4. Sustained abdominal pain with or without the passage of blood by mouth or rectum not
from an obviously minor source.
5. Signs and symptoms of serious high altitude illness.
6. Infections that progress for more than 24 hours despite the administration of
7. Chest pain that is not clearly originating from a minor musculoskeletal injury.
8. The development of a psychological status that impairs the safety of the person or the
9. Large or serious wounds, or wounds with complications (e.g., open fracture, gunshot
wounds, deformed fractures, fractures impairing circulation, impaled objects, suspected
spinal injury, certain burns as indicated in Chapter 7).
Travel may continue if it is towards definitive care in the case of points 3, 4, and 8, or
when descending in the case of point 5 above. This is understandably a general list, and
specific comments on relevant medical concerns are made in the chapters that follow.
II. GUIDELINES FOR GROUND EVACUATION
If the decision has been made for a member of the party to walk out to obtain definitive
care, the individual must not go alone unless there is no other alternative. Whenever
possible, at least two members of the party, who are mentally and physically equipped to
do so, must accompany the patient.
If anything more complex than a simple walkout of the patient is required, e.g., a
litter carry, an on-site leader must be identified who will assume responsibility for the
evacuation. If an outside rescue is to be requested, a decision must be made on the most
efficacious method of requesting this help. A request for help is often exercised via
electronic communication, e.g., a cell phone, but it all cases the request should be written
first to ascertain inclusion of all the relevant information. The written request should
include an assessment of the patient, of the situation to include equipment, personnel,
food, water, and a detailed location (map preferred) of the patient. The note should also
include potential hazards to rescuers, limitations for vehicles, etc. Experience has shown
that taking the time to write out a detailed note actually decreases total evacuation time.
In assessing the anticipated length of evacuation time, the note must include the expertise
and rescue experience of the persons in the field with the victim. In many countries a
method of payment must be indicated before a rescue will be made. Without electronic
communication, a written request for assistance will be hand-carried out by one,
preferably two or three, members of the party.
During a litter evacuation, at least four, and preferably six bearers must handle the
litter at all times, except when physically impossible such as carries over a narrow bridge.
Additional personnel must be available to relieve those handling the litter. The number of
litter carriers will ideally be 8 persons per 100 meters of travel over rough terrain and 6
persons per 100 meters over reasonably smooth trail. A total of 18 litter carriers are
required for the safest management of the litter over an extended distance. It is very
demanding to carry a loaded litter for more than 15 to 20 minutes without rotating porters
or a significant break. Litter-carries, especially over rugged terrain, can be agonizingly
slow. One bearer will be in charge of the litter, directing lifting and moving, directing the
passing of the litter over obstacles, and assuming responsibility for continuously
monitoring and reassuring the patient. Many teams standardize the position at the left