Medicine and Climbing (Twin Stream Guide)

Medical Essays, Video and A Selected Climbing Guide

This started out as a guide for climbing at Twin Stream from 2019 then after a sabbatical in 2021 became a place to put some essays and a talk on various aspects of modern healthcare. You can contact me, Evan Cameron for comments etc at emc03323@gmail.com

Emergent Phenomena during Mass Casualty Incidents

“Plans are Nothing, Planning is Everything”

 

In recent memory there have been three mass casualty incidents in New Zealand; the 2011 Christchurch Earthquake, followed by the Christchurch Mosque Shooting in 2019, and then in 2021 the White Island/Whakaari Eruption. In each case hospitals activated disaster plans and the organised team response saved countless lives. For anyone who has experienced a mass casualty incident (MCI) the gap between the written plan, and the chaotic reality is difficult to describe. This dissonance, where planning fails in the face of an unforeseen event, is a well-known if poorly understood reality. Military planners have long attempted to find ways to control the inevitable chaos of battle- Clausewitz, the military theorist writing in 1830, noted that “the enemy of a good plan is the dream of a perfect plan”. Eisenhower, the Supreme Commander of Allied Forces during World War II and 34th American President, knew the limits of planning when he said, “plans are worthless, but planning is essential”. This essay, based on my own and others personal experiences, is an attempt to shed light on this grey area, where the disaster plan has little utility and emergency responders must navigate an overwhelming and unpredictable event.

As background I’ll briefly describe New Zealand’s three recent mass casualty incidents.

The Christchurch Earthquake began at 1251 on Monday the 22nd February 2011. There had been a significant earthquake in the early hours of September 2010, but the February earthquake was far more lethal. This epicentre was located nearer the city and produced very high ground acceleration, so buildings weakened by the previous earthquake collapsed entirely. Unlike five months prior, it was lunchtime so many more people were in the city centre. Within Christchurch Hospital an MCI response was activated immediately, triage was set up, and 20 trauma teams formed. The first patients arrived in private cars within minutes. 231 casualties arrived in the first hour. Injuries were mostly blunt and crush, amputations were performed on scene so that patients could be extracted from collapsed buildings. The hospital backup generators failed leaving the Emergency Department (ED) in intermittent darkness, the basement flooded, and hospital telephone communications failed. Staff worked for the next 24 hours in a building that shook heavily, not knowing whether their family and friends were injured or worse. 185 people died, 6700 sustained injuries.

The second mass casualty incident to strike Christchurch took place at 1340 on 15th March 2019. A man armed with automatic weapons attacked the Al Noor and Linwood Mosques where hundreds of men, women and children were attending Friday prayers. Within half an hour the gunman was apprehended after his car was rammed by police. The speed of events meant that the hospital was unaware until a victim, having run from the Al Noor Mosque, arrived at the ED triage desk. Simultaneously, armed police in tactical gear appeared in the ED waiting room. The disaster plan was activated and resuscitation bays began to be cleared. Within seconds patients started arriving in private cars. 49 seriously wounded patients arrived within the hour. There was no time to retrieve the MCI plan and equipment, nor was there time for prehospital triage or adequate registration. The ED response was over as quickly as it had begun. By 1700 the ED was virtually empty and in lockdown (because a second shooter was thought to be still at large). Most patients had been transferred to theatre, ICU or to wards. In total 51 people died, and 40 were injured. There was 1 death in the ED.

The third incident occurred on White Island/Whakaari at 1411 on Monday the 9th December 2021. 47 tourists and guides were exploring the volcanic island when it erupted. The nearest hospital was in Whakataane, 50km away across water, the larger hospital at Tauranga, 90km away. Three tourist helicopters immediately flew to help and between the available helicopters and boat operators’ victims were transported to Whakataane, Tauranga and Waikato, each of which declared an MCI. Later that day patients were flown to plastics centres in Auckland, Lower Hutt, Christchurch, and Hamilton. The Australian army retrieved patients back to Australia in the ensuing days. Despite the relatively low numbers and rapid distribution of patients throughout New Zealand, the severity of both chemical and thermal burns required significant resource over the following weeks. Repeat visits to theatre for debridement and dressing changes combined with prolonged ICU stays meant that elective surgery and ICU capacity throughout New Zealand was impacted for weeks. 15 died at scene, 7 died over the coming days and weeks. Only 3 of the 25 survivors sustained minor injuries.

These are difficult events to recount and to read about. Instinctively, one wants to learn the hidden lesson that tells us how to stop disasters before they begin. Yet, despite natural disasters like earthquakes and volcanoes being planned for, particularly here in New Zealand, chaotic variables always interject. Time of day, mechanism of injury, distance to medical care, transport availability and how a hospital is functioning on the day are just some of the countless factors that no plan can fully account for. So, if planning only goes so far how can we manage, or at least mitigate unforeseen consequences?

