“We’re on our way:” A message from the mountains

How do we improve the quality and safety of care? In healthcare, we commonly look at outcome measures when pondering this question. But safety-critical processes are not visible in these measures. And if they remain undetected, they can be a dormant source of sudden harm. This past year, I have immersed myself into the study of mountain rescues as part of a funded scientific investigation. At patient safety meetings, I have long encountered comparisons to the airline industry. “What can healthcare learn from aviation safety?” Patient safety research has begun to compare healthcare teams with flight crews. It has implemented aviation-based “Crew Resource Management (CRM)” models into the healthcare setting. But on what foundation? From a scientific standpoint, building this bridge into practice based on purely theoretical arguments seems insufficient. Instead of accepting the validity of this comparison at face value, I decided to take a closer look at safety-relevant processes in a context where both industries work together to save patients’ lives. Where this comparison is not merely a rhetorical exercise, but observable in practice. This is how I came to participate in airborne mountain rescues. I have spent all of the past year flying along with rescue teams and analyzing hundreds of rescues at the regional emergency call center (144). I interviewed all participating actors in this highly interprofessional setting, where pilots, physicians, paramedics, mountain guides, and 144-staff must work together smoothly under high-stakes conditions to prevent harm while saving patients’ lives. One of the rescues I attended was on a warm Friday afternoon in the Fall of 2020. We had just brought an injured skier with a shoulder dislocation from a ski slope at 4,000 m elevation to the regional hospital, when we were called about a patient with cardiac arrest in a nearby mountain village. The primary difficulty of airborne rescues is always to find a place to land the helicopter. Sometimes, if there is no possibility to exit by foot, the physician or mountain guide have to rappel from the airborne helicopter on a 200 meter free-hanging rope to be with the patient. In the case of this particular rescue, there was a meadow where we could land. The son and wife of the patient waived at us frantically, signaling us to follow them. Still in glacier suits and loaded with the heavy resuscitation equipment, we followed them into their house. The physician immediately asked pointed questions to find out what happened. The son’s voice shifted between hope, despair and distress as he proclaimed repeatedly: “He’s dead, I think he’s already dead.” Through repeated questioning, the story emerged: The patient, a man of about age 60, had been chopping wood behind the house when he felt a sudden, severe pain in his chest and collapsed. The son and his wife had brought him back into the house and laid him on the couch in the living room, where the patient shortly after proclaimed: “I’m going now.” The patient went into cardiac arrest about 5 minutes before we arrived. There he was, lying in front of us. He looked peaceful. His mouth was slightly open, his eyes were closed as if he were sleeping. The way he was lying on the couch looked stiff and uncomfortable. His cheekbones were very visible, and his skin was grayish pale. I felt powerless. The physician and the paramedic however immediately went into emergency mode. The paramedic, much younger than the more experienced physician, seemed to be in a constructive panic. He knew they had to act fast. At the same time, he had to attend to the needs of the physician: “Scissors!” Within less than a minute, the furniture had been moved and the patient was lifted down onto the wooden floor and stripped – a naked body with no visible signs of life. The body arched from the electric shock and fell heavily back onto the floor. Chest compressions, mouth-to-mouth breathing, and several needle injections were attempted to infuse life back into the patient’s body. In the background, the unattended wife and son alternated between panic, nausea, and flight-fight-freeze responses. After 10 min, the patient still looked the same to me, but the physician and paramedic had observed some response to their physical labor. The paramedic seemed more enthused than the physician, who whispered: “I don’t Commentary