Barbaric Limb Splinting

[Happiness]

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.

I had a nerve block once when having a tendon reattached in my index finger and your right there is no pain until it wears off . I dont disagree with your comment on slamming a trauma pt on hard surfaces and having straps tightened on broken boards but if you make sure there is alot of padding on both the board and around the straps this does minimize the any further damage and pain. Now with that being said if you have done your job to the best of your ability you will have some idea of where the broken bones are and you then dont tighten the straps in that area, you move them so they dont go over the injury. I have only had to pack one patient a far distance http://www.queencharlotteislandseh.com/parks/tow_hill/index.htm this will give you an idea of the terain and if you think the wooden pathway was easy it was slippery as hell and was not strether safe so the clam shell was used. Anyway the pt was elderly and slipped and the end of the path, she had a very broken ankle, we took the time to make sure everything was padded well and with the help of others packed her out. She was given entonox from start to finish and in the end she said it wasn't as bad as she thought it was going to be. By the way the roads to Tow hill are even more horrible with pot holes etc.

One thing out station does is make sure the everyone gets a code three ride laying on the stretcher so they know how it feels for the ones in the back.

Now also experience has a big part in the equation, and by that I mean I dont feel the panic I once did on calls and am very compfortable being in the back longer if it means more compfort for the pt. And if my driver is not driving to what I want I will say so.

[b.anderson]

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.

I appreciate the advice, and agree with you. I'll use this as incentive to get some more practice in and learn more. Thanks for the warm welcome! I've been enjoying my experience here so far.

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.

Well said. I can't say I envy your experience as a patient, but I can appreciate it as an informative experience.

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.

Entonox isn't the best, and there are much better alternatives that you've described. We were given the opportunity to try it in class and it certainly doesn't get rid of pain, but it as you said does disassociate you from it (though, my experience was only with newly inflicted pain, not withstanding pain. I doubt it makes much difference though). Though, I am thankful that BLS in BC have access to it. I'd have to assume that some pain management is better than none. I've discussed this with some EMT-B friends from the US. Most of them don't have access to it (in fact none that I know actually have access to it) even though it's widespread in Canada and in the UK.

ALS is definitely better equip to deal with pain management. I can't disagree with that. I'm not sure about fracture management however, I'm only somewhat familiar with the BC EMA fracture management protocol and it's the same across the board for EMR, PCP and ACP levels. Link to the relevant protocol here. So from what I gather the point is basically that ALS can provide better pain management thus better fracture/orthopedic injury management?

As a side note (for unfamiliar or not in BC), ACP's in BC have an additional pain management protocol with Morphine and Nitrous Oxide. I'm not sure if they have anything else though, the protocol I looked at only included Morphine and Nitrous Oxide in addition to the separate pain management with Entonox protocol.

Forgive the long winded post.

All the best,

B. Anderson

[Bernhard]

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.

Midazolam, ketamine (no problem with hypotension), lift with scoop stretcher on a vacuum mattress (no problem with comfort), if long/bumpy transport and appropriate flying conditions call a HEMS soon (at night just expect a bit more effort with preparing LZ). Anything else? Next, please!

Yes, I love my vacuum mattress and my scoop stretcher, won't trade them for a spine board, which has it's advantages but just not in transporting patients on it. Oh, I love my drug kit and an available HEMS at night, too. Yes, I hate it, when those available tools aren't used properly...(BTW, in our yesterday's training session we coincidently played with all available splinting systems).

Whistling classic Star Trek theme when helicopter starts: priceless.

Edited January 13, 2012 by Bernhard

[Bieber]

So we got a preview of our new protocols (which are, for the most part, awesome), and they made a forum for us to post our comments, concerns, questions, etc. in and I (predictably) have been posting a lot of threads there, but one thing I hadn't tackled yet was the pain management protocol (yes, we finally have a dedicated pain and nausea protocol now). However after reading this, I was motivated to do so and have inquired into the possibility of adding a sedative to our pain protocol, based in large part on this thread. So thanks Asys and I'll let you know if we get it!