Pelvic Fractures

Originally posted on Little Medic:

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Epidemiology: 

  • Pelvic Fractures occur in 5-11% of all major blunt Trauma 
  • Early Suspicion, Identification, Management and Triage are critical for good outcomes
  • Mortality is between 7-19%. (mortality increases to ~50% in open pelvic fracture)
  • The Most Common Mechanism of Injury resulting in pelvic fracture is MVA (Motor Vehicle Accident)

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Recognition:

  • Springing the pelvis is BAD! don’t do it! (springing to asses for fracture has a specificity of 71% and a sensitivity of 59%, suggesting that routine use of this examination should be abandoned.)
  • Instead, pain, MOI and S/Sx should be sufficient indication for management and radiology.
  • In this study, 90% of pelvic fractures involved the Pubis along the Rami.
  • In the Gonzalez et al‘s study ( Gonzalez R P, Fried P Q, Bukhalo M. The utility of clinical examination in screening for pelvic fractures in blunt trauma. J Am Coll Surg 2002. 195740.) of patients with GCS 14 or 15, the most common positive finding in patients with pelvic fractures was…

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Pelvic Binding and Prehosptial Traction Splinting, Results of a Survey

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Ove the past few months I’ve been running a Poll via word press and eventually a more comprehensive survey on the use of Prehospital Pevic Binders and Traction splints

The G+ Conversation that started it all

Over all I’ve had 75 responses to the survey. While this is by no means exhaustive it provides a basic idea of what the world are doing.
Respondants were sources via twitter and came from Australia (various states), UK, USA, Canada, South Africa, Scotland, The Middle east, Ireland and Sweden (listed in prevalance of response).

Brands of binders: SAM II, T-POD, Bedsheets + Clamps, Promethus Binder, KED.
Brands of Traction Splint, Donway, Hare, CT-6, Sager, Trac 3.

88% indicated that pelvic binding was indicated by their service and they have equipment to perform it.

97.33% of respondants are using a Traction Splint on Femur Fractures w/o pelvic trauma.

 48.54 %of respondants indicated that their service had in place a protocol for dealing with multi trauma of pelvis/femur.
22.06% indicated no guidance for Pelvic and Femur traction concurrently.
13.24% have a protocol but it isn’t routinely applied by clinicians and 16.18% indicated that they don’t have a protocol but providers have applied it.

Respondants included, Paramedics (Road and Air based), flight RN’s, Students, Numerous Doctors from all around the globe. 
Doctors were the most international group and paramedics came a close second.

While this was in no way intended to be exhastive research into what is applied as standard it was intended to give a general view of the Prehospital managment of specific traumatic injuries.
In the absence of evidence we practice based on concenus opinion. The responses were gathered by me for the purpose of better understanding what the Prehospital Community is doing world wide with there pelvic and femur fractures.

Thanks to all respondants, I hope this serves as a gathering of a small ammount of information to enlighten you as to the current state of play.

If anyone ever wants to talk about this, bring along the evidence your service or hospital is using and we’ll get a podcast going

 

Resources;

Institute of Trauma and Injury Managment

http://www.aci.health.nsw.gov.au/networks/itim

Adult Trauma Clinical Practice Guidelines; Managment of Hemodynamically Unstable Patients with a Pelvic Fracture:   

http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0011/195176/Management_of_Haemodynamically_Unstable_Patients_with_a_Pelvic_Fracture_Full_Report.pdf

If your still hungry to learn more:

Initial management of pelvic and femoral fractures in the multiply injured patient

Amer Mirza, MD, Thomas Ellis

http://www.ubccriticalcaremedicine.ca/academic/jc_article/Pelvic%20and%20Femoral%20Fractures%20in%20Multitrauma%20Management%20Review%20(Feb-14-08).pdf

Featured image from:

http://www.emcram.com/showimage.asp?ID=89

Some of the information provides during the talk.

http://www.fphc.co.uk/content/Portals/0/Documents/2013-12%20Pelvic%20Consensus%20COMPLETE.pdf

 http://www.ncbi.nlm.nih.gov/pubmed/11239259

http://www.swissrescue.ch/dossier/traction_splint/traction_splint_angl.pdf

http://regionstraumapro.com/post/19178815208

A Link to the podcast it will be in your I-Tunes shortly. If you haven’t subscribed, please do! Leave a comment, recommend me to your friends.

