So, today we’re going to talk about what you’d do about the video scenario I posted a couple of days ago. If you haven’t had a chance to watch it, head on over and do!
Basically, the story is that our patient, Lexi DeForest, went for a hike with her boyfriend in Vedauwoo, Wyoming. While hiking down, she fell, landing on her ankle. While her boyfriend headed out for help, she recorded the video you watched. I have to say, I’m impressed with her composure.
So, you’re the responding medic, or you’re the guy that came across Lexi while hiking. What are you going to do?
Here are the things I noticed:
- Broken, or Not Broken? In pre-hospital medicine, we generally teach not to speculate on whether or not a bone is broken or sprain/strained. It’s generally difficult to definitively tell, and the treatment is the same for each, namely immobilization, ice/pain management, and evacuation. In this case, I can say with a high degree of confidence that Lexi has broken her ankle.
- A Little Bit of Blood: I see a bit of blood on her shoe; based on the camera angle, I’m not able to tell if the bone is protruding from the skin (an open fracture), or if she just has some lacerations on the lower leg. I’d want to investigate that a bit further.
- Head/Neck/Spine Involvement: Another question I’d want to answer is if Lexi hit her head or injured her back during her fall. I see she’s already sitting upright, so at this point further immobilization will probably not be a priority. However, this is good information to have.
So, how will we manage Lexi’s injury? As with everything else in wilderness medicine, we have to answer a couple of questions; What definitive care does this injury require, and what can we provide while out here? Can we self-evacuate, or will we need additional resources? How will we get to definitive care? I’m going to answer these questions on several levels, as a WFR/WEMT, and then also as a paramedic.
- C-Spine, head/neck/back: It’s never a bad idea to consider c-spine precautions when first encountering a patient, especially one who has recently taken a fall. I’d argue, especially in this case however, that c-spine isn’t that large a concern. Lexi is sitting upright, and appears to have fallen directly down onto her ankle. To be sure, there is mechanism (there is ALWAYS mechanism…), but we don’t immobilize based on mechanism alone. So, consider it, ask if she struck her head or has pain/discomfort in her neck or spine, even palpate the spine, but then I’m moving on. If she had fallen and not moved since, I may have her stay in that position and performed a focused spine assessment later on. Since she’s sitting up, my hypothesis is she would have caused whatever injury I’m attempting to prevent when she sat up, and so I’m not going to attempt to prevent injury that would have already been evident.
- ABCs: Lexi is speaking well, so she obviously has a patent airway and is moving air without difficulty. I’d like to take a look at that ankle and determine where the blood is coming from. From the video, I just see a little bit on her shoe; I don’t see any spurting that would indicate an arterial bleed, and I also don’t see any active bleeding that would suggest venous bleeding. If I would find arterial bleeding, I’d move directly to direct pressure and possibly a tourniquet. Venous bleeding could be managed with basic pressure bandages. If I were responding at the WFR/WEMT level, now would be a great time to get some vital signs as well; as a paramedic, I’d already be considering drugs for pain management, so a blood pressure would be pretty important as well.
- Pain management: Normally, we think of pain management as a later step in treatment. In this case, I’d recommend getting pain meds on board early, as everything else we do (splinting, lifting, carrying, etc) isn’t going to be comfortable.
- On the WFR/WEMT side of things, options are somewhat limited. The Wilderness Medical Society Practice Guidelines for the Management of Acute Pain in Remote Environments recommends combining Ibuprofen and acetaminophen (Tylenol) for first-line pain management. Giving both produces a multiplicative effect which, I’m told, mimics Percocet in strength and pain-killing ability without the narcotic effects. The dosage would be 600-1000 mg acetaminophen, up to 4 grams/day (that’s 4000 mg), with 600-800 mg ibuprofen up to 2400 mg/day, every six hours by mouth (PO).
