Barbaric Limb Splinting

[Asysin2leads]

That's my new acronym for BLS. Now before everyone gets up in arms, let me recite the paramedic's pledge.

"I do solemnly swear that BLS comes before ALS because EMTs save paramedics, airway, breathing, circulation and that children are not little adults, so help me, my medical director."

That being said, having suffered and currently recovering from a shattered distal humerus, I have gotten a new view on what is considered BLS care, and unfortunately, its not a really pretty picture. I cannot any more accept that manipulating orthopaedic injuries with BLS techniques alone is acceptable modern medical practice.

I had a very bad break. The lower half of my upper arm was in several pieces and the radial nerve was being crushed between the bone ends. I was very lucky, though. I had an excellent prehospital care team that was able to supply some amount of pain relief and did some of the best prehospital orthopaedic care I've ever seen. It was still some of the worse pain I've ever been in, and I came very close to losing significant function in my hand. Luckily I'm making a full recovery. A lot of people who dial 911 are not anywhere near as fortunate as I am.

We think of the sprains and strains as the "minor" calls that maybe some of us roll our eyes at while hoping we get a "real" call, but I think its high time we approach prehospital pain relief and orthopaedics with the same attention we give STEMI's or multi-trauma victims.

While I was sitting in the cast clinic, I saw a sign saying something to the effect that good casting is an art that combines psychology, engineering, medicine, and artistic talent. I think that's very true. Why don't we start moving away from the first aid kit we have left over from World War II and towards modern orthopaedics? BLS transport should become a thing of the past, IMHO, and if the best an area can do is EMT-I, then let's find a pain medicine that even they can't screw up.

We shouldn't be proud of our current standards for injuries. We need to focus less on the big ones we can't do anything for and more on the little ones that we can make a tremendous difference in.

Edited January 4, 2012 by Asysin2leads

[BAYAMedic]

That being said, the best crew I have worked with in the field in regards to orthopedics is my former Ski Patrol crew. When packaging up 3-4 "snowboarders wrist", or Skiiers knee, or ulnar boot top Fx per weekend, you got the practice to do it well. When the only pain control you have is your soothing voice, well timed distraction and a shredded wool GI surplus blanket for padding. You learn to play with what your dealt.

Fireman1037

[scubanurse]

I agree wholeheartedly! I recently had to call our local 911 service in a blizzard because my shoulder dislocated and I had no one to take me to the ER. With obvious deformity and an incredible amount of pain, all they did for me was blow 2 IV sites, try IN Fentanyl which didn't do jack because it all came pouring out my nose anyways, and put a loose sling on my arm, no swath to help stabilize for the bumpy snowy ride in...

I don't see why EMS can't spend a good bit more focus on various ortho injuries out there... EMS is more than respiratory and cardiac. Practicing and learning to splint better should be a high priority.

So sorry about your arm!!

[b.anderson]

From a post-BLS student perspective: I agree. I found that during the EMR course (equivalent to EMT-B in Washington) there was a strong focus on respiratory, and cardiac emergencies. In whatever spare time we had we'd talk about splinting and throw in some pain management stuff as well.

Luckily, in BC, EMR's and above are licensed to use Entonox for pain management. It's difficult to mess up, and the only way you can is by failing to rule out the contraindications. Basically, 50% nitrous oxide and 50% oxygen mixed together, and self-administered by the pt. with a bite stick they suck on to get it out. It works quite well and gives us BLS folks something to work with at least--though it's certainly not as good as anything that can be pushed through an IV. I know it's not commonly used in the United States, if at all. Here's the drug monograph for anyone who isn't familiar with it: http://www.paramedic...mc/Entonox.html

Even though we're licensed to use it, it's not emphasized during the course work. I find that, at least in my experience emphasis is put on "the other stuff": cardiac, respiratory, spinal, patient assessments, etc. It doesn't take much experience to realize that a pt's main concern is simply when their pain will be gone in most trauma and medical cases. That's not to say emphasis should be removed from any other topics, but I do find pain management is something that's rushed through, at least in the EMR courses. I can't say anything for EMT-B courses, or the NR.

As far as splinting and limb management goes, I'm only really in a position to say that just like pain management, splinting and limb management should have more emphasis. At times it can be just as important as proper spinal management, especially in pt's with a polytraumatic MOI. (I recently learned that term here on emtCity--so thanks!)

I'll be the first to admit that I personally am not the best with splinting, and with all sincerity, I hope I'm not the best in any other areas either. It would be a sad day for EMS. Faux self-loathing aside however:

I agree more should be done in the way of educating students of the importance of pain management and splinting. I'm only familiar with the BLS ways of dealing with orthopedic injuries, so I can't form an educated opinion on if they should be dealt with in any more capacity than BLS. I'll trust the far more educated though that there are likely better ways to deal with said injuries apart from the way BLS is taught.

Speaking of the far more educated: what are some common things that irk you when you see BLS managing orthopedic injuries? Of course within the limited and varied protocols we have to work with, I'd like to do the best I can.

All the best,

B. Anderson

P.S. Asysin2leads, accept my best wishes for a full recovery.

[scubanurse]

+1 for a post with links to pertinent info... kudos and welcome to the city!

As for your posted question, my suggestion is try to think as far out of the box as necessary. Splint boards are great...but aren't that easy to conform to an angulated forearm fracture. Use your environment and the patient's belongings if necessary to aid in splinting. Also, practice practice practice and more practice. You can not possibly go through splinting scenarios enough in my opinion. No two fractures or dislocations will ever look the same so try and practice different possibilities. As with much in EMS, challenge yourself to be more creative and find a better way to do something.

Again, welcome

[Just Plain Ruff]

If I have the time I always pre-medicate with fentanyl or morphine prior to manipulation or splinting any type of obvious fracture or if the patient appears to be in pain.

Why cause more pain than you have to when if you are a medic and have the protocols to give Narcs on standing orders for pain relief. If you aren't giving pain meds to a patient with a suspected fracture prior to splinting or moving them I just don't understand why not!!!!

When you are the patient and you have a broken bone or something that really hurts and you don't get some pain management and then the crew begins to manipulate or splint you, then you will understand just as Asys did that pain relief is mandatory for this type of treatment.

Besides, what does it hurt to give them pain relief for their pain? It's not your ambulance bill nor your emergency so why not give what you have to give in your arsenal.

For those of you who don't have standing order in your protocols to give narcs for suspected fractures or significant pain then I feel sorry for your patients.

[Happiness]

I also give entonox for pain relief for any suspected fracture. When I first started with BCAS all I need was the OFA 3 course and apperently I was lucky to have an instructor that made us do alot splinting and trauma packageing. I have used pillows for ankles, Sam spints and metal flexable splints for arms. To help stablize shoulders and clavicals I use a towel up into the arm pit and zap straps to hold the arm in place. When dealing with hips or femurs zap straps and a blanket are my best friends. And if it is with in my guidelines they get the entonox asap.

The one thing I never really understood during classes was using the Segar splint in trying to convince a pt that me pulling on their leg and applying this contraption was going to make them feel better until I actually used it. I asked this particular Pt if it was true and she said the relief was amazing.

So I guess back to the original theme, I would like to be able to completely eleviate any of my pts pain to 0, and I have found that entonox has been a good to get most of the pain at least down to a 2. The one call that comes to mind in useing all of my resourses what a 20 yr old Dirt bike accident. He was wearing a helment thank god, was riding down the beach hit a rock, went over the handle bars, wacked his head on a rock, flipped and smacked his hip on another rock. He heard and felt the snap of his femur. Did a complete spinal and femur stablization with zap straps gave him the entonox for relief while we packaged and moved him. By the time we got him to the hospital which was 5 min away his leg was 3 times its normal size, so with that in mind in using the straps is that you have to keep evaluating and adjusting the straps so that it dosnt turn into a tornique.

[Asysin2leads]

That being said, the best crew I have worked with in the field in regards to orthopedics is my former Ski Patrol crew. When packaging up 3-4 "snowboarders wrist", or Skiiers knee, or ulnar boot top Fx per weekend, you got the practice to do it well. When the only pain control you have is your soothing voice, well timed distraction and a shredded wool GI surplus blanket for padding. You learn to play with what your dealt.

Fireman1037

That being said, it wasn't you who had to play with the hand you were dealt. It was your patients who had to play. That's why being a patient was such an informative experience. I'm sure you're proud of your soothing voice and shredded GI blanket, but your patients probably were not as impressed.

Happiness: I don't think the use of any analgesia currently on the market can bring pain down to a zero. The other thing I learned about in the hospital is a nerve block. Its what they did on me prior to surgery. That made any pain a 0. Of course I couldn't move my arm for a good 12 hours or so. I liked Entonox not so much for its analgesic effects but for its dissociative effects. For me it kinda more dulled the pain, which was definitely still there. Morphine, fentanyl, dilaudid, they're fun and they do work to some extent, and the euphoric side effects are a nice distraction, but still for pain control in an acute injury they can be lacking.

Which brings us to multi-trauma victims. Poor, poor, conscious multi-trauma victims. Pouring water in someone's face to elicit information is in some circles considered unethical. But strapping someone with several broken bones down to a hard plastic board and taking them over rough terrain is considered proper medical procedure. For these poor souls, I would suggest conscious sedation. Even if they're AMS. Even if they're hypotensive. There's no contraindication against giving a hypotensive patient benzodiazepines, only cautions. I think we are so focused on rapid transport with trauma patients that somewhere along the line we forgot that when you're in that state, no transport is rapid enough. Until we invent the Star Trek teleporter that time between we pick them up, deliver them to definitive care, and definitive care does its thing, is usually an unacceptably long time for a patient to be in agonizing pain.

Edited January 4, 2012 by Asysin2leads

[Just Plain Ruff]

I think that we in EMS and Healthcare in general need to be a patient.

I remember a movie, can't remember the title but it William Hurt playing a doctor (educator) with Cancer. He took all his residents and put them in a empty wing in the hospital and gave them each a fictitious diagnosis from UTI all the way to Cancer.

He then made them go through all the tests and procedures and little nuances that patients go through. He even brought nurses down to do the actual nursing tasks.

This gave his student's/residents a greater understanding of what it's like to be a patient.

I wholeheartedly agree with this approach. It will make your perspective change. And if it's a real condition and not a fake one then all the better.

Asys you will be a better medic for going through this situation and I know that when I had my Migraine which took boatloads of narc's(and I mean boatloads) to get rid of(ask me and i'll tell you sometime about it), I had a completely different outlook on how to deliver healthcare than I did going into the situation.

[Asysin2leads]

Oh, and thanks for all the well wishes. I'm progressing along pretty quickly.