A.J. discusses standard EMS care failures, resulting in a poor sports knee injury outcome and why the REEL could have made all the difference. ~ 2004
JEMS Editor-in-Chief A.J. Heightman, MPA, EMT-P, has a background as an EMS director and EMS operations director. He specializes in MCI management.
I’m really passionate about fracture care. Perhaps it’s because I grew up with EMS in the ’70s when the “art of EMS” wasn’t starting a difficult IV or interpreting a 12-lead ECG. Rather, it was the ability to relieve pain and suffering by carefully applying splints to angulated fractures.
Back in the “old days,” you completed American Red Cross advanced first aid training before you became an EMT.
Those programs spent hours drilling splinting into your head, as well as requiring you to immobilize fractures and dislocations anywhere on the body.
Every student was required to learn at least two dozen splinting techniques using items you could find in a home, in the wilderness or on an accident scene. We used rolled up newspapers, magazines, tree branches, towels and blankets. We also used the sleeve of a winter jacket and a padded sun visor obtained from a wrecked vehicle.
Although most ambulances in the ’70s carried lace-up TIMMINS splints, padded board splints, air splints and traction splints, the objective was to make emergency responders “think on the fly” and innovate to manage fractures and dislocations wherever they were encountered.
I’m also passionate about splinting because I’ve witnessed and experienced how good (and poor) splinting affects a patient’s short- and long-term outcome. I’ve written before about the devastating, