Tricky Horse Rider

[firedoc5]

Edit. Parts redundant as JPINFV were posting at the same time.

And it should not have because this really isn't an impaled object, unless I'm missing something substantial here. We don't remove an impaled object if possible because not only does it normally clearly define that path that the object took, (a visual aid for further treatment) but it can also allow internal bleeding that can't be controlled outside of surgery.

Unless you felt that the boot was going to bleed to death, the fact that it was "impaled" really should not have been a consideration for leaving or removing that part in contact with the bones.

Not trying to snipe at you FD5, buy again this is an absolute statement that shouldn't be absolute. If you've got good pulses distally, then protecting against infection and additional damage by not allowing the bone ends to retract is a good idea. If you lack pulses distally then it may in fact be necessary to reduce this fracture until you get them back...all else be damned.

Just sayin'....

Dwayne

No sniping taken. You know what they say, "There are not "absolutes" in medicine. There's always the potential of diverse circumstances.

The cuff (top) of the boot was wedged in between the tib/fib, but according to the one doc you handle as an impalement. We did cut the boot off but leaving enough around the wound to prevent the bones from reducing. It was already like hamburger. There was good pedal pulses which we checked very often, especially after any movement. Also had to contend with the hip. (turned in ward). There was not a hip fx. but it was dislocated. Prior to x-rays we were concerned of multiple fx, hip, femur, knee, all down the leg. Turned out no other fx., luckily.

[zzyzx]

I would treat his obvious injury and give morphine before I moved him, but I would also be sure to do a very thorough physical exam with a high index of suspicion for other injuries, especially abdominal injury. We can't be sure that there isn't more to the story than we were told regarding the mechanism of injury. Maybe the horse stepped on him after he fell. Perhaps he was knocked out for a moment. Witnesses are unreliable. I suppose all this is obvious, but it's easy to get distracted by a nasty extremity fracture.

[explenture]

I would lean towards morphine or fentanyl but would like to get a least a rapid trauma or a head to do before giving meds.

[fiznat]

I would be careful with morphine if I thought there was a potential for multisystem trauma based on the mechanism of injury. If there is strong evidence that suggests the injury is isolated to the extremities, I'd probably go ahead with the drug. Otherwise, it's a CYA call to the medcon for me. Morphine in trauma can get you in trouble if you're not careful...

As far as the boot, hell I'd cut it all off. I'm not going to take all day carefully snipping around the boot so that only certain parts remain there while others are removed, screw that. ...Barring some aspect of this decision that isn't obvious without actually seeing it, I'd just cut it off, stabilize, treat and transport. The less time we spend on scene with trauma, the happier I am.

[fireflymedic]

Drug me but don't cut my boots ! Lol, them suckers are expensive ! That being said, a real concern for development of compartment syndrome is there with injury. If vitals are stable, and MS is normal, go for giving him a little pain killer. MS is an option, but you have the option of fentanyl I'd prefer it as you don't have the vital signs effects that you do with morphine as great, plus it'll make him care less that you're cutting off his boot ! Be safe.

[iMac]

Tell patient to "Cowboy up" and walk it off. Dang they make "cowboys" a lot weaker than they used to. :shock:

And why did you not enter with the horses in the arena? Were they attack horses?

OK while I prefer to give MS or other pain killer prior to moving patients with injurys I have to hold that until I get some info.

Vitals?

Skin?

Allergys?

Meds?

While gathering that info would quickly establish 2 large bore(at least 18 but prefer 16) IV's. By then should have all other info to use for pain management choice.

Patient would not be eligible for selective spinal criteria due to detracting pain, so will get full spinal precautions.

LOL "walk it off"... you son of a :wink: I would love to give you a mouth full about broken body parts caused by horses.

I would board him first. It really onle takes a couple mins to board and while doing it you can take your Hx-be ready to administer the meds by the time you are in the back.