- When I wear my paramedic hat, I’m blessed with the ability to provide slightly stronger medications. The most typical pain medications an ambulance medic carries are morphine sulfate and fentanyl citrate, both of which are narcotics. Bear in mind, once we start talking about narcotics we have to keep several things in mind. First, one of the side-effects of narcotics is respiratory depression, so we’ll have to monitor Lexi’s respiratory rate, and pay attention to her oxygen concentrations. Second, another side-effect of narcotics can be a drop in blood pressure, so we’ll have to re-assess that frequently. If we’re considering giving Lexi morphine, the formal dose is 0.1 mg/kg, though some studies have suggested this initial dose isn’t enough to manage pain adequately in many adults. Usually, we give 5-10 mg. If we’re giving fentanyl, which is generally stronger than morphine, the usual dose range is 1-3 mcg/kg (micrograms); generally, most medics will give fentanyl in increments of 25, 50, or 100 mcg. The great thing about fentanyl is that it doesn’t effect blood pressure quite as much as morphine, but it also doesn’t last as long. I’m an advocate for titrating narcotics for effect, rather than simply using weight to determine how much to give; I’m also a fan of starting low. Here’s what I mean; Lexi appears to be in the 125-130 pound range, so that’s around 55-62 kg (Lexi, if you happen to read this and I’m way off, I apologize!). So, if we’re using Fentanyl at a dosage of 1-3 mcg/kg, we could give Lexi anywhere between 55 and 180 mcg of Fentanyl. That’s a big range! Narcotics effect people differently; folks who are not used to strong medications will feel more of the effect than those who have been exposed to them in the past. My suggestion would be to start small, with 50-75 mcg and then re-assess after a few minutes. If the pain is still pretty severe, we can always give more in 25-50 mcg increments until we’ve taken the edge off. On the other hand, if we start with a high dose, we can’t take medication back if we start to see signs we’ve given too much (suppressed respiratory drive, etc.). We can give these drugs in a variety of ways; if we’re able to start an IV and then maintain it, we can give them that way. If not, it may be better to give the meds as an IM (into the muscle) injection or using a nasal atomizer, up the nose (intra-nasal, or IN).
- I’m sure several of my twitter friends will discuss various other medications for the management of pain once they read this; this is a topic medical folks love to talk about. If I don’t get at least one comment about ketamine (I’m looking at you, @ketaminh), I’ll be disappointed. I didn’t include discussion of these alternative medications here simply because I don’t have much experience with them. I’d welcome being educated.
- A side effect of narcotic pain management in some patients is nausea. Bear in mind, severe pain can also cause nausea. We should be prepared to manage this. If we have some favorite non-pharmacological methods for doing this, let’s do it! If not, and we’ve got access to drugs, 4 mg of ondansetron (Zofran) may go along way. Zofran can be given IV, IM, or IN.
- Immobilization: One of the best ways to manage pain is to properly immobilize the injured extremity. This keeps it from bouncing around, and keeps the bone ends/injured tissue from moving. In Lexi’s case, I’d want to first determine if she has pulses in her foot; this will determine if I attempt to move the foot back into line in an attempt to re-establish perfusion, or if I’m going to leave it in place and splint as is. In the video, Lexi says she has feeling in her foot, and that she can move her toes a little bit. This suggests to me that she probably also has pulses. If we would have to move her foot back into line, we’d get one chance to re-establish pulses. If our attempt was unsuccessful, we’d splint and go. I’d guess that attempting to re-align Lexi’s foot would not go very well.
- Evacuation, with Monitoring: Once Lexi’s leg is immobilized, we’ll carry out in a Stokes basket, evaluating the injured leg for pulses, sensation, and skin color/temp/moister, and vital signs looking for signs of too much pain management and general deterioration. Lexi is going to need a surgical center, and one with orthopedic specialists. I’d lean towards taking her to the larger, “trauma center” hospital over the local community hospital.
So, those are my thoughts on the management of this injury. If you have ideas, or want to educate me on some alternative mountain pain management strategies, as I’ve said many times over the past several years, “a good paramedic is always learning.” Have at it in the comments, or on twitter using #wwydwednesday. good news; Lexi has posted several updates on YouTube, So I can leave you with some closure: