Weird Call Need Some Opinions

[uglyEMT]

Ok folks had a weird call last night. Well the call itself wasn't weird the outcome was and I need to know if I could have done something else.

Quick backstory... regular duty crew was off I was with replacements, folks with many more years experience then me.

Dispatched to an 84yr Female w/ possible broken hip. Arrive on scene and find an elderly lady sitting in a chair. Husband states she fell while getting up, screamed, and he helped her back into the chair. We ask a quick history and find out she was recently at the doctor for Xrays of her left hip and leg due to constant pain and everything was negative and unremarkable. Palpate the hips, nothing unstable felt, no crepitus, patient states no pain. Palpate the left leg and feel nothing remarakable, visual everything appears normal. Patient states pain from about 2 inches (pointed to region) below the hip to her toes. Thinking back, this is why she was at the docs to begin with last week. Right leg is unremarkable no pain. Take PMS and have strong results bilat. Both extremities are same length.

I suggest a reverse KED due to a high index of suspition (treat for the worst thinking here). My crew looks at me like I am nuts. They suggest that due to the findings, which they concur with, that it doesnt appear to be a fracture. After a breif back and forth I digress twords the more experienced folks. We stair chair the patient to the cot, cot to rig, and begin transport. Reevaluate in route, no change other then she feels more comfortable now with her legs straight. Again palpate, visual, PMS no change.

On the way to the ED get caught by a train. Delays transport 8 to 10 minutes (we were freakin two blocks away).

Get to the ED and transfer from cot to bed. Patient states pain is now more severe then before and she "feels swelling" nurse palpates and feels something. She looks down the leg and it is now rotated slightly outward and now shorter then the other. We cut the pant leg open and there is remarkable bruising and deformity. ER Doc comes over and gets her to Xray stat. Find out later it was a femur fracture.

OK WHAT THE HELL DID WE MISS???? How do we go from nothing remarkable to femur fracture in a split second? I am wondering if it was fractured all along but not broken through thus my KED idea would have been the right call or that some how it fractured during the final transfer from cot to bed thus being an underlying ailment (remember the history) and it was just exaserbated by the fall, the ride, and the transfers.

I don't know folks, it had the ER nurse and Doc stratching their heads after reading the PCR, it had my experienced crew scratching their heads at what we missed if anything, and has me wondering if I should have pushed my idea harder and thus this is my first official FAIL that I must own and learn from it.

Anything will help folks, anything.

[usalsfyre]

Probably had a non-displaced fracture which y'all summarily displaced. Sometimes there's not a lot of helping it.

[armymedic571]

Not to Monday Morning Quarterback......but someitmes the most expirienced crews get caught by complacency.

I would chalk this up to a learning experience. Seems your gut instinct was headed in the right direction.

Cheers.

K

[akflightmedic]

You asked for insight and this is all I have to offer...

You stated visually the leg seemed all right" on scene but it was not until you cut the pant leg at the ER did you see what had truly occurred.

This was a trauma patient, an elderly one who is very, very high on the susceptibility to fracture from a seemingly benign mechanism category.

You did not see the injured area with your eyes until you arrived at the ER. You did perform an exam with palpation and maybe lifted pant leg some but did not pull down or remove pants...correct?

Knowing that elderly bones break easier, knowing she is female (low calcium, high pain tolerance)a more thorough VISUAL exam should have been performed. It is justifiable and the patient would more than likely allowed it.

Is this what happened or am I assuming the wrong things from what you wrote?

[PCP]

Sounds like it is one of those calls that just can't be explained I am probably thinking the same thing as you mentioned in your post. It was probably fractured, but not a complete break and all it took was that final move or bump on the road, but just guessing here.

I don't think you failed at all, it is just one of those calls that you think to yourself By reading your post it sounds like you did a good assessment and if I remember correctly did you not say a week prior she had X-Rays done on her hip and at that time they did not detect anything wrong? Only thing you can learn from this call, as I am learning as well is go with your gut feeling.

[uglyEMT]

Re AK: We did remove her pants down to her knees. Thus the visually unremarkable statement. I should have clarified better. But yes at the home we were able to lower the pants without cutting to check for deformity and skin discoloration. I agree with what you said about fractures w/ benign causation thus my wanting the KED ie high degree of suspition. It was at the ED we cut because of the pain she experienced when we tried just lowering the pants again.

Re PCP: Yes on Friday she went to the Doc because of left leg pain that wouldn't go away and it was noted on the discharge sheet negative findings, unremarkable. Thus I believe our complacency in not using the KED because it was an aggrevation of a preexisting condition.

So far everyone has it going to experience and "just one of those calls". Thats what my QA said as well but I would like to hear from more of you folks. I just want to make sure I didn't miss something or could have done something better. I guess its because it was the first time I had something like this happen and I am now second guessing myself.

Edited February 17, 2011 by UGLyEMT

[island emt]

You wrote that on arrival she was sitting in chair, & you used the stair chair to move her to the stretcher, then stretcher to hosp, then stretcher to hospital gurney.

So you had to move her four separate times in total.

How did you move from one to the next? Did you completely lift her or allow the leg to carry some of the load in transferring each time?

Elderly FX's can be caused by the slightest insult.

She probably had a previous FX or breakdown and the multiple moves might have been the final trigger , since you noted no displacement on initial exam ,.

Yet at the ER she has ecchymosis, shortening & rotation.

Been there done that got the T shirt.!!

Always have that high suspicion in the back of your brain.

One Doc calls it your "Spidey sense"

[uglyEMT]

RE island: From the chair to the stair chair we did a complete lift never putting weight on the leg. The stair chair to the cot was to get her in the rig and again we supported her. Cot to hospital bed was a lift with the sheets and the cot. So basically never once did we allow weight to bear on the leg. Yes nothing on intial exam and nothing during reevaluation on the way to the ED. The ride over wasn't too bad as far as bumps and like I said she seemed comfortable and lacked additional pain. Even allowed us to lower her pants to do the visual. It was only at the ED after the final transfer did we see the ecchymosis, shortening and rotation. I just couldn't believe we went from unremarkable except continued pain, no change, to 10/10 pain and a femur fracture in just the time it took to transfer from cot to ED bed.

Another thing after I made the post was that another reason I wanted to use the KED was she would be placed on a backboard, I was actually just going to secure the legs so she could sit up if necessary. I wanted the backboard that way it would have only been one move from the chair to the backboard. Once on the board she wouldn't be needing transfers except with us doing the lifting and her fully supported.

Edited February 17, 2011 by UGLyEMT

[tniuqs]

So when doing initial P/E did you manipulate or check any note decrease in ROM ?

Have you ever used a stethoscope to listen for crepitus ?

And before you ask what am I smoking .. click on the link.

http://www.ems1.com/ems-products/EMS-Equipment/articles/592414-Wait-a-Minute-You-Auscultated-What/

btw You did not fracture this head of femur, from history highly likely pathological condition and complication from a fall but this was done way before you booked location.

At minimum pad and strap legs together, figure 8 of feet ... maybe I missed that in original post, yes visualize even it they are a religious sect that is predisposed to modesty.

cheers

[fiznat]

Well what are you suggesting you should have done differently? Sometimes fractures are not obvious in the field, and clinical presentation can change with time and position. Your case wasn't the first that seemed to present differently in the ED. Don't forget that a "hip" fracture is usually a proximal femur fracture anyways, so the end result wasn't really all that different from what you had originally suspected.

I haven't found that the "reverse KED trick" does all that great of a job for hip fractures. If I suspect a hip fracture I usually stabilize with pillows, use pain control, and get some extra help to move the patient gently. It sounds like you guys did pretty much the same thing.