Fortunately, mitigating phenomena do emerge during an MCI. Without training or prompting, individuals will identify and solve problems in the moment. For example, during the earthquake response, staff recognised that many of the crush injured patients were at risk of hyperkalemia, so suxamethonium was removed from intubation packs and hyperkalaemia treatment bags were made up. Blood bank staff arrived unannounced with as much universal blood as they could carry. When hospital communications failed medical students volunteered as runners between departments.

During the Mosque Shootings, before the first patient arrived, a senior nurse gathered a small team and rapidly transferred and discharged patients out of the ED making vital space for incoming victims. Another nurse distributed morphine and fentanyl to the trauma teams. A cardiologist with an ultrasound machine arrived and calmly went from bay to bay evaluating thoracic gunshot wounds. Chest drain bottles became scarce so a nurse fashioned a temporary underwater sealed drain. Vials of intravenous antibiotics and tetanus shots were brought to each patient by a pharmacist, and nursing students gave water to adrenalized staff.

In Whakataane, an off-duty nurse went to the local supermarket and bought all the cling-film she could carry, bringing it to the ED to dress burns victims. A pharmacist arrived with the hospital stock of propofol so patients could be sedated for wound management and escharotomies.

It appears that beneficial emergent phenomena during MCIs is universal. In the USA during the Las Vegas Shooting of 2017, the largest mass shooting in history, staff at Sunrise Hospital used endotracheal tubes when chest drains ran out, then created an assembly line system for intubating, and when ventilators ran out, used Y connectors to ventilate two patients with a single machine.

These spontaneous solutions are a consistent feature of mass casualty incidents. Witnessing individuals solving vital resource problems while under huge pressure is impressive to see. This behaviour can’t be planned or practiced, but it is reassuring to know that ad hoc ingenuity undoubtedly emerges during a disaster.

Another mitigating factor that quickly becomes apparent is frontline staffs’ ability to prioritise. Inevitably, with an overwhelming of resource, the ability to deliver normal care ceases and is replaced with austere emergency medicine. This means providing care that is sub-standard so that resources can be stretched and save as many lives as possible. Essentially, quantity becomes more important than quality. Prehospital and emergency department staff are experts at this, daily ED overcrowding and flexing of resource is something we are all used to. A mass incident requires a further drop in the standard of care. Knowing how to recognise and manage hypotension and hypoxia, with minimal resource (and potentially without monitoring), in order to maintain perfusion while definitive care can be arranged is vital. Using permissive hypotension, maintaining oxygenation with simple airway manoeuvres, diagnosing without CT scan, and staying away from time consuming procedures that add little value, like central and arterial lines, are skills most emergency staff are familiar with.

The deterioration of the usual standard of care affects responders differently. For those who are highly conscientious, or perfectionist, delivering substandard care produces stronger feelings of guilt at not having done enough. Having said that, guilt, along with other grief responses like anger, denial, bargaining and sadness are emotions felt by everyone in the wake of a mass casualty incident. Intrusive thoughts are inevitable in the weeks after but normalising of these emotions does occur, and most people carry on not unduly affected by bearing witness to mass trauma. Interestingly, the hours spent locked-down in the empty Christchurch ED after the Mosque Shooting meant there was time for staff to decompress in the same environment, to let the nerves settle, even to relax with colleagues before heading home to friends and families who could never fully understand what being part of a response was like. A similar effect occurred with the earthquake where, because the whole community had been affected and everyone had been through a similar experience, it became somewhat normalised and therefore more manageable psychologically. Another feature that Professor Karim Brohi, the medical lead for London MCIs (an unenviable role) points out is that a person who moves on from their colleagues to another job shortly after an MCI may struggle more with this normalisation process. So, doctors or nurses rotating frequently through short term jobs, or those who go on prolonged leave, may be at risk of a more prolonged psychological recovery.

Finally, there are two further issues that are not often recognised in disaster planning which may help prepare for an MCI.

Firstly, managing the medical record when tagging and registration fails to keep up, either because too many patients arrive at once (as in the Mosque Shooting), or when a computer system fails because of power failure or cyber-attack. A switch to a paper system should be part of any disaster plan but a simple temporary solution is to use mobile phone cameras. Being able to photograph the patient, the injuries, the portable X-ray and ultrasound image, and the drugs and fluids given (the vials themselves or the drug chart if available) means a coherent record can be passed on to successive teams. Patient privacy is forgone but for an unregistered gunshot victim who urgently needs to go to theatre these images provide vital information for surgeons, anaesthetists and ICU doctors who are taking over care.

Secondly, regarding crowd control and communication. Managing incoming relatives and bystanders is a well understood part of an incident plan yet controlling the large influx of medical staff is less well appreciated. In a large hospital, like here in Christchurch, one can expect fifty to a hundred staff arriving within minutes of notification. The solution is to corral staff in a central area, near the ED coordinator. Communication from the teams in individual resuscitation bays as to what type of specialist they need is passed to the leader who can then call out to the collected staff the person they need e.g. we need a general surgeon to bay one. In large EDs where mobile phones or voice activated communicators quickly become redundant because of so many calls being made, a loud voice or better, a tannoy system (which ideally shouldn’t be connected to the IT system) can be an old fashioned but vital tool in getting the right people to the right patient effectively, and for communicating to all teams the availability (or unavailability) of equipment.

