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Competitive rock climbing is a fast-growing sport. Despite comprehensive reviews on adult climbing-related injuries, few pediatric-specific reviews exist, and studies exclusively on competitive youth climbers are needed. Objectives of this study include 1) estimating the injury rate (IR); 2) describing injury patterns and mechanisms; and 3) identifying injury risk factors in competitive youth climbers.The study design was cross-sectional. Competitive youth climbers were included. Participants completed an anonymous questionnaire to document climbing injuries over the preceding 12 mo. Demographic data and data regarding injuries were collected. The IR was calculated. Analyses were performed to assess association between injury and multiple variables. Multivariate logistic regression was completed for significant variables to control for exposure time.The IR was 2.7 injuries per 1000 climbing hours. Hand/Finger injuries were most frequent; chronic overuse was the most common etiology. Injury severity was low overall. Risk factors significantly associated with climbing injury were climbing discipline (boulderingsport/lead climbing), return to climbing while still in pain, finger taping, higher number of hours climbed per session and per year, climbing at higher bouldering difficulties, and unsupervised climbing.The IR in competitive youth climbers was found to be lower than previously reported but higher than suggested by adult studies or those that exclude chronic injuries. Findings are consistent with types, severity, and mechanisms reported in other studies. Modifiable risk factors, especially return to climbing while still injured, warrant further prospective investigation.

Introduction Prior research identified possible interstitial pulmonary fluid, concerning for early high altitude pulmonary edema (HAPE), in a large percentage of trekkers above 3000 m using a comprehensive 28-view pulmonary ultrasound protocol. These trekkers had no clinical symptoms of HAPE despite these ultrasound findings. The more common 4-view lung ultrasound protocol (LUP) is accurate in rapidly detecting interstitial edema during resource-rich care. The objective of this study was to evaluate whether the 4-view LUP detects interstitial fluid in trekkers ascending to Everest Base Camp. Methods Serial 4-view LUP was performed on 15 healthy trekkers during a 9-d ascent from Kathmandu to Everest Base Camp. Ascent protocols complied with Wilderness Medical Society guidelines for staged ascent. A 4-view LUP was performed in accordance with the published 2012 international consensus protocols on lung ultrasound. Symptom assessment and 4-view LUP were obtained at 6 waypoints along the staged ascent. A 4-view LUP was positive for interstitial edema if ≥3 B-lines were detected in 2 ultrasound windows. Results A single participant had evidence of interstitial lung fluid at 5380 m as defined by the 4-view LUP. There was no evidence of interstitial fluid in any participant below 5380 m. One participant was evacuated for acute altitude sickness at 4000 m but showed no preceding sonographic evidence of interstitial fluid. Conclusions In this small study, sonographic detection of interstitial fluid, suggestive of early HAPE, was not identified by the 4-view LUP protocol.

Introduction Campus board training in adolescent climbers is controversial. Evidence, albeit limited, suggests this type of training may lead to the development of finger epiphyseal stress fractures. The purpose of the present study was to investigate coaches’ attitudes toward campus board training in the United States. Methods Surveys were sent to 116 coaches at gyms across the United States with affiliated adolescent climbing teams. Outcomes collected included demographic information, training time, campus board use prevalence, coaches’ attitudes toward campus board use, and willingness to participate in future research. Results Seventy-three coaches representing 3090 adolescent climbers completed the survey. Forty-six coaches (63%) reported using full weight (no foot contact) campus board training in some or all of their climbers. A variety of factors were cited by coaches when deciding which climbers should or should not use the campus board, including physical maturity, climbing ability, and age, among others. Conclusions Climbing coaches in the United States disagree on the use of campus board training in adolescent climbers. Some coaches avoid using this training modality entirely, whereas others believe certain climbers can use it safely. There is lack of consensus in determining who those certain climbers are.

Finger flexor pulley system injuries are the most common overuse injury in rock climbers. These injuries occur rarely outside of rock climbing, owing to the sport's unique biomechanical demands on the finger. As rock climbing continues to grow and earn recognition as a mainstream sport, an understanding of how to diagnose and treat these injuries also has become important. Our purpose is to describe current concepts in anatomy, biomechanics, clinical evaluation, imaging, prevention, and treatment strategies relating to finger flexor pulley system injuries. Our literature search was performed on PubMed with MeSH terms and keywords as subject headings to meet the objectives of this review. The "crimp grip" used in rock climbing is the mechanism for these injuries. The A2, A3, and A4 pulleys are at the highest risk of injury, especially when loaded eccentrically. Physical examination may reveal clinical "bowstringing," defined as the volar displacement of the flexor tendons from the phalanges; however, imaging is required for characterization of the underlying injury. Ultrasound is highly sensitive and specific for diagnosis and is recommended as the initial imaging technique of choice. Magnetic resonance imaging is recommended as an additional imaging study if ultrasound is inconclusive. Properly warming up increases the amount of physiologic bowstringing and is thought to prevent injury from occurring. Pulley injuries may be classified as grade I through IV. Conservative treatment, including immobilization, the H-tape method, and the use of a protective pulley splint, is recommended for grade I to III injuries. Surgical repair is reserved for grade IV injuries that are not amenable to conservative treatment.

Introduction A significant number of climbers on Mount Kilimanjaro are affected by altitude-related disorders. The aim of this study was to determine the main causes of morbidity and mortality in a representative cohort of climbers based on local hospital records. Methods We conducted a 2-y retrospective chart review of all patients presenting to the main referral hospital in the region after a climb on Mount Kilimanjaro, including all relevant records and referrals for postmortem studies. Results We identified 62 climbers who presented to the hospital: 47 inpatients and 15 outpatients. Fifty-six presented with high altitude illness, which included acute mountain sickness (n=8; 14%), high altitude pulmonary edema (HAPE) (n=30; 54%), high altitude cerebral edema (HACE) (n=7; 12%), and combined HAPE/HACE (n=11; 20%). The mean altitude of symptom onset ranged from 4600±750 m for HAPE to 5000±430 m for HAPE/HACE. The vast majority of inpatients (n=41; 87%) were improved on discharge. Twenty-one deceased climbers, most having died while climbing (n=17; 81%), underwent postmortem evaluation. Causes of death were HAPE (n=16; 76%), HAPE/HACE (n=3; 14%), trauma (1), and cardiopulmonary (1). Conclusions HAPE was the main cause of death during climbing as well as for hospital admissions. The vast majority of climbers who presented to hospital made a full recovery.

