % were due to trauma. These results are similar to Canadian results in which 24% of deaths were due to trauma (Boyd et al 2009). Multisystem trauma (38 %) head trauma (31%) caused over half of trauma deaths. A larger proportion of deaths were attributed to trauma than those previously reported in Europe (Hohlrieder et al 2007) and Utah (McIntosh et al 2007). A similar review is currently being undertaken in Scotland, predicting that trauma is likely to contribute to a large number of deaths in Scotland due the nature of the terrain.

Boyd J, Haegeli P, Abu-Laban RB et al. Patterns of death among avalanche fatalities: a 21-year review. CMAJ 2009; 180(5):507-512.

Pattern and severity of injury in avalanche victims. Hohlrieder M, Brugger H, Schubert HM et al. High Alt Med Biol 2007; 8(1):56-61.

Cause of death in avalanche fatalities. McIntosh SE, Grissom CK, Olivares CR, et al. Wilderness Environ Med 2007: 18(4):293-297.

4.2.8 Emergency ultrasound in an alpine setting (Andrea Orlandini, Italy)

A literature search found 413 papers on prehospital ultrasound, but only 12 papers on ultrasound in alpine environments.

Uses of ultrasound in mountain environments include diagnosis of cardiac arrest, nerve blockade, IV cannulation, confirming fractures, checking the position of endotracheal tubes, focused assessment with sonography in trauma (FAST) and extended FAST (e-FAST) with lung sonography. In a high altitude environment, it can also be used to assess optic nerve sheath diameter (ONSD) in acute mountain sickness (AMS) and high altitude cerebral oedema (HACE), however ONSD is only useful for research rather than clinical applications.

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Garabaghian L, Anderson KL, Lobo V. et al. Point-of-care ultrasound in austere environments: a complete review of its utilization, pitfalls, and technique for common applications in austere settings. Emerg Med Clin North Am 2017; 18(2):270-280.

Otto C, Hamilton DR, Levine BD, et al. Into thin air: extreme ultrasound on Mt. Everest. Wilderness Env Med 2009: 20(3):283-289.

4.2.9 The effect of body position on management of buried avalanche victims (Hermann Brugger, EURAC)

Background: The survival rate of completely buried victims is much higher when they are extricated by bystanders than by rescuers (74% versus 19% p=0.002)

Mair P, Frimmel C, Vergeiner G et al. Emergency medical helicopter operations for avalanche victims. Resuscitation 2013; 84(4):492-5.

This study raises the questions: Does the position of the completely buried victim affect CPR? How long does a lay rescuer take to bring a victim into a position allowing resuscitation?

Kornhall DK, Logan S, Dolven T. Body positions of buried avalanche victims. Wilderness Environ Med 2016; 27(2):321-5.

Kornhall et al showed that buried avalanche victims prone and head down is more frequent than supine and head down. Head position: 159 victims: downhill 65%, uphill 23% and across slope 11%. Body position 253 victims: prone 45%, supine 61%, sitting/standing 16%, on side 15%

Methods: This study used a simulated avalanche in natural snow compressed by a snow machine Manikins were buried 1 m deep prone or supine with head downhill or uphill. Rescuers were randomly assigned and blinded to scenario. In all positions 1 or 2 rescuers performed the rescue.

Conclusions: The airway can be freed in all positions before the patient is extricated, saving significant time. If the patient is in the prone position, ventilation cannot be performed before extrication (45% of completely buried victims). Chest compressions can be performed in all positions before extrication, as soon as the chest or back is free. This could save time, but quality may not be adequate. Quality of chest compressions in positions other than supine requires further studies. Chest compressions without ventilation doesn’t comply with BLS guidelines for asphyxia cardiac arrest.

Possible recommendations: In both single and multiple victim scenarios free the airway as soon as possible. In a single victim scenario (victim/rescuer ratio ≤1), start CPR before extrication if the victim is supine and after extrication if the victim is prone. In multiple victim scenario (victim/rescuer ratio >1), start CPR before extrication if the victim is supine.

4.2.10 Virtual Learning Environment (VLE) using Moodle (Mike Greene, MREW)

There are many challenges to educating volunteers. Virtual learning environments (VLEs) are versatile and flexible. They can incorporate multimedia. VLEs are interactive rather than passive. They can be easily updated and can be used almost anywhere, any time the student has access to the internet. VLEs are less expensive than books.

Moodle is a free, open source VLE used by over 14,000 institutions. Tools are maintained by the Moodle Community. Moodle is a platform for blended, active learning. Moodle can be used for initial learning and for continued practice development. There are costs for servers, training for administrators and a lot of time to write the material and keep it updates.

Mike gave a demonstration of Moodle and recommended the book Moodle for Dummies. SMR will be working with MREW on the Casualty Care Moodle site so members will able to access valuable interactive resources in the future to improve training and continued professional development.

4.3 Summary

During the course of the two days a number of interesting research papers were presented along the common themes of suspension syndrome, avalanche resuscitation, hypothermia and traumatic injury.

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The importance of evidence-based practice, education and the sharing of ideas between organisations was highlighted, all of which ultimately improve survival and outcome of mountain rescue casualties.

It emphasised the need for SMR to collect better information on what we currently do, to explore how we can best adapt ICAR recommendations, improve casualty care training and enhance the quality of medical care we provide to our casualties. The field of mountain emergency medicine is always advancing forward and therefore it is essential we aim to follow the latest ICAR MedCom recommendations and strive towards best practice.

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5 Terrestrial Rescue Commission – Andy Ravenhill

After an initial talk and Q & A the first order of business was three Terrcom recommendations:

5.1 Using Connector/Carabiner in Mountain Rescue Organizations

The only change here is the inclusion of ‘triple action’ locking carabiners as main belay crabs. This is as well as recommending normal screw gate crabs for main anchors Terrcom are including ‘triple action’ locking carabiners. These crabs are generally a type of twist lock that has an extra step to release the twist. i.e. a button as in the Petzl AMD ball lock or pulling the sleeve of the twist down before twisting.


5.2 Static Rope Knots for Rope Extension or Rope Connections for Rope Extension.

Recommendations for joining rescue ropes with pictures to make it clear as some knots have different names in different commissions. Nothing new here. Recommendations for different rescue loads.


5.3 Redundancy for Lowering or Raising People with Fiber Ropes

The ICAR Terrestrial Rescue Commission recommends Two-Tensioned Rope Systems for, high consequence terrain, when lowering or raising with fiber ropes that provide a mutual backup in the event of a failure of one of the rope systems. No changes just updated


5.4 Talks Lectures and Presentations on Big Wall Rescue

Over the following couple of days I watched several talks on big wall rescues in a variety of countries from Norway to Yosemite. The majority of these were helicopter based. The consensus being a terrestrial approach to these rescues was unjustifiably hazardous. Various permutations of a long line technique were deployed which can be broken down into three classes.

a. Normal helicopter winch distance, usually up to 80m

b. Helicopter fixed line. Usually fixed under the helicopter body. No line retrieval. Distances of up to 300m (1000ft) of line




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c. Winch line extensions. A rope is added to the end of the winch line of up to 300m. Line retrieval is

possible.

The helicopter crews really has two choices. To access the face they either go close to the face (Long Line) or above the wall (Super Long Line). Both techniques have significant hazards. Rotor strike being the greatest hazard of being next to the wall

The majority of big wall rescues in both Switzerland and Norway currently are from BASE Jumpers and Wing Suits. A big problem with this type of rescue was re-inflating the parachute and blowing the casualty off the mountain with the helicopter. We were shown a variety of rescues involving BASE jumpers all very serious, including one gory talk from the Swiss Coroner. Moral of this story, don’t take up BASE jumping!

Big wall techniques were used in a variety of situations including Canyon rescue and cave rescue. With some interesting talks by the Cave Rescue Italy where they have massive 500m deep shafts. One of which has a 300m ice climb within it! The underground rescues used mainly counterbalance haul techniques to get the stretcher/ casualty up the cave system.

Good to see the Norwegians are still using Seaking Helicopters for super long line rescues. I can’t see Bristow/HMCG even remotely entertaining these techniques even though they offer significant safety advantages for both helicopter crew, rescuers and casualty.

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There was an interesting talk by RECCO on their helicopter based system which can be slung under a helicopter. This can detect Recco tags from 250m altitude and also detect phones and other metal objects such as cameras and transceivers from the air. It was used successfully on a big alpine search in Switzerland/Italy when climbers, one with a Recco reflector was buried in an avalanche / crevasse.

The majority of the ‘on face’ systems are simple. If a team need to be on the face they would be using normal mountaineering techniques to access the casualty. Very few team seemed to use mechanical friction devices such as the Petzl ID and similar. Friction devices for lowering varied from the Italian’s with the Cortina W (pic) and the Kong plate (pic) to the Americans with CMC/PMI friction devices

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5.5 Saturday General Lectures. Combined all commissions

On Saturday all the commissions come together to share their lectures with the other commissions.

a. Rescue techniques from big walls by Air Rescue Switzerland. Gave us a talk about a rescue from the Eiger north wall. They used a long line to extract a fallen climber from the exit cracks high on the face.

b. The Terrestrial Commission went over the new recommendations detailed earlier in the report.

c. The Rigopiano Disaster – Avalanche Commission. Told the story of a huge avalanche that destroyed a hotel in Italy

d. Canyoning Guidelines from the Italian delegation. An interesting report on the problems of canyon rescue with some interesting insights into trauma and the possibilities on success in giving cpr in a canyoning situation. With immersion hypothermia being a major problem with casualties in canyons.

e. Suspension Trauma. This was also covered in one of the workshops detailed earlier in the report. Current thinking is to get the casualty horizontal as quickly as possible and not sit in a semi recumbent position as previously recommended.

f. Mountain first Aid – given by the Swiss Air ambulance. Still a work in progress and we were asked not to record anything on this one.

g. Base Jumping Fatalities from the Swiss. Not the talk to have after lunch. Basically don’t do it its dangerous.

h. Triage Strategies. Avalanche rescue strategies. Companion rescue options with one rescuer and more than one buried. Dig one out and do CPR of 5 -7 mins then move on to find second casualty seemed to be the conclusion

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5.6 Summary.

Most of the systems shown and demonstrated over the congress were helicopter based utilising long or super long lines. This was not particularly relevant to Scottish mountain rescue as we are mainly ground based but it was interesting to see and meet the other delegates

I would recommend that Bristow/HMCG joins the Air Rescue Commission at ICAR to share best practice.

Photos and video clips folder of the workshops and lectures with SMR.

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6 Summary

This year’s ICAR congress was a well-attended international event. Scottish mountain rescue sent a strong delegation of three mountain rescue team members. Each delegate report contains a number of positive points, ideas and recommendations. Each delegate made useful connections with individuals and organisations from around the world.

The real value of attending the annual congress is what each delegate takes to the congress and brings back to Scotland. This two way dialogue makes a positive contribution to mountain rescue at home and around the world.

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Appendix A - Future Congress

The 70th Congress will be held in Chamonix, France. The theme of the congress will be ‘The Effect of

Climate Change on Mountain Rescue’.

Table A-1. Congress Locations

Congress Location Dates

70th Chamonix 17

th -20

th October 2018

71st TBC 2019

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Appendix B - Conference Programme

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icar 2017 smr delegation report - scottishmountainrescue.org · within icar, elected...

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