So, if you work in the frontline and it has dawned on you that you may find yourself thrust into a disaster response, hopefully this essay alleviates some fears of the unknown that are inherent in mass casualty events. Knowing the plan and thinking about what you would actually do is vital. But do keep in mind Mike Tyson’s thoughts on managing the unpredictable, “everyone has a plan until they are punched in the face.”

 

For further reading

A stunning account of the response to the biggest mass shooting in US history by the ED staff of the Sunrise Hospital

http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/

 

ACEM disaster policy

https://acem.org.au/getmedia/f955b382-891c-46d1-aaf6-11f9a695ee35/Policy_on_ED_Disaster_Preparedness_and_Response

 

And a literature review of emergent behaviour during disasters

https://www.researchgate.net/publication/235287945_Emergent_phenomena_and_the_sociology_of_disaster_Lessons_trends_and_opportunities_from_the_research_literature

Evan Cameron May 2022

Our Current Health System Viewed through the Lens of the History of Medicine

The talk can be found on YouTube at 

https://www.youtube.com/watch?v=ZBsYmE16C5g&t=12s

March 2022

A Recent History Of Sepsis

Late on a Saturday evening and a 42 year old women with septic shock is struggling to survive in an Intensive Care Unit. Admitted that morning with staphylococcal septicaemia, she remains close to death, despite all the antibiotics, fluids and vasopressors we could give her. The evening team had performed a risky intubation for impending respiratory failure, she wasn’t expected to survive.

This was 2006 and like any good registrar I was keen on evidence based medicine. Around 2001, managing septic shock changed, and was no longer a case of source identification, antibiotics, fluids, and vasopressors. It was scientific, it was evidence based. River’s trial on Early Goal Directed Therapy was all the rage. Even the definition of sepsis had changed. No longer was a fever, white count and low blood pressure enough. Mean arterial pressure, central venous pressure, central venous saturations, procalcitonin, and lactate were all in. It made for a busy time in the ICU.

So there I was, trying to get the central venous saturations over seventy as River's trial advised, when it struck me that this situation needed Xigris, the new sepsis drug from Eli Lilly. The initial PROWESS trial of this new wonder drug looked like it would change sepsis management forever. Published in the New England Journal of Medicine, FDA approved, and even better, part of an exciting world-wide ‘Surviving Sepsis Campaign’ this medicine was going to make the difference.

So I phoned my consultant and he agreed to let me use Xigris despite the $8000 price tag. The on-call pharmacist pointed out, because of the cost, it had to be okayed by the Hospital Director. I’d never spoken to a hospital director before and waking such a person up at midnight on a Saturday made me nervous. A sleepy voice answered, I explained the request, he sounded skeptical so I unleashed a torrent of facts and data from PROWESS arguing the case for using Xigris in this dying woman. There was a long silence then an odd comment, which at the time seemed irrelevant, about how many gastroscopes you could buy for $8000. Finally a 'yes' came from the man at the top. I ran up to the pharmacy, collected the precious vial, drew it up and gave the drug myself, terrified of dropping it. A few hours later the poor woman developed a fixed pupil, from an unexpected cerebral haemorrhage. I finished the shift writing her death certificate.

Xigris, it turned out, was not good for you. Giving an anti-thrombotic to someone with severe sepsis and sepsis coagulopathy has a propensity to cause bleeding. That important fact was obscured in the original paper. It still took 10 years for this to become apparent and for the FDA to rescind approval. The ‘Survive Sepsis Campaign’ that Eli Lilly’s PR company invented, along with a funded ethics committee that implied not using Xigris was unethical was heavily criticised, but no-one was ever struck off or, charged with fraud.

Despite its dubious origins the Surviving Sepsis Campaign continued to thrive, having another moment in the sun in 2013. New York State mandated that their ‘sepsis care bundle’ be followed to the letter of the law following the death of a 12 year old boy from sepsis. Again it took years for it to be recognised that aggressively pursuing a one size fits all approach wasn’t working. The clouds rolled back in again in 2018 when there were serious objections to the ‘one hour bundle’ which amongst other recommendations advised starting vasopressors within the first hour.

Regardless, the Society of Critical Care Medicine has spawned ever more 'care bundles' along with broader definitions of sepsis, despite growing evidence that none of its protocols or guidelines, aside from giving antibiotics early, are based on good evidence. The negative effects of these efforts are seen on a daily basis in hospitals and in the community. Sepsis from the urinary tract is massively overdiagnosed and over treated, the worst harm coming to young women who, because of multiple courses of antibiotics for infections that were never there, end up colonised with multi resistant E. coli. A more acute danger for patients is premature closure, a common cognitive error in which a physician fails to consider alternatives after an initial diagnosis is made. Being misdiagnosed and treated as having sepsis, when the real problem is a serious metabolic, endocrine, cardiovascular or autoimmune disease produces near-misses and/or significant harm to patients. 

As much as I’d like to get the tin foil hat on and blame it all on big pharma or self serving bureaucracies this is not the whole story. There is certainly bias, and there may be some mild corruption in the form of free conference trips and honoury titles, but everyone working in the sphere of sepsis who looks at the huge number of sepsis deaths in the the developing world, and closer to home, the rare but catastrophic meningococcal or streptococcal deaths, wants to find the answer.

Unfortunately, the only proven certainties when managing sepsis appear to be early recognition (which isn’t always easy) and giving antibiotics early. Perhaps the fundamental problem  is infection is such a wide spectrum of disease that trying to standardise management is incredibly difficult. It certainly leaves the doctor in a tricky spot, over-diagnose infection and prescribe unneeded antibiotics and you risk antibiotic resistance, fail to recognise the early meningococcemia mimicking a benign viral illness, and your patient dies. The future may be in big data and AI learning- one can only hope, but in the meantime be wary of blindly following a sepsis guideline or protocol that's puprorts to be 'evidence based'.

December 2021

What is a Hospital?

What is a hospital? Seemingly a simple question, but scratch the surface and things get complex very quickly. On the face of it, a hospital is a large, expensive building where doctors and nurses help the sickest people in society get better. Here in Christchurch, the yearly budget for the hospital is a staggering 1.5 billion dollars; but then it does employ about 3000 staff- a veritable army of doctors, surgeons, nurses, clerks, cleaners, cooks, radiologists, orderlies, therapists, dieticians, social workers, pathologists, technicians, engineers, educationalists, students, executives, and managers.

Yet despite Christchurch hospital being around since 1861, and hospitals existing since Antiquity, no-one really knows the answer to questions any designer and manager of a hospital would love to know, like how many beds should a hospital have, how many doctors and nurses are needed, what illnesses should a hospital manage (and importantly, not manage) and how much will it all cost?

Instead hospitals are organised in ad hoc fashion, forever reorganising according to the latest cause of morbidity and mortality, whether that be a viral pandemic, a spike in mental ill-health, or more often than not, a government whim. Funding seems to cycle though periods of boom and bust, money arriving only after a prolonged hospital crisis and multiple avoidable patient deaths.

So, if we are to solve the problem of managing hospitals effectively where do we begin?Accurately defining the problem is usually a good start, yet we can’t go there until we can achieve an agreed upon definition of what a hospital is and does, and this, as far as I can tell, doesn’t exist. If it did hospitals would be standardised by now, built to a blue print that was proven and reliably successful. Perhaps all we can do is look to analogous systems out there that can give us insight into our dilemma.

The car factory model was fashionable for a while. Unfortunately it turns out that supply and demand for cars is a bit simplistic compared to running a hospital. The supply of healthcare here in New Zealand amounts to around 9% of gross domestic product. As for demand, its hard to quantify, but the desire for health care could well be insatiable, perhaps infinite. And, as it turns out, fixing cars is a lot simpler (and cheaper) than fixing people.

I once had a friend who was convinced that being a doctor was like being a soldier, and we, as first year house officers, were the infantry, ordered out of the trenches by our Senior House Officer, to battle opposing specialities in an attempt to gain the upper hand for our patients. As an analogy I reckon he was onto something. Like the armed forces, we are led by a Minister of Health who sits atop health boards, CEOs, Chief Medical Officers, Clinical Directors, Consultants, Fellows, Registrars and House Officers. Health systems are certainly more anarchic that the rigid hierarchy of the Minister of Defence, his Generals, Majors, Sergeants and Privates but like the army we have to respond as best we can to unpredicted demands, to battle on even when our resources are overwhelmed. And like an army we deal in cycles of funding, having to absorb the cost of expensive new technology and treatment, then watching the cash roll in when war is on the horizon. The big question in this analogy though is ‘who is the enemy’? Is it our patients? Probably best not to go there. Perhaps every hospital department is at war, fighting each other over prestige and resource. And who hasn’t, as a junior doctor, been sent nervously into no-mans land with a soft referral, armed with a feeble case of acopia or a chronic pain exacerbation, only to return defeated by the medical registrar, and then listened in as the big guns are wheeled out in a consultant to consultant disposition telephone battle .

My favourite analogy is the health system as a religion. The Hippocratic Oath, as a solemn promise, doesn’t necessarily invoke a divine witness but certainly demands a special obligation to one’s fellow man. The undertones of devotion or of a ‘calling’ are evident. Then there’s the business of becoming a Fellow. Essentially one is admitted or ‘ordained’ into a College that confers special authority, and the right to perform various procedures on the public (can intubation be described as a ritual?). And how much of what we do is based on good quality scientific evidence as opposed to tradition, even myth? Of course I’m doing a disservice to Medicine, we may cause harm but we certainly aren’t on the level of some of the better known organised religions.

Current thinking suggests we are actually employed not in a Hospital, but in a Complex Adaptive System. The study of which is a subset of nonlinear dynamical systems (whatever that means). It’s a weird blend of sociology and mathematics defined as network of interactions which are non - linear (small inputs can lead large effects), that can self-organise, where emergence can occur, that can learn and at the same time be influenced by unpredicted feedback loops and local history. As a system it is open, thus defies boundaries, one part of the system can be entirely ignorant of what other parts are doing, and while it never attains equilibrium it requires a constant flow of energy to maintain organisation. Sound familiar? Currently a Complex Adaptive System is thought to be inherently unpredictable. Yet there is hope. Apparently, with the advance of mathematics, these types of systems will become predictable. And if that were the case perhaps we could finally understand what a hospital is, and so we could organise our health systems effectively, and ultimately, end the ubiquitous boom bust cycles that plague our hospitals.

January 2022

A Climbing Guide for Twin Stream, near Mount Cook Village, New Zealand, 2020

A video of what I ended up calling ‘Taking Liberties’. A route description and topo can be found below

Taking Liberties. 600m grade 11. An interesting scramble with spectacular positions involving two pitches of easy but exposed climbing. Follow the terrace above Half Moon Slab, past the Southerly Front Slabs until the terrace ends. Avoid the chockstone gully and instead climb a 30m v-groove (8) to its left. This leads to a large central gully. Scramble easily up for about 200m. Where the gully steepens to a tower climb up and left, following a narrow terrace into an exposed position above a huge rotten gully. Climb through big chockstones regaining the tower (crux). Follow the cheval and ledges heading left before ascending the final tower. Abseil or down climb 30m to the top of Shindig Gully. Best descent is to walk to the road, heading east via peak 2155m, to the weather station and 4wd track. Descending the upper parts of Shindig Gully in summer does not look pleasant. E Cameron, March 2020.

An Introduction and Selected Guide to Climbing at Twin Stream

Twin Stream comprises an enormous 800m high buttress which in its lower half contains remarkably solid greywacke rock infused with veins of quartzite that make climbing here an absolute delight. Along with a few outlying crags there are currently 90 routes, all set within the stunning cirque of Ferintosh Peak, Glentanner Peak, Mount Dark and Kai Tarau. 

Developed in the mid-nineties, the climbs are multi pitch, and use a mix of bolt and traditional protection with bolted belays that allow the weaknesses in the unique slabs, cracks and flakes to be navigated. There are routes that encompass the whole 800m buttress and for the energetic there is abundant potential for new routes, both summer and winter.

The buttress lies hidden from the Mount Cook road, at an elevation of 1400 metres, seven kilometres from the road bridge over Twin Stream.  The genius of Twin Stream is the Glentanner helicopter station is situated where the walk-in begins,  so the 4 hour approach (which involves 800m of up) can be avoided with a cheap, five minute flight to the crag, saving time and energy for the excellent climbing. Walking out is much more straightforward.

Routes are often long with individual pitches of 40 metres or longer, the longest being over 200 metres. Most routes have bolted belays, allowing quick descents. Twin 60 metre ropes are ideal. For the longest pitches take a rack of 14 extendable draws, up to 10 cams and large selection of nuts and RPs. Even on bolted pitches take trad gear. For the bolted belays take a few metres of 6mm cord or similar, and perhaps a few maillons or old carabiners, to rig abseils on belays where there are no lower offs or rings on the bolts.

Newcomers to Twin Stream often encounter difficulties with either the walk in, the keas and katabatic winds that making camping noisy, or tricky route finding amongst the massive buttresses and gullies. This can be avoided by a fly-in walk-out approach, and by sleeping in the excellent bivy caves that provide a good nights sleep. Finally, and hopefully,  this guide will help you steer clear of major route finding issues.

For a successful trip begin with routes like Moon Rise, Moon Struck, Wily Spaniard, Peanut Slab, El Niño/Central Buttress, Centrefire, Aftershock, and Hungry Heart where not only is the climbing excellent but the access, protection and descents are relatively straightforward.

If you get up a few of these then you’ll be good to go. Other top picks are March Hare, Once We Were Wasters, Boy Germs, Pulp Friction, Blade Runner and Fibrillator. If its all too much just got for a nice walk instead

It goes without saying that Twin Stream is a serious mountain crag with all that entails, including the ability to route find, mange loose rock and self rescue or summon help in the event of an accident. There is patchy phone signal at points on the walk in and at higher points in the cirque.

DEVELOPMENT

Climbing at Twin Stream  began in the 1970s with Hugh Logan climbing with Paul Scaife and John Hobison. Development began in earnest in 1995 with the three pitch route 'Stealing a March' by Andy Macfarlane and John McCartney. Andy MacFarlane and Murray Judge became the main driving force over the next 6 years. Development has slowed in the last 15 years with only a few routes added to the impressive initial development. The potential for new routes remains huge, ranging from easy trad climbs to hard technical walls, often hundreds of metres long.