This Lessons from History article about the naming of the extreme altitude "Death Zone" explores the historical mountaineering and medical literature relevant to the topic. Swiss alpinist and radiologist Edouard Wyss-Dunant (1897-1983) authored several reports and books about expeditions to arctic regions, deserts, and the Himalaya. Encouraged by the success of a Swiss expedition to the Garhwal Himalaya in 1947, Wyss-Dunant joined his fellow climbers from Geneva on a 1949 expedition to several peaks in the Kanchenjunga region. Wyss-Dunant was then invited to lead the spring 1952 Swiss Everest expedition. Despite this being the first Swiss attempt on Everest and on an untried route, Raymond Lambert and Tenzing Norgay nearly summitted Everest from the Nepal side. Wyss-Dunant earned mountaineering immortality by coining the phrase the Death Zone during the expedition's foray into the upper regions of Everest. Wyss-Dunant went on to become a president of the Swiss Alpine Club and the International Climbing and Mountaineering Federation. His writings and that of others provide an evocative supporting narrative to illustrate some of the problems of living (or dying) at extreme altitude.

Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.

Introduction Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey. Methods The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy. Results Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1–2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor. Conclusions Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

Introduction Finger growth plate injuries are the most common injury among youth climbers, and the association between these injuries and speed climbing, a mandatory discipline in the 2021 Olympics, has not been examined previously. Our primary purpose was to examine the demographic and training characteristics of adolescent competition climbers who reported a history of a finger growth plate injury compared to those who did not report a history of a finger growth plate injury. Our secondary purpose was to determine whether training characteristics differed between adolescent competition climbers who did and did not report speed climbing. Methods Our study was a cross-sectional study design. We surveyed adolescent climbers who competed in the 2017 USA Climbing Sport and Speed Youth National Championships. Questions assessed climbing injury history and current rock-climbing training characteristics. Results Two-hundred sixty-seven adolescent competition climbers, 14±3 (9–18) y of age (mean±SD with range), completed the survey. Those with a history of a finger growth plate injury reported greater approximate time spent speed climbing throughout the year (β=1.28, 95% CI 0.11–2.46, P=0.032) and training regularly on the International Federation of Sport Climbing speed wall (adjusted odds ratio=3.95, 95% CI 1.14–13.7, P=0.031). Conclusions Training regularly at practices on the speed wall was associated with a self-reported history of finger growth plate injuries among elite youth competition climbers. Speed climbing should be limited, especially during periods of rapid growth.

Introduction Sudden cardiac death in a young athlete is the leading cause of mortality in athletes during sport. Specific knowledge about cardiac adaptations are necessary for a better understanding of the underlying causes of such events. Methods A retrospective analysis of the electrocardiogram and echocardiographic data obtained during the yearly medical examination of the entire German junior national climbing team was undertaken. First, data from 1 examination were used. In a second step, data from 2 examinations spaced 2 y apart were analyzed for a selected subgroup to gain more knowledge about adaptations to climbing. The data from the subgroup were compared to an age- and sex-matched control group of Nordic skiers from the German junior national Nordic skiing team. Results Forty-seven young climbers (20 girls, 27 boys) were examined once. There were no pathological findings in the electrocardiogram or echocardiography. The left ventricular (LV) measurements fell between those for athletes and nonathletes. Eight boys and 6 girls from this group were tested twice over a timeframe of 27.5 mo. All LV measurements increased over time. After 2 y, the measurements from the climbers were comparable to those of the Nordic skiers. Conclusions Hypertrophic cardiomyopathy (hypertrophy of the LV) is the leading cause of sudden cardiac death in athletes. An increase in LV dimensions was observed in the young climbers in this study. LV dimensions being comparable to high-level Nordic skiers after 2 y in the national team imply structural changes over time in this cohort.

Introduction Suspension syndrome describes a potentially life-threatening event during passive suspension on a rope. The pathophysiological mechanism is not fully understood; however, the most widespread hypothesis assumes blood pools in the lower extremities, prompting a reduction in cardiac preload and cardiac output and leading to tissue hypoperfusion, loss of consciousness, and death. The aim of this study was to assess venous pooling by ultrasound in simulated suspension syndrome using human subjects. Methods In this trial, 20 healthy volunteers were suspended in a sit harness for a maximum of 60 min with and without preceding exercise. Venous pooling was assessed by measuring the diameter of the superficial femoral vein (SFV) with ultrasound at baseline in supine and standing positions as well as during and after suspension. Results SFV diameter increased and blood flow became progressively sluggish. In 30% of the tests, near syncope occurred. However, SFV diameter did not differ between subjects with and without near syncope. Conclusions Free hanging in a harness leads to rapid venous pooling in the lower limbs. The most important measure to prevent suspension syndrome might be constant movement of the legs.

Introduction High altitude headache (HAH) and acute mountain sickness (AMS) are common pathologies at high altitudes. There are similarities between AMS and migraine headaches, with nausea being a common symptom. Several studies have shown ibuprofen can be effective for AMS prophylaxis, but few have addressed treatment. Metoclopramide is commonly administered for migraine headaches but has not been evaluated for HAH or AMS. We aimed to evaluate metoclopramide and ibuprofen for treatment of HAH and AMS. Methods We performed a prospective, double-blinded, randomized, field-based clinical trial of metoclopramide and ibuprofen for the treatment of HAH and AMS in 47 adult subjects in the Mount Everest region of Nepal. Subjects received either 400 mg ibuprofen or 10 mg metoclopramide in a 1-time dose. Lake Louise Score (LLS) and visual analog scale of symptoms were measured before and at 30, 60, and 120 min after treatment. Results Subjects in both the metoclopramide and ibuprofen arms reported reduced headache severity and nausea compared to pretreatment values at 120 min. The ibuprofen group reported 22 mm reduction in headache and 6 mm reduction in nausea on a 100 mm visual analog scale at 120 min. The metoclopramide group reported 23 mm reduction in headache and 14 mm reduction in nausea. The ibuprofen group reported an average 3.5-point decrease on LLS, whereas the metoclopramide group reported an average 2.0-point decrease on LLS at 120 min. Conclusions Metoclopramide and ibuprofen may be effective alternative treatment options in HAH and AMS, especially for those patients who additionally report nausea.