 

 

I’m back, finally

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Sorry for the silence over the last little while, be assured the podcast and blog will be back in full swing shortly, I’ve now relocated from Metro to Rural,unfortunately the process behind that left me rather busy between relocating and working my job, I’ve not had much time to put words to paper.

The blog will remain the same, the podcast should increase! Lets see what the future brings.
All I ask is that you remain loyal throughout this transition period!

Mitchell Thomas
DSCOT Blog.

Scene awareness

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In the same vein as my last post today I want to talk about Scene Safety, a fundamental of paramedic response.
But something we placed at the start of the DRABC algorithm to our detriment.

When I went through university the “Scene Safety, BSI” was a 1 second mantra we used to say upon entering the room
While this works in examinations its not really training or preparing students for the real world.I can attest to this, I used to do it. Especially when your new its easy to get focused on what you need to do at the expense of all else. Making split second critical decisions on a medical patient comes easily to us, however my partner an I have often had long discussions over if we want police present or not. The conversations have gotten shorter over time as I now do a lot of the risk assessment in my head and communicate my results of that to my partner, rather than the open consciousness approach that was encouraged as a student.
As medical personnel we are used to the idea that the primary and secondary survey are to be repeated at any sign of deterioration or change in the patients condition.
Why don’t we have the same attitude towards our scene safety.

New person enters the room : re assess scene
pt changes location in the house; re assess scene
car pulls up out front; re assess scene
about to depart scene; re evaluate, ensure pt is ready for transport, ensure pt is safe for transport.

What do I mean by all this.

When someone enters the house you want to have a good idea of where they are, ideally one officer should approach them to maintain your workspace while you assess and treat. I’ve had people shatter most of the vials in our kit because they were jumping over it and landed dead center on the drugs bag (note; this is not paperwork you want to do….) this was a failure on our part to control our workspace and recognise issues involved with family arriving on scene. While some family remain calm and collected in the corner, asking few questions and waiting for us to do what we need to do some react completely the opposite. They will try and be as close to you as they can, asking questions after every single thing you do. They may be aggressive, they may be confrontational or very standoffish.
People react to stress in different ways, its up to you to anticipate and monitor this continuously! Don’t assume that because everything starts out calm and collected that the arrival of an inflammatory family member won’t completely change the situation from safe to hostile.

When a situation is moving towards unmanageable, family members are getting to close or aggressive I have a very simple escalation process for communication of my intent and plans. Everything is said very simply, so I know, my partner knows and family know.
Obviously if there is an immediate threat of harm jump right to the last step.

1. “Sir/ Ma’am, the way you are behaving is scaring me, could you please give me and my partner some space”
2. “Sir/Ma’am, if you continue to behave in this manner I will leave, this is your last warning”
3. ” I’m leaving, your behavior and actions are threatening and I feel I am in immediate danger

I’ve found that by the time I’ve given the second warning the family have usually shunted them to another room or put them in their place.
I’ve found meeting aggression with aggression to be a failing tactic that only ends in trouble.

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If there are people armed with weapons, or physically aggressive towards me or bystanders on scene its a very quick press of the duress alarm followed by movement to the ambulance and a safe location.

Intoxicated patients and you; scene awareness, some sage wisdom and going home safe

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Now for a story in many metro stations round Australia and the world Friday/Saturday nights wouldn’t be complete without the call to a 16/17/24 year old male or female with the chief complaint of “drunk” the call comes from a bystander, parents , hotel security or the patients themselves.

The drunk patient can be one of our most dangerous, frequently paramedic assaults occur in the setting of an intoxicated patient.

It’s isn’t solely focused on the intoxicated patient, scene safely should occur at every job, never let any part of your work become a routine job, don’t only become alert for “dangerous jobs”
I once did a job where police were on scene after a house had been attacked with bricks, pieces of metal and wood as well as tools, we assumed because police were on scene that it was safe 10 minutes into talking to the occupants we heard crashes and windows smashing, the house was under attack again despite the police presence. Never assume that because a scene begins as a safe scene that it will remain that way. Never take police presence to be an automatic indicator of safety.

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That’s the wrong danger zone…..

My scene survey focus is on the areas of

Me; what factors are affecting my ability to operate, how do I feel about the call ( if any doubt hold off and await police), am I highly stressed, hungry or fatigued this will affect reactions, situational awareness and mood.

The environment; personal dwellings, public locations, busy pub, the location of the call effects how we act and react, in busy locations the focus is on putting us in the safest location so moving a patient quickly to the ambulance is usually the key here not remaining in a large crowd of people at various states of intoxication, weapons ( purpose made and incidental, anything can be a weapon when swung/ thrown at you)

The patient: has any specific information regarding violence or aggression been stated in the call info, I will usually pause for 10 seconds outside most front doors and listen before knocking, try and gleam some info from inside before everything is focused on the outsiders that have just entered. If police are on scene we can usually gleam some information from them regarding the patients status with police, we’re also now lucky enough to have warning notices on our computer system of assaults and aggression in the past.

Now for a case; this is what you need to be prepared for as you move into paramedics, this if you are a seasoned provider will sound very much like a familiar story to you.
this doesn’t relate to any call in particular it is a amalgamation of my stories and those of others.

Your called to a 16 year old male, who has been picked up by his brother and brought home to his parents following calling dad while intoxicated.
The family have called you in to assess the patient

Your dispatch info is as follows ” ct; 16 YO M conscious and breathing, caller statement ” pt drunk, ? Alcohol, no police please”. At the address 123 Fake st in Janice Heights.

You arrive to the address a nice enough well lit house on a quiet street, your greeted at the door by a concerned brother of the patient who leads you the Lounge room.
The patient is roused by his family members and immediately upon seeing you stands up and begins a sentence of profanity directed at you and your partner. Including threats of assault, physical and sexual and general disrespect towards our profession.
The family are quick to attempt to dismiss your concern, “he’s not like this usually”, “he’s not violent”, we can clearly see our presence here is aggravating the patient,

Let’s stop here, I think we have all the story we need, if any patient demonstrates aggression, keep your self and your partner safe, don’t feel compelled to stay, the situation has the potential to go badly for you.
There’s no reason to go to the hospital as a patient. Explain what you are doing to the patients family and leave the scene, it important to go home safe.
If the patient requires assessment stand off, await police and go back to the scene. Don’t stay in a scene with an increasingly hostile patient if you have the opportunity to get out then do so before you become trapped.

Some advise I received from some senior paramedics during a staff development day (distilled from 30- 40 minutes of conversation)
Further more to the safety of you try not to position equipment behind you if your hurrying out of the scene it becomes a trip hazard.
Put your self between the patient and the exit, plan your path out of the scene and try and keep the doors open.
Establish who’s in the house and try and keep tabs if your uninvolved in treating and assessing the patient your job is security. Keep your situational awareness up and keep your wits about you.
Carry a powerful pocket torch with you, illuminating scenes that may not have the best light for various reasons ( I also think you should carry a small pocket lamp for pt assessment and treatment)
Try and talk and reassure patients that are agitated a fair amount of aggression can be mitigated by attitude
Learn to recognise an unsalvageable and potentially dangerous situation.
If in doubt call your friends with guns, tasers, and training in dealing with violent and aggressive people.
Always trust your “gut” “spidey sense” if it’s feeling bad it may well be.

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Stay safe out there

The Graduate Paramedic experience

I originally started this post during the end of my supervised period of time on road and prior to going back for qualification to Graduate Paramedic

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Last shift ever at Liverpool as a trainee

Having gone though almost all of my supervised inroad time now I can say to all you grads who will be walking into jobs soon that it does get better. It will take you some time to find how you work and don’t be surprised if you have to try a few ways of practice that don’t work with you before you find your system.

The first few shifts were crazy, I was exhausted most night’s, the learning was at a lightning pace, I had the privilege of joining the ambulance in the traditionally busy period for most ambulance services. This left little time to consolidate my knowledge between jobs.
But wow, initially I questioned what I was doing, I’d been through 3 years of university and numerous placements and even worked with defence in a medical role. I remember remarking to my initial training officer that I was wondering what I had signed up for initially.
My first training officer was amazing she didn’t even attempt to teach me anything clinical, her focus was on scene safety, looking after your partner and using the radio effectively.
My second training officer placed detailed patient assessment above all else, performing a complete exam on patients and asking relevant and specific questions.
My third training officer was clinically one of the best, her skills are wasted on the General Duties cars.
My forth training officer was a station officer and often spent time as a manager so he was a great source of information regarding all items of administration and operational protocol and procedure.
My fifth and final training officer was a new P1 it was a great opportunity to have roles reversed at that point I had been practicing as a qualified paramedic trainee longer than she had been a P1 it was a great opportunity to help her through her first LMA insertion, cannulas and running a cardiac arrest.
That roster really solidified my confidence and comfort in my skills and abilities before I went back for my qualification course.