The skiing and winter climbing at Twin Stream is worthy of note. With a fly in and high drop-off excellent ski descents of Mount Dark and Kai Tarau can be had. Steep skiing is found in Shindig Gully and on surrounding couloirs. It is feasible to fly in and ski multiple lines and walk out in a day. Ice does form but not in such quantities as Bush Stream. In the right conditions though, there is much potential for ice and mixed routes.

The approach is in red, the descent from the top of the buttresss is in green. Red dots and arrows are helicopter landing sites for skiing

ACCESS

Access begins at the road bridge over Twin Stream, a 20 minute drive south of Mount Cook Village on the Twizel to Mount Cook road. Flying in and walking out is highly recommended, thus avoiding the 4 hour walk-in that involves 800m gain on indistinct sheep tracks and river bed.

Glentanner Park Helicopter Line is situated a few hundred meters from the start of the walk and as of 2021, up to 5 can fly in for about $360. Ask to be dropped off at the Twin Stream camp site.

If you do decide to walk in, the track starts on the true right of the road bridge. Occasional red/white markers and cairns mark the way which stays on the true right the whole way. Initially follow the river bed for 10 minutes then follow cairns onto the terrace. A vague track then ascends the left hand spur to reach the higher terrace.

Follow sheep tracks and markers through the matagouri until reaching a large eroded gut after 90 minutes. Cross this and again follow markers and indistinct path for a further 30 minutes until cairns mark a 10m decent to the flat river bed.

Then boulder hop for a further 1-2 hours, finally reaching the large flat camping area beneath the dramatic Central Buttress. Expect to get lost at various points. As an alternative, the river bed has been followed for the whole way thus avoiding the terraces.

The walk out, even if you lose the track, is much easier and takes two and half hours.

An excellent (although difficult to find) rock bivouac can be found at the far end of the meadow, 50m above the flats, on the true left, in the large rocks beneath Central Buttress. There is a flat balcony rock at the entrance. It accommodates 2 comfortably, 3 at a push. There are another two good bivys in the rocks below this, accomodating two in each. Aside from the advantage of not needing to carry a tent, it avoids the katabatic winds and keas that make camping noisy. There are multiple other less weather-proof rock bivouacs that require a bivy bag.

If camping, the keas will attack unoccupied tents so gear needs to be stashed during the day. Keas are endangered so tolerate their brazenness and don’t feed them. It goes without saying, carry out all rubbish.

With regrds the photo topos- please excuse the childish annotations. Red crosses are a double bolt belay, red circle is a trad belay, green circles are best descent routes- you can rap of anything but these are generally the most straightforward way down. Additional bolts are not always marked - refer to the old guide.

Below is a selected guide that so far contains about half of Twin Streams 90 routes, and should be used in conjunction with the old NZ Alpine Club Guide for Barron Saddle to Mount Brewster, and the website climbnz

https://climbnz.org.nz/nz/si/canterbury/ben-ohau-range/twin-stream.

I will add to this site over time.

The top pitches of the Southerly Front Slabs with Kai Tarau (2542m) behind.

HALF MOON SLABS

 

Moonrise, a common starter route, is two pitches and relatively easy to find. Walk up to the bottom of the buttress and follow it left up scree slopes for about 30 minutes. It cannot be seen from the campsite. Walk off to the left or rap. Gives access to the massive slabs routes of Southerly Front.

A Moonrise 16, 17 follow the line of bolts

B Moonstruck 17, 17 * two bolts at the top of the first pitch

C Titan 19

D Moonshine Buttress 16, 15 *

E  Reservoir Chocks 16, 17 80m. Can be used as a direct start to Pulp Friction and the Southerly Front Slabs. Starts at the base of a wide chimney on the way up to Half Moon slabs. The first pitch is protected by prominent chockstones, belay from the broken ledges. Don't forget your micro wires for the second pitch, a good rock spike belay at the top allows a rap back down or continue directly onto the massive Southerly Front wall. A further thread rappel can be found on the small butress as shown.

F Pulp Friction

SOUTHERLY FRONT SLABS

An absolutely stunning wall which can be accessed by walking along a fun ledge that begins behind and to the left of Half Moon Slabs. Alternatively, climb routes on Half Moon Slabs; or for a really big day climb The Lost Boys (5 pitches) or The Big Picture (4 pitches).

 

Gomers Go Round 18, 17, 17. Somewhere left of the slab, climbed to gain access for bolting. Not shown.

Gomers Go To Ground 24 ** Fine slab climbing left of the first pitch of Pulp Friction. 3 bolts to first belay of Pulp Friction. Not shown.

A Fully Wired 22, 20. Climb the first pitch of Pulp Friction or Gomers Go to Ground.  Traverse 3m  left from the first belay then up to bolt. Through bulge. 5 bolts to belay. Then straight up past 2 bolts to grassy cracks then move right to third belay of Pulp Friction

B Pulp Friction ** 19, 20, 19, 17, 13, 16. Straight up the centre of the slab. Amazing first pitch on perfect rock, 7 bolts. The next two pitches are almost as good, 11 bolts and 5 bolts respectively.

C Ground Hog Day 17, 19, 20. Climb the first pitch of Southerly Front, continue up to shallow pillar, belay on a flake. 7 bolts. P2 climb the pillar to a quick pull onto the upper slab and up to belay ledge, 6 bolts. P3 traverse left across the slab to the left edge and up. 7 bolts.

D Southerly Front 17, 20, 23, 23, 18, 15 ***. The first four pitches of Southerly Front took a week to put up because of the need to make fequent runs back to Mount Cook to recharge the six volt battery used to drill the ultra hard greywacke. Andy Mafarlane endured a thirteen metre whipper on the fourth crux pitch during the first ascent. Start below the large chockstone, climb the shallow pillar to a horizontal break and traverse left to the belay. Three pitches up the right hand slab to the ledge below the headwall.

E  Sticky Date Pudding 24, 24. Two long pitches to the right of Southerly Front

F Rock Vandals *.Two pitches on the right of the white corner. Grades 20, 22 to the ledge, climb the upper wall on natural gear. Grade 14, 16 to bolt belays.

G The Western World* 21, 22

H Stealing a March 16, 17, 18. The climb that started modern development of the crag. "Andy Macfarlane was on the phone, excited: I’ve just seen the biggest unclimbed slab in Australasia and we’re going to put a route up the middle of it." Dave Brash, New Zealand Alpine Journal, 2001. From the valley scree climb a broken rock pillar (the right hand of the three pillars) to the base of Southerly Front slabs. The broken rib leads to a groove left of the arête, higher up traverse right around the arête to a thin crack on the upper wall.

I March Hare 17, 18, 17, ***. Three excellent pitches up the arête, grades 17, 18, 17. Great position and exposure at the grade – a must.

J Forced March * 18, 20

K Unnamed 18

L Corner Chimney 15

M Splitting Hares 16, 17

Southerly Front Slabs

CENTRAL BUTTRESS LEFT SIDE

 

A Secrets and Lies 21. 11 bolts

B Stone Showers 14, 17. Descend by abseiling Wily Spaniard, or scramble off left along the ledges.

C Peanut Slab 19 *. Recognisable line of 6 bolts. Take gear.

D Wily Spaniard  15, 19, 17 **. Lovely trad crack to trad anchor on ledge. Step right onto slab clipping two bolts, heading right to a flake, then up, aiming to pass overhang on left. A long classic pitch. Semi hanging belay. P3 Up to ledges. Left hand line on pitch 2 is My Evil Twin 20.

E Fault Line 12, 20, 20. Up large blocks to ledge below overhang. P2 step left to break through roof, 5 bolts. P3 right hand line is 20, 7 bolts. Straight up is 23, 7 bolts. Bold in places.

F Once Were Wasters 18, 21 **. Left slanting slab to semi-hanging belay. Up corner and right to hyperclassic flakes.

G Rock Wren 24. Starts at El Niño. 7 bolts.

H El Niño first pitch. See Central Buttress below for full route description

I Swing In 24. Abseil from the top of Once were Wasters to start. Past 3 bolts. 

J Slab it to Me 19. Abseil to strart, follow flakes.

K South of the Border ** 21, 20, 20. Stunning and sustained from start to finish on occasionally friable rock

L Feathered Friends 20, 18, 18 **. Pull through overlap then leftwards through wide crack to belay, 3 bolts. Follow jugs left of the overhang, 2 bolts. Continue up.

 

Central Buttress Left Side

CENTRAL BUTTRESS

Sits directly above the bivy rocks- marked in black.

A Lost Boys 12, 20, 20, see Central Buttress Left Side

B Once Were Wasters 18, 21 ***, see Central Butress Left Side

C El Nino 16*, 5 pitches, best line shares pitches 2,3 and 5 with Central Buttress, the the right hand line on pitch 1 is Central Butress pitch 1

P1 4 bolts Start at an unstable looking triangular block on the left of the arete, it actually feels very solid when you’re standing on it. The initial gear looks bad but it is all there until the bolt on the arete. Get round the arete then for El Niño (16) go up just right of the arete on occasional bolts as marked. For the crux at 2/3 height there’s a sneaky bolt left around the arete on the next door route Rock Wren.


P2 is short, about 20m (14). Leave the right facing corner, up the slab a little boldly heading right around the little overhang. The next belay bolts are easily missed.


P3 ** A long excellent pitch (15) throughto the terrace.

P4 12* 50m Start a few yards left of the arete, up and head right underneath the overhang to belay

P5 15 up and left up to the arete and to the tilted belay slab.