We experienced a case involving prolonged cardiopulmonary resuscitation (CPR) during cardiac arrest on Mt. Fuji (3776 m), demanding lengthy exertion by the rescuers performing CPR. Considering the effects of exertion on the rescuers, we examined their percutaneous arterial oxygen saturation during simulated CPR and compared the effects of compression-only and conventional CPR at 3700 m above sea level. The effects of CPR on the physical condition of rescuers were examined at the summit of Mt. Fuji: three rescue staff equipped with pulse-oximeters performed CPR with or without breaths using a CPR mannequin. At 3700 m, the rescuers' heart rate increased during CPR regardless of the presence or absence of rescue breathing. Percutaneous arterial oxygen saturation measured in such an environment was reduced only when CPR without rescue breathing was performed. Scores on the Borg scale, a subjective score of fatigue, after CPR in a 3700 m environment were 13 to 15 of 20 (somewhat hard to hard). Performing CPR at high altitude exerts a significant physical effect upon the condition of rescuers. Compression-only CPR at high altitude may cause a deterioration in rescuer oxygenation, whereas CPR with rescue breathing might ameliorate such deterioration.

High altitude cerebral edema (HACE) is a rare complication of ascent to altitudes of over 2500 m (8200 ft). We are not aware of a previously published case report of HACE in a patient under the age of 18 y. We report on 2 cases of suspected HACE in 2 patients, aged 12 and 16 y, who presented to the Manang Himalayan Rescue Association clinic at 3500 m. The 16-y-old patient presented with severe headache, vomiting, and ataxia after rapid ascent to 3800 m. The 12-y-old patient presented with severe headache, vomiting, visual disturbances, and ataxia at 4500 m, which began to resolve with descent to the clinic at 3500 m. Our cases suggest that HACE can occur in children and adolescents. Because there are no specific guidelines for treatment of acute mountain sickness or HACE in patients under the age of 18 y, we recommend treatment as for adults: oxygen, immediate descent, and dexamethasone. Simulated descent in a portable hyperbaric chamber can be used if oxygen is not available and if actual descent is not possible.

This wilderness essay about high altitude deterioration will explore the historical mountaineering and medical literature with a limited discussion of physiology. The writings of mountaineers and physician-mountaineers provide an evocative supporting narrative to illustrate one of the problems of living at altitude.

Introduction Previous research identified a trend for increasing numbers of injuries sustained while rock climbing. This study investigates whether that trend continued and describes characteristics of climbing injuries. Methods The National Electronic Injury Surveillance System registry was searched for rock climbing injuries in US emergency departments in 2008 through 2016 among patients aged ≥7 y. Variables included each patient's age, diagnosis, injured body part, mechanism of injury, and disposition. Injuries were graded using International Mountaineering and Climbing Federation injury grades. National estimates were generated using sample weighting. Results An estimated 34,785 rock climbing injuries were seen in emergency departments nationally, a mean of 3816 per year (SD 854). The median age of injured climbers was 24 y (range 7–77), with those aged 20 to 39 y accounting for 60% and males for 66%, respectively. Fractures (27%) and sprains and strains (26%) were the most common types of injuries. The most frequently injured body parts were lower extremities (47%), followed by upper extremities (25%). The most commonly fractured body part (27%) was the ankle. The knee and lower leg accounted for 42% of all lacerations and were 5.8 times as likely as lacerations to other body parts. Falls were the most common mechanism, accounting for 60% of all injuries. Conclusions This study reports continued increase in annual numbers of climbing injuries. Whether this is based on a higher injury rate or on a higher number of climbers overall cannot be stated with certainty because no denominator is presented to estimate the injury rate among climbers.

Introduction We tested the hypothesis that individual susceptibility to freezing cold injury might be reflected in an attenuated cold-induced vasodilatation (CIVD) response by comparing the CIVD responses of an elite alpinist with a history of freezing cold injury in the feet (case alpinist) with those of an age- and ability- matched noninjured alpinists control group (controls). According to this hypothesis, the vasomotor responses to a CIVD test of the case alpinist would represent a pathophysiological response when compared with the normal physiological response of a noninjured cohort. Methods The case alpinist and the controls in the cohort group conducted a cold water immersion test comprising sequential immersion of a hand and foot for 5 min in 35°C water, followed by a 30-min immersion in 8°C water and a 10-min recovery period in room air. During this test we monitored the finger and toe skin temperatures. Results The case alpinist had a significantly attenuated CIVD response and a lower skin temperature in all injured and noninjured digits during immersion (∼2°C lower than in the control group) and an attenuated recovery of finger skin temperatures (∼6°C lower than in the control group). Conclusions The attenuated CIVD response of the case alpinist may reflect a previously unrecognized enhanced susceptibility to frostbite. In addition to the poor vasomotor response observed in the injured toes, he also exhibited a poor vasomotor response in his noninjured fingers. The results of the present study indicate that a test of vasomotor activity during thermal stress may identify individuals predisposed to cold injury.

Introduction North American guidelines propose 125 mg acetazolamide twice daily as the recommended prophylactic dose to prevent acute mountain sickness (AMS). To our knowledge, a dose lower than 125 mg twice daily has not been studied. Methods We conducted a prospective, double-blind, randomized, noninferiority trial of trekkers to Everest Base Camp in Nepal. Participants received the reduced dose of 62.5 mg twice daily or the standard dose of 125 mg twice daily. Primary outcome was incidence of AMS, and secondary outcomes were severity of AMS and side effects in each group. Results Seventy-three participants had sufficient data to be included in the analysis. Overall incidence of AMS was 21 of 38 (55.3%) in reduced-dose and 21 of 35 (60.0%) in standard-dose recipients. The daily incidence rate of AMS was 6.7% (95% CI 2.5–10.9) for each individual in the reduced-dose group and 8.9% (95% CI 4.5–13.3) in the standard-dose group. Overall severity of participants’ Lake Louise Score was 1.014 in the reduced-dose group and 0.966 in the standard-dose group (95% CI 0.885–1.144). Side effects were similar between the groups. Conclusions The reduced dose of acetazolamide at 62.5 mg twice daily was noninferior to the currently recommended dose of 125 mg twice daily for the prevention of AMS. Low incidence of AMS in the study population may have limited the ability to differentiate the treatment effects. Further research with more participants with greater rates of AMS would further elucidate this reduced dosage for preventing altitude illness.

Introduction Cardiac events are one of the leading causes of death in the Spanish population. Given the increase in the nontraumatic medical conditions found in mountain rescues, the objective of this study was to report on the heart conditions of patients rescued in the mountains of Aragon in the Spanish Pyrenees. Methods We conducted a retrospective observational study based on data collected from patients' medical histories for rescues undertaken in from 2010 to 2016 (at altitudes between 500 m [1640 ft] and 3404 m [11,168 ft]). Results Of the 2079 individuals rescued from 2010 to 2016, 34 (2%) were diagnosed with heart conditions, accounting for 21% of all nontraumatic medical conditions. The data showed a statistically significant increase in the age of the rescued patients with heart conditions (55±15 y) and those with acute coronary syndrome/sudden death (60±8 y). Eighty-five percent of the rescued patients with heart conditions were men, 62% were rescued above 2000 m (6500 ft), 42% had acute coronary syndrome (of whom 56% had inferior infarction), and 35% died suddenly. Conclusions Aragon mountain rescues show an increase in patient age in recent years. The most common medical case among rescued individuals with heart conditions was a hiker over the age of 50 y with cardiovascular risk factors, inferior infarction, and occurrence at an altitude above 2000 m. Based on our observations, appropriate training should be undertaken, especially by older hikers, who may also benefit from cardiac screening, and rescue vehicles/personnel and mountain huts should be equipped with semiautomatic external defibrillators.

Extremities are the area of the body most commonly affected by frostbite, which can also affect the face, ears, perineum, or genitals. Optimum management has moved away from early amputation and debridement toward maximizing tissue preservation and delaying surgical intervention. Increasing length of digit amputation increases morbidity, in terms of loss of hand function, experienced by patients. Reconstruction of affected digits is limited by bone necrosis, which often leads to shortened residual stumps and limited functional outcomes. This case describes the management of a severe frostbite injury affecting both hands and feet in a 39-y-old man, sustained during descent of Mount Everest. The use of a pedicled abdominal flap to provide soft-tissue cover permitted optimized digit length and function and sensate digits. The case highlights the benefits of early multidisciplinary team involvement in the management of severe frostbite to optimize functional outcome.

Introduction Carrying standard safety gear (beacon, probe, and shovel), planning a route of descent, and recreating with companions can help to mitigate the risk of injury or death resulting from avalanches in the backcountry. The goal of this study was to identify factors associated with performance of these safety practices. Methods A convenience sample of backcountry skiers and snowboarders was surveyed in 2016 at the backcountry gates of Jackson Hole Mountain Resort. Each participant was surveyed on characteristics including skill level, sex, age, prior avalanche education, and residency in the Jackson Hole area. Safety practices were also measured against avalanche hazard forecasts. Correlations were assessed using Fisher's exact testing. Results A total of 334 participants were surveyed. Factors associated with carrying avalanche safety gear included higher expertise, being a resident of the Jackson Hole area, and prior avalanche education. Factors associated with having a planned route of descent included higher expertise and being a resident of the Jackson Hole area. Factors associated with recreating with companions included younger age and lower expertise. Sex had no association with any of the surveyed safety practices. Participants were less likely to carry avalanche safety gear on low avalanche hazard days. Conclusions Certain individual characteristics of backcountry skiers and snowboarders are associated with increased frequency of adherence to recommended safety practices. These findings suggest that particular categories of backcountry recreationists may benefit from further avalanche safety education. The results of this study could help direct future educational efforts among backcountry recreationists.

Severe frostbite occurs frequently at extreme altitude in the Himalayas, often resulting in amputations. Recent advances in treatment of frostbite injuries with either intravenous or intra-arterial tissue plasminogen activator, or with iloprost, have improved outcomes in frostbite injuries, but only if the patient has access to these within 24 to 48 h postinjury, and ideally even sooner. Frostbitten Himalayan climbers are seldom able to reach medical care in this time frame. We wished to see if delayed iloprost use (up to 72 h) would help reduce tissue loss in grade 3 to 4 frostbite. In a series of 5 consecutive climbers with severe frostbite in whom we used iloprost, 4 of whom received treatment between 48 and 72 h from injury, 2 had excellent results with minimal tissue loss, and 2 had good results with tissue loss less than expected. The 1 patient with a poor outcome likely experienced a freeze-thaw-refreeze injury. This small series suggests that iloprost can be beneficial for severe frostbite, even after the standard 48-h window and perhaps for up to 72 h.

Canyoning is a recreational activity that has increased in popularity in the last decade in Europe and North America, resulting in up to 40% of the total search and rescue costs in some geographic locations. The International Commission for Mountain Emergency Medicine convened an expert panel to develop recommendations for on-site management and transport of patients in canyoning incidents. The goal of the current review is to provide guidance to healthcare providers and canyoning rescue professionals about best practices for rescue and medical treatment through the evaluation of the existing best evidence, focusing on the unique combination of remoteness, water exposure, limited on-site patient management options, and technically challenging terrain. Recommendations are graded on the basis of quality of supporting evidence according to the classification scheme of the American College of Chest Physicians.

