Suspension trauma is a state of shock induced by passive hanging. Those who survive passive suspension are at risk for rhabdomyolysis. In a wilderness setting, one can see this in cases of persons suspended on rope by their harness. In a conscious person, leg movements work the venous pump to return blood to the central circulation. In the person passively hanging, blood pools in the legs leading to hypoperfusion of vital organs. In the experimental setting, passive hanging has led to unconsciousness in a matter of minutes. Based on a previous series of deaths on rope that included 7 after rescue, many authors have recommended nonstandard treatment for shock including keeping rescued patients upright or squatting for 30 minutes prior to laying them down. This recommendation assumes that sudden death is a risk from acute volume overload or exposure to waste products in the returning blood. This suggestion is not supported by the original series that demonstrated sudden deaths after rescue nor by modern understandings of physiology. Search and rescue teams and party members assisting a colleague suspended unconscious on rope should follow standard resuscitation measures to restore circulation to vital organs immediately.

This article describes a case of leptospirosis in a man who returned from caving in Sarawak, Malaysia, and includes a discussion of epidemiology, pathophysiology, diagnosis, prevention, and treatment. The patient presented with symptoms of leptospirosis, which was confirmed by microhemagglutination titers. He became infected despite taking doxycycline daily for malaria prophylaxis. Leptospirosis is an important consideration in any returned traveler with fever. The spirochete spreads from animals to humans via water. Caving in tropical endemic zones may increase exposure risk due to the combination of multiple skin abrasions with immersions. Water in caves may increase infection risk because of increased water pH. Standard prophylaxis may be inadequate in cases of high-risk exposures.

A 29-year-old man was caving and could not ascend his rope. He was rescued after 4+ hours of hanging after which he could not feel his legs and could not move one of them. He was shivering but still alert. In the field, he received calcium chloride, normal saline, and bicarbonate. At the hospital, he was found to have elevated creatine phosphokinase levels that resolved after continued intravenous fluid. Suspension trauma can include early syncope and late rhabdomyolysis. Persons suspended passively must be rescued immediately and given intravenous fluid to prevent rhabdomyolysis and renal failure.

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