The abseil is tricky to find. It’s at the lookers left end of the tilted slab. 2 bolts cunningly hidden on a scary looking small block with the abyss below. Second rap is at the right end of a ledge 50m down. This will take you down to the terrace where you can walk round to the El Niño line and rap that. Quite a long day out.

Central Buttress 17*, 8 bolts. Same start as El Niño then once on the arete keep traversing horizontally to line of bolts. Then join pitch 2 of El Niño.

D Jumbo Burger 18*, 7 bolts classic friction climbing

E Dial a Pizza 21, 7 bolts

F South of the Border ***see Central Buttress Left 

G Feathered Friends *** see Central Buttress Left

H 12**, pitch 4 of El Niño, see above 

I 17, 3 bolts, pitch 4 of Central Buttress

J Marigold 16, follow stepped flakes

Central Buttress

SHINDIG GULLY

 

Shindig Gully is a stunning couloir with an impressive right hand wall. To get there walk down to where the river leaves the camping flats, then head up and right across scree slopes and an unstable gut. Be careful not to end up in the grotty gully right of Siberia wall, you’ve not gone far enough right if you end up in there. Takes 40 minutes. Keep going up and surmount the gully sized chockstone to access Aftershock and Centrefire, then a little further up to get to Hungry Heart, Fibrillator and Boy Germs.

A Steerpike 19, 17, 19 ** Gain starting ledges via left to right diagonal. Then aim for immaculate leaning corner with roof near top. Pitch 1 up thin crack and small corner to gain main corner. Second pitch - up corner, step right, gain crack line above roof to trad anchor. Then to arete, descend this to Aftershock anchor.

B Superconnector 15, 17, 14 Thin hand crack up and left of the orange wall then up the corner above. Move onto arete at the top of the corner 

C Chimney Sweep 15, 18, 16

D Aftershock 17, 17, 18 ** Lovely climbing. Looks gearless from the deck but there is plenty in horizontal breaks and 3 bolts. Head up to the little alcove belay which is a difficult to spot from the deck. Continue up, 5 bolts. Then head left and up to abseil anchors from second belay, 2 bolts. Second pitch right hand line is You be the Judge 23,  5 bolts. Same second belay, then directly up corner to top 3 bolts. Descend 

E Art for Arts Sake. 20, 21, line between Centrefire and Aftershock. 2 pitches, second pitch not marked.

F Centrefire 17,19, 20 *** Awesome second pitch. Start about 20m down from the Aftershock starting ledge. Either belay at a bolt below the first roof or better, go through the roof (well protected) and make a trad anchor in solid cracks above. The second pitch goes up the obvious cracks. The gear is perfect. The third pitch is a diabolical single move off the belay. French free it/stand in a sling then easy to the top. Descend down Aftershock. Three abseils. 

G A Big Day Out 17, 19, 13 Loose and bold second pitch

Shindig Gully

SHINDIG GULLY UPPER

 

A Fibrillator 22, 19 *** The first pitch is a classic, sustained thin edges, 13 bolts. Head  left from the belay and up through overlaps, 9 bolts

B Hungry Hearts. ** 16, 15, 15, 15.First three pitches marked. Find Fibrillator then walk right. Spot a high single bolt on a triangular wall with a left facing corner on the right. You should be able to see the second bolt from the deck.  Climb up, clip the first bolt, head right a metre or two, place gear then step left up onto an improbable looking hand traverse which is straightforward. (If you keep heading right from the first bolt you’ll end up on Boygerms- a full 50m trad pitch). Then easily up to the third pitch which is a cracker. Finish after 3 pitches on lunch time ledge or do the final 15 pitch. Best descent from the ledge is down Fibrillator - the first abseil is off a hole in the rock piece of tat and a bolt. You’ll know it when you see it. Use your prussiks. 

C Boygerms 20 ** Well protected mega pitch. Climb the first section of Hungry Hearts as described above then trad belay on the pedastal at about 8m to avoid rope drag. Place sling to abseil off block. 

Approaching the crux of Fibrillator

Shindig Gully Upper

PHOTOS AND VIDEO below

A-Moonrise B-Pulp Friction C-March Hare D-The Big Picture E-Peanut Slab F-Wily Spaniard G-Once Were Wasters H-El Nino I-Fibrillator J-Boygerms K-Centrefire L-Blade Runner

Pitch 4 El Niño (12)

The bivy

Fibrillator to the right. The 200m buttress is foreshortened.

Typical bolted belay. Bring tat and get creative.

The death block at the start of El Niño/Central Buttress

Blade Runner (22)

Skiing Shindig Gully

On the ledge above Wily Spaniard. Unclimbed rock above.

Shindig Gully

Pitch 2 Wily Spaniard

Late winter conditions Wingers wall/Siberia with potential winter routes

Pitch 2 Hungry Hearts

Second abseil off Central Butress

Pitch 2 Fibrillator