Introduction The popularity of adventure recreation in wilderness areas across the world continues to increase. Nevertheless, the risk of injury and illness remains significant. The purpose of this study is to analyze the mountain rescue operations performed in Slovenia between 2011 and 2015. Methods This retrospective study reports mountain rescue operations documented by the Slovenian National Mountain Rescue Association. The annual number of ground-based and helicopter-based rescues were identified and compared. For 2015, the indication for rescue and the severity of injury were also analyzed, specifically for interventions requiring the use of a helicopter. Results From 2011 through 2015, the number of rescues remained consistent with an annual average of 413 (SD ±15; range, 393–434) rescues. However, the percentage of ground-based rescues varied significantly year by year ( P =0.016), with highest rate in 2014 (68%) and the lowest in 2015 (56%). In 2015, 434 mountain rescue operations were reported in Slovenia. Injury accounted for 44%, illness for 10%, and fatality for 9% of the rescues. In 37%, no illness or injury was reported. Helicopter rescue was used in 190 (44%) of all interventions. Among the 190 helicopter rescues, 49% of patients had nonfatal injuries, 29% required no medical treatment, 15% had illness, and 7% had fatal injuries. Conclusions A significant number of mountain rescue operations were conducted in Slovenia from 2011 through 2015. Most of these were needed for injured, ill, or deceased persons. A notable number of rescues in 2015 required a helicopter.

We present a case of inappropriate dexamethasone use in a trekker in the Everest region of Nepal. We aim to increase awareness among health professionals of the possible use of this medication by trekkers and promote knowledge of potential complications. In this case, a previously altitude-naive trekker was prescribed prophylactic dexamethasone by physicians in a Western travel clinic before high-altitude trekking in Nepal. There were no indications for prophylactic medication nor for the use of dexamethasone. The trekker reported that no discussion regarding risks and benefits, alternatives, side effects, contraindications, or dose tapering on completion of the course had occurred before travel. Side effects were temporary, but serious complications may have ensued if it not for timely interventions by doctors at the International Porter Protection Group rescue post. The events leading to inappropriate dexamethasone use in this case cannot be known for certain. However, it is clear that the trekker lacked the knowledge to use the medication safely. Although the efficacy of dexamethasone in the prevention of acute mountain sickness is undisputed, associated side effects and other limitations make acetazolamide the prophylactic drug of choice. Inappropriate use of dexamethasone can lead to severe complications, and such a case has been reported from Mount Everest. Clinicians prescribing dexamethasone must understand the indications and risks, and health professionals at altitude should be aware of its use by trekkers and the potential complications.

Intersection syndrome is an inflammatory condition located at the crossing point between the first and second dorsal compartments in the wrist. It is an uncommon presentation but has been recognized as an injury typical of rowers (when it is named oarsman's wrist) and other sports such as racquet sports, baseball, cycling, hockey, golf, ice hockey, skiing, and softball. It has not been previously described in climbers. This report details 2 cases of intersection associated with the use of an ice axe. The first presentation was in a female climber who was using an ice axe for climbing in the Nepal Himalayas and the second was in a male climber using an ice axe for winter climbing training in the Alps. Both climbers presented with wrist pain, swelling, and crepitus over the dorsum of the wrist, about 5 cm proximal to Lister's tubercle. Although well documented in other sporting populations, there seems to be limited reporting of intersection syndrome in the climbing population. It may be worth considering a diagnosis of "ice axe wrist" as a differential in patients who have been using ice axes in climbing or mountaineering.

Objective To continuously monitor oxygen saturation (SpO 2 ) by pulse oximeter and assess the development of acute mountain sickness (AMS) using the Lake Louise Score (LLS) during ascent from 1154 to 4559 m in 2 groups of subjects: 10 moderate-altitude residents (MAR; ≥1000–≤2500 m) and 34 low-altitude residents (LAR). MAR are reported to have a lower incidence of AMS during ascent to higher altitudes compared with LAR. Whether this is related to higher SpO 2 is still open to debate. Methods Seventy subjects were recruited; 24-hour SpO 2 monitoring with finger pulse oximetry was performed. All subjects rode a cable car from 1154 to 3275 m and then climbed to 3647 m, where 60 subjects (LAR) overnighted. The second day, 34/60 LAR reached the highest altitude. Ten subjects who lived permanently at 1100 to 1400 m (MAR) climbed directly to 4559 m without an overnight stop. Results One LAR was excluded from the analysis because he performed a preacclimatization. We compared data of 10 MAR with data of 33 LAR who reached 4559 m. Two MAR had an LLS of 3, and 8 scored 2 monitoring showed higher mean SpO 2 in MAR during ascent above 3600 m compared with LAR (MAR, 79±4% vs LAR, 76±5%; analysis of variance, P = .03). Conclusions The results of this preliminary study suggest that residence at moderate altitude allows maintenance of higher SpO 2 and reduces risk of developing AMS during rapid ascent to higher altitude.

Diarrhea is a common problem among long-distance backpackers, ranging in overall incidence from 11-56% as reported by previous studies on the Appalachian Trail and Long Trail. Differences in age, sex, and regularity of standard backcountry hygiene recommendations and practices have been shown to significantly affect the incidence of diarrhea. No study to date has investigated these trends among long-distance backpackers on the John Muir Trail (JMT) in the Sierra Nevada mountain range of California.Retrospective analysis of online survey data gathered from long-distance backpackers who attempted a JMT trek in 2014. Data were assessed for the significance of variables that might contribute to the incidence and severity of on-trail diarrhea.Of 737 valid responders, 16.4% reported experiencing diarrhea (82% with minimal/mild severity; 18% with significant severity). Regular hand sanitizer use was significantly correlated with more severe diarrhea (P.05), but had no effect on incidence. Regular hand sanitizer users followed all other recommended hygiene practices as frequently as or better than those not using hand sanitizer regularly. Of all backpackers, 88% filtered or treated their drinking water regularly, with 18% of those reporting diarrhea of any severity.JMT backpackers have a comparatively lower incidence of diarrhea than backpackers on other major long-distance backpacking routes in the United States. Most JMT backpackers follow standard backcountry hygiene recommendations, including regular filtration or treatment of drinking water. No statistical significance was found between the incidence of diarrhea and compliance with standard hygiene recommendations. Regular hand sanitizer use was significantly correlated with more severe diarrhea but was not associated with incidence. There was no significant difference in compliance with standard backcountry hygiene practices between regular and infrequent hand sanitizer users.

