Tricky Horse Rider

[firedoc5]

I grew up raising and riding horses so I felt comfortable where we had one call. I had three others with me (don't ask). Luckily my EMT-I was a rodeo rider. The other two, nervous.

OK, Call of someone fell off a horse, not uncommon in our area. When we get there. 35yr. old man. Horse slid while making a cut (turn) and laid on his left leg. The same horse and two others running around the pen. Obvious compound fx tib/fib. The patient's boot actually between tib/fib, minimal bleeding. Inward rotation of left leg with shortening. They finally do get the horses out of there. Question, do you give MS for pain at this point? Also, do you do full spine immmob.? Pt. breathing about 24 but hard to assess due to pain. We do put pt. on O2 per n/c. Nurse on radio actually asks how we know that there is a tib/fib fx. without x-ray. DUH!

How would you treat and transport?

Didn't know to put this here or in Scenarios, but...

[spenac]

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.

[firedoc5]

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.

Jeff (my EMT-I) and I did, the other two wouldn't (wussies). Not a good way for me to help cert. them.

We did go with full spinal immob. All vitals normal other than the eradict resp. No chest pain or trauma noted. No meds, no allergies. Note that some mud in leg wound with the compound fx. Top of boot still impaled between tib/fib. Pt. also complain of right wrist pain, slight edema to right hand.

[AZCEP]

One IV would be plenty. I'd guess from the given information the patient has a blood pressure enough to get some pain relief. Allergies and meds would be good to obtain first. Some morphine, cut the boot off if you can, immobilize, transport.

[firedoc5]

One IV would be plenty. I'd guess from the given information the patient has a blood pressure enough to get some pain relief. Allergies and meds would be good to obtain first. Some morphine, cut the boot off if you can, immobilize, transport.

But to what extent do you cut the boot off?

[spenac]

But to what extent do you cut the boot off?

All the way if possible. It definitely needs cut to avoid constriction.

[AZCEP]

I'd cut as much of it off as possible. Using the analgesic prior to attempting would greatly facilitate doing so.

[firedoc5]

When this was presented to some EMT students in a class I was helping with I had answers of leaving the boot on, cut the boot completely off and removing it from in between the bones, cutting off the sole only. What I was trying to convey to them was to cut the boot off but leaving the top of the boot which was impaled between the bones. Reminding them, "Never remove an impaled foreign object." It didn't occur to some that it was an impalement. But you also want to be sure that the tib/fib did not recess back into the leg, causing more muscular and vascular damage. And if possible, irrigating the would with NS.

Since there was minimal bleeding and BP stable. Just one IV needed to be established. Later in the day I ran into the Ortho that did the surgery on him and he said that just the one IV was sufficiant as long as it was at least an 18g. I asked him because I put in a 14g. and debated another IV anticipating surgery. If another IV was needed it would only would have been established for meds. in OR.

[JPINFV]

Without a picture, would it be more of a wedge than an impalement? Based on the description, it sounds like the foot either inverted or everted (really doesn't matter for the basis of this discussion) and when the bone penetrated the skin, the boot slid into the interosseous space. This isn't exactly a penetration since the boot didn't break anything itself. Now if the boot is doing something useful, like say, preventing the bones from reducing themselves (albeit it sounds like the patient was going to have some fun with osteomyelitis regardless), it doesn't sound like this case fits the text book reasons for not removing an impaled object (tamponade and preventing additional injuries).

[DwayneEMTP]

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

Reminding them, "Never remove an impaled foreign object." It didn't occur to some that it was an impalement.

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.

But you also want to be sure that the tib/fib did not recess back into the leg, causing more muscular and vascular damage.

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