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Flare training

I was lucky at all times to have amazingly supportive team surrounding me from management to other on road staff, when you spend 12 hours with people a day you get to know them well.

As far as my programed training went there was a period of 5 weeks induction on campus at Rozelle a minimum 12 month rotation as a trainee onroad and. A further 3 weeks in the education center.

Its easy to be sucked into the fear mongering of other students and staff who all detail their horrible experience as trainees, I’ll be the first to say the reception I had as a grad was nothing but professional and warm.
There are some out there that are still opposed to Graduate Paramedics, its our job as Grads to show what we have to offer, show our selfs to be willing to learn and check any ego we may have at the door.
Ego and aggression towards other providers have no place in the team sport that is out of hospital care. For the most part this isn’t an issue.
paramedics attracts a certain type of person these days.

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Holding my P1 Certificate to Practice

I’m now a qualified paramedic in a busy metro center, one of the busiest in NSW, but thats all about to change.
I’m about to go back to learning, learning how to be a rural paramedic.

Maybe undertaking some further education.
Stay tuned for more

This post has been sitting in my draft box for 6 months now, I wrote it towards the end of my Graduate Trainee year, coming into the stage where I was about to head back to Rozelle

 

Time to talk; getting good on the radio

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Time to talk about talking. Lots of my work involves communications.
Be able to give a report in a format recognisable at the other end is invaluable. Ensuring your not leaving out crucial information that needs to be communicated to dispatchers and managers involves some preparations.

When I was in the military we used to give all out reports by proforma precisely planed encoded reports to ensure both ends of the radio knew what they were talking about.
While the message no longer needs to be encoded information still needs to be passed.

To this day I still use proformas for my important radio reports. I’m currently using commercially available cards however if you have access to a printer and a laminator I’d highly encourage you to have a go at making your own.
I’m not a huge fan of using notebooks when I have gloves on, and I love that I can fully clean the surface of the card if it becomes contaminated.
I think this is just another case of prior planning to prevent a poor performance

Interesting ECG and why you should use a 12 lead

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I just wanted to quickly post up an interesting ECG, in the past this ECG would probably have been missed by ambulance 3 lead monitors, in a pt without chest pain nothing would have been though of it. This is why, almost every in almost critically ill patient I will attempt a 12 lead, not only to try and give me a full picture of what may be occurring with my patient but to avoid delivering the wrong pt to the wrong hospital and bringing a delay in treatment.
We love sexy pelvic binders, CT6s and exciting trauma procedures. But I think the 12 lead needs to be treated with the same reverence. The more information we can gain about our pt the better we stand to be in the handover.

Pre Hospital Pelvic Binding and Femur Traction Survey (Directors Cut)

Head over to survey monkey and take my quick 6 question survey on Prehospital Pelvic Binding, I got a feel for the topic with a limited one question survey 2 months ago, It had 38 Respondents, I’m looking for more!

Please get this out around the world. I’ll be doing something exciting with the results, more to come on that.

https://www.surveymonkey.com/s/RKWG5BK

Thanks for your time

Mitchell Thomas
@jrparamed on Twitter

http://dscotblog.com/2014/07/23/prehospital-pelvic-binding-and-femoral-traction-poll/ previous post can be found here

Training Podcast show notes

The podcast really speaks for its self, most of the items we used were from the local hardware store or peoples sheds

http://en.wikipedia.org/wiki/Moulage

The Cannula trainer, easily made from items at your ED or ambulance station.

http://dscotblog.com/2014/04/09/the-elcheapo-cannula-trainer/

You can find the podcast over on Itunes at the link below.
If your not already a subscriber add me and leave a comment, make the show easier to find.

https://itunes.apple.com/au/podcast/downstairs-care-outthere-podcast/id876296199

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