Objective Hamate hook fractures are rare injuries, comprising 2% to 4% of all carpal fractures. Climbing athletes seem to be affected more frequently than others, as they strain the passive and active anatomical structures of their hands and fingers to maximum capacity during training or competing. This stress is transmitted to the hook of the hamate by tightened flexor tendons, which creates high contact pressure to the ulnar margin of the carpal tunnel. Injuries of the hamate hook, caused by contact pressure of the anatomical structures, are rare and occur nearly exclusively during climbing. Methods We diagnosed 12 athletes with hamate hook fractures who presented with diffuse pain in the wrist joint, which occurred either during or after climbing. Radiographs or computed tomography revealed fractures in the hamate bones in most of the patients; therapy consisted of consequent stress reduction. Results Follow-up investigations found that all athletes were free of symptoms after 10.7 ± 5.1 (6–24) (mean ± standard deviation with range) weeks. Resection of the hamate hook was necessary in 3 patients. All patients regained their preinjury climbing level. Conclusion Climbers with an unspecific, diffuse pain in the wrist need to be examined by radiograph and , if radiograph is unclear , computed tomography or magnetic resonance imaging to detect or exclude the diagnosis of hamate fracture in order to avoid severe complications.

Objective To describe the resources for medical condition management in mountain huts and the epidemiology of such events. Methods We conducted a 3-step study from April 2013 to August 2014 in French mountain huts. The first step consisted of collecting data regarding the first aid equipment available in mountain huts. The second step consisted of a qualitative evaluation of the mountain hut guardian's role in medical situations through semistructured interviews. Finally, a prospective observational study was conducted in the summer season to collect all medical events (MEs) that occurred during that period. Results Out of 164 hut guardians, 141 (86%) had a basic life support diploma. An automatic external defibrillator was available in 41 (26%) huts, and 148 huts (98%) were equipped with a first aid kit. According to semistructured interviews, hut guardians played a valuable role in first aid assistance. Regarding the observational study, 306 people requested the hut guardian's help for medical reasons in 87 of the 126 huts included. A total of 501 MEs for approximately 56,000 hikers (0.85%) were reported, with 280 MEs (56%) involving medical pathologies and 221 (44%) MEs involving trauma-related injuries. Conclusions MEs had low prevalence, but the hut guardian played a valuable role as a first aid responder.

When performing detailed tasks related to climbing or hiking, accurate vision is important for safety. Acetazolamide is a medication commonly used to prevent acute mountain sickness, but it has an uncommon side effect of transient myopia. Reports of this side effect are mainly associated with its use in obstetrics, where it is often prescribed in higher doses than used in acute mountain sickness prophylaxis. We describe the case of a climber taking low-dose acetazolamide who developed transient myopia. We further describe potential mechanisms of this rare side effect as well as a novel approach of field management utilizing possible materials at hand.

Objective It is well documented that cognitive performance may be altered with ascent to altitude, but the association of various cognitive performance tests with symptoms of acute mountain sickness (AMS) is not well understood. Our objective was to assess and compare cognitive performance during a high-altitude expedition using several tests and to report the association of each test with AMS, headache, and quality of sleep. Methods During an expedition to Mount Everest, 3 cognitive tests (Stroop, Trail Making, and the real-time cognitive assessment tool, an in-house developed motor accuracy test) were used along with a questionnaire to assess health and AMS. Eight team members were assessed pre-expedition, postexpedition, and at several time points during the expedition. Results There were no significant differences (P >.05) found among scores taken at 3 time points at base camp and the postexpedition scores for all 3 tests. Changes in the Stroop test scores were significantly associated with the odds of AMS (P

Objective The aims of this study were to assess incidence of acute mountain sickness (AMS) and summit success on a 6-day ascent profile of Mt. Kilimanjaro and evaluate potential risk factors for these outcomes. Methods All trekkers through a single Australian tour company between August 2012 and July 2014 were included. Participants ascended via the Rongai route and attempted the summit on day 6. Daily assessments were made using the self-reported Lake Louise score (LLS) questionnaire. Two different AMS diagnostic criteria (LLS ≥3 and LLS ≥5) were used for data analysis. Risk factors for development of AMS and summit success were analyzed. Results Over the 24-month period a total of 175 participants undertook the trek. Incidence of AMS was 52.6% (LLS ≥3) and 22.9% (LLS ≥5). Summit success was 88%. Age, sex, body mass index, and acetazolamide use were not associated with risk of AMS development. Age ≥40 years ( P = .0002) and female sex ( P = .0004) were both significantly associated with reduced summit success rate. Conclusions Our cohort found a lower incidence of AMS and better summit success on a 6-day ascent of Mt Kilimanjaro than previously described in other groups on 4- and 5-day ascents. Female sex and age ≥40 years both predicted failure to summit, but did not increase risk of developing AMS. AMS is a common cause of morbidity on Mt. Kilimanjaro, and although the risk can be mitigated by a slower ascent, there is an ongoing need for education of individual trekkers, tour companies, and local authorities.

Objective To assess the medical knowledge and preparedness of mountain climbers on Colorado's 14,000-foot peaks and to compare differences in knowledge and preparedness based on demographics, training, and difficulty of the climb. Methods Mountain climbers from 11 14,000-foot peaks in Colorado were surveyed at the time of summiting. These peaks represented every major mountain range and class of difficulty in Colorado. Marijuana use and demographic information including age, gender, state of residence, and income level was collected in the survey. In addition, participants were scored on medical knowledge and preparedness using a novel assessment tool. Scores were then compared and statistically analyzed. Results Mountain climbers scored 2.84 ± 1.25 and 3.92 ± 1.20 out of 6.00 on medical knowledge and preparedness, respectively. Medical training was shown to be the only significant predictor of medical knowledge, whereas age, race, income, and group status were all shown to be significant predictors of preparedness. It was shown that 9.4% of participants were using marijuana. Only 25% of individuals climbing class 3 mountains elected to wear helmets. Conclusions Most mountain climbers had no formal wilderness medicine training and did worse on the medical knowledge assessment than those who did have training. Consistent with previous studies, participants performed poorly on the medical knowledge assessment. As such, ways to improve wilderness medical knowledge among outdoor recreationalists should be sought. The low rate of helmet use on Colorado's technical peaks represents an important area for education and injury prevention.

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

Objective To investigate whether ultrasonography can be used for field volume status assessment and to determine whether a detectable difference in intravascular volume exists in individuals with acute mountain sickness (AMS) compared with those without. Methods Study was performed at the Himalayan Rescue Association Clinic in Manang, Nepal, located on the Annapurna trekking circuit at an altitude of 3519 m (11545 feet). A convenience sample was taken from individuals trekking over 5 to 8 days from 760 m (2490 feet) to 3519 m (11,545 feet), comparing asymptomatic trekkers vs those who experienced AMS. Subjects were evaluated for AMS based on the Lake Louise AMS Questionnaire (LLS ≥ 3 indicates AMS). After medical screening examination, both groups (control, n=51; AMS, n=18) underwent ultrasonography to obtain measurements of inferior vena cava collapsibility index (IVC CI) and left ventricular outflow tract velocity–time integral (LVOT VTI) before and after a passive leg raise (PLR) maneuver. Results There was no statistically significant difference between groups regarding change in heart rate before and after PLR, or IVC CI; however, there was a statistically significant greater increase in LVOT VTI after PLR maneuver in control group subjects compared with those with AMS (18.96% control vs 11.71% AMS; P Conclusions Ultrasonography is a useful tool in the assessment of intravascular volume at altitude. In this sample, we found ultrasonographic evidence that subjects with AMS have a higher intravascular volume than asymptomatic individuals. These data support the hypothesis that individuals with AMS have decreased altitude-related diuresis compared with asymptomatic individuals.

Objective To assess whether previous freezing cold injuries (FCI) would affect digit skin temperatures and rewarming rates during a follow-up cold stress test protocol. Design Nonrandomized control trial. Methods Twenty elite alpinists participated; alpinists with previous FCI requiring digit amputations (injured, INJ: n=10 total, n=8 male) were compared with ability-matched, uninjured alpinists (control, CON: n=10, all male). Digit skin temperature was measured using infrared thermography as an index of peripheral digit perfusion after a cold stress test, which consisted of 30 minutes of immersion in 8°C water. Results The INJ alpinists' injured toes were warmer (approximately 6%) than their uninjured toes immediately after cold immersion (95% CI, 0.01°C to 1.00°C; P = .05); there were no differences between the rates of rewarming of injured and uninjured toes (INJ, 0.5° ± 0.1°C/min; CON, 0.7° ± 0.3°C/min; P = .16). Although the INJ alpinists had colder injured fingers immediately after the 35°C warm bath compared with their own uninjured fingers (32.2° ± 2.0°C vs 34.5° ± 0.5°C; P = .02), there were no differences observed between the rates of rewarming of injured and uninjured fingers after cold exposure (INJ, 1.1° ± 0.2°C/min; CON, 1.3° ± 0.5°C/min; P = .22). Conclusions Even after FCI that requires digit amputation, there is no evidence of different tissue rates of rewarming between the injured and uninjured fingers or toes of elite alpinists.

Objective Backcountry travelers should carry a standard set of safety gear (transceiver, shovel, and probe) to improve rescue chances and reduce mortality risk. Many backcountry enthusiasts are using other advanced equipment such as an artificial air pocket (eg, the AvaLung) or an avalanche air bag. Our goal was to determine the numbers of backcountry users carrying advanced equipment and their perceptions of mortality and morbidity benefit while carrying this gear. Methods A convenience sample of backcountry skiers, snowboarders, snowshoers, and snowmobilers was surveyed between February and April 2014. Participants of this study were backcountry mountain users recruited at trailheads in the Wasatch and Teton mountain ranges of Utah and Wyoming, respectively. Questions included prior avalanche education, equipment carried, and perceived safety benefit derived from advanced equipment. Results In all, 193 surveys were collected. Skiers and snowboarders were likely to have taken an avalanche safety course, whereas snowshoers and snowmobilers were less likely to have taken a course. Most backcountry users (149, 77.2%), predominantly skiers and snowboarders, carried standard safety equipment. The AvaLung was carried more often (47 users) than an avalanche air bag (10 users). The avalanche air bag had a more favorable perceived safety benefit. A majority of participants reported cost as the barrier to obtaining advanced equipment. Conclusions Standard avalanche safety practices, including taking an avalanche safety course and carrying standard equipment, remain the most common safety practices among backcountry users in the Wasatch and Tetons. Snowshoers remain an ideal target for outreach to increase avalanche awareness and safety.

Mountain sporting activities are an increasingly popular practice that exposes mountaineers to a high risk of adverse events. This report describes a unique case of recovery in an austere environment that involved explosives. In June 2012, a 52-year-old man ascended a cliff tower in the Eastern Alps, Italy. A landslide occurred, and a boulder crushed the climber against a large stone located farther down the cliff, causing compression of the lower limbs and the pelvis with consequent severe musculoskeletal trauma. The National Alpine and Cave Rescue Unit (NACRU) arrived and proceeded with stabilization of the injured climber, which took 6 hours and involved a difficult extrication supported by the Cave Rescue division of NACRU. Unfortunately, during transport to the trauma center of Borgo Trento, Verona, the patient exhibited signs of progressive traumatic shock because of crush syndrome, hypovolemia, and acidosis, which led to cardiac arrest and death. Based on an extensive literature review, this report was determined to be the only one of a mountain rescue using explosives for the extrication of a victim in the Northeast Italian Alps. This case describes how a rescue in austere environments can represent a high-risk situation, and it shows how improvisation and cooperation between rescue teams are crucial for a successful recovery.

Objectives As the highest peak on the planet, Mt Everest provides a truly austere environment in which to practice medicine. We examined records of all visits to the Everest Base Camp Medical Clinic (Everest ER) to characterize the medical problems that occur in these patients. Methods A retrospective analysis of medical records from the first 10 years of operation (2003 to 2012) was performed. Results Medical reasons accounted for 85.3% (3045) of diagnoses, whereas 14.0% (500) were for trauma. The most common medical diagnoses were pulmonary causes such as high altitude cough and upper respiratory infection, comprising more than 38% of medical diagnoses. For traumatic diagnoses, 56% were for dermatologic causes, most commonly for frostbite and lacerations. Pulmonary and dermatologic diagnoses were also the most frequent causes for evacuation from Everest Base Camp, most commonly for high altitude pulmonary edema and frostbite, respectively. Conclusions Medical professionals treating patients at extreme altitude should have a broad scope of practice and be well prepared to deal with serious trauma from falls, cold exposure injuries, and altitude illness.

Rock climbing is a widely performed sport. This prospective single-institution study evaluated the demographics of climbing-related injuries to improve our comprehension of current injury characteristics.During a 4-year period, 836 patients with a total of 911 independent climbing injuries were prospectively evaluated using a standard questionnaire and examination protocol.Of all injuries, 833 were on the upper extremities, 58 on the lower. Seventeen injuries were Union International des Associations d'Alpinisme (UIAA) grade 1 injuries, 881 were grade 2, and 13 were grade 3. No higher UIAA graded injuries occurred. Overall, 380 were acute injuries (359 were seen in clinic, 21 were seen through the emergency department), and 531 were overstrain injuries (all seen in clinic). Finger injuries accounted for 52% of all injuries, the shoulder being the second most frequent location. Pulley injuries were the most frequent finger injuries. Of 20 injured young climbers under the age of 15 years, 14 had an epiphyseal fracture (all epiphyseal fractures: mean age 14 years, range 12 to 15 years). Male climbers were significantly older (P.05), had more climbing years (P.05), and were climbing at a higher climbing level (P.01). Older, more experienced climbers had significantly more overstrain injuries than acute injuries (P.05).When comparing this study with our previous study from 1998 to 2001, there are some notable differences. Although pulley injuries are still the most common climbing injury, there are now more A4 pulley injuries than A2. Shoulder injuries are becoming more common, as are epiphyseal fractures among young climbers. It is important to understand current patterns of climbing injuries so that health providers can target interventions appropriately.

To provide guidance to clinicians about best practices, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for prevention and treatment of acute mountain sickness, high altitude cerebral edema, and high altitude pulmonary edema. These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations about their role in disease management. Recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens according to criteria put forth by the American College of Chest Physicians. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate these recommendations. This is an updated version of the original WMS Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness published in WildernessEnvironmental Medicine 2010;21(2):146-155.

Objective Ski mountaineering is becoming a popular sport. The ascending techniques (tracks) can be divided into 3 different groups: flat field, direct ascent, and traversing. This study examines the relationship between different mechanical loads on the foot and the 4 different mountaineering ascending techniques. Methods All subjects used the same pair of ski boots and the same skis while performing the 4 different ascending techniques. An in-shoe dynamic pressure measuring system was used to measure the mechanical load on the foot soles of each ski mountaineer. The foot sole was divided into 6 anatomic sections to measure the different loads in each section. Results Thirteen men with an average age of 29 years were enrolled in the study. The results showed small, not significant differences in the mechanical foot load in the flat field or in the direct ascent. The average mechanical foot load was highest on the valley side foot while traversing (179 kPa to 117 kPa). The higher load forces were in the medial ball of the foot and the longitudinal aspect of the foot side closer to the hill. Conclusions The higher impact placed on the valley side foot and the concentration of force placed on the medial ball of the valley side foot suggested the influence of the track on the load pattern of the foot sole. This higher impact may result in upward forces that affect the force distribution in the ankle and knee joints.

Medical science has its own objective language for describing the effects of high altitude. Mountaineers' words and metaphors tell the story with subjectivity and feeling. This essay will include only limited physiology about lowlanders and high altitude. Instead, the focus will be literary, using the quotations of 20th-century mountaineers and mountaineer physicians to provide color commentary about the hardship. These are Words From on High.

This article describes a private initiative in which professional Swiss rescuers, based at the foot of the Matterhorn, trained Nepalese colleagues in advanced high altitude helicopter rescue and medical care techniques. What started as a limited program focused on mountain safety has rapidly developed into a comprehensive project to improve rescue and medical care in the Mt Everest area for both foreign travelers and the local Nepalese people.

Mountain rescue operations often present helicopter emergency medical service crews with unique challenges. One of the most challenging problems is the prehospital care of cardiac arrest patients during evacuation and transport. In this paper we outline a case in which we successfully performed a cardiopulmonary resuscitation of an avalanche victim. A mechanical chest-compression device proved to be a good way of minimizing hands-off time and providing high-quality chest compressions while the patient was evacuated from the site of the accident.

Mountaineering and mountain-related sports are growing in popularity and are associated with significant risk of injury. There is a perception that mountaineers possess unique personality characteristics that attract them to the sport. We aim to determine whether there are any identifiable differences between the personality characteristics of experienced mountaineers and a normal control population and to determine whether there is an association between specific personality traits and risk of injury.Questionnaires were utilized to obtain data on demographics, accidents, and personality characteristics from a population of experienced mountaineers. The Temperament and Character Inventory (TCI) was used, and the results were compared with normative data from age-matched controls.Forty-seven mountaineers from 8 different countries enrolled in the study. The mean age was 33 years, and 44 (90%) had been mountaineering for more than 5 years. Twenty-three climbers (49%) had been involved in a total of 33 accidents. Mountaineers scored higher on novelty seeking (P.05) and self-directedness (P.05) and lower on harm avoidance (P.001) and self-transcendence (P.001). There was a significant association between the character measure of cooperativeness and the total number (-.33, P.05) and severity (-.475, P.05) of accidents.Mountaineering is associated with significant risk of injury. Wide variation in the scores of personality traits suggests that there is not a tightly defined personality profile among mountaineers. Scores on cooperativeness may assist in determining risk of injury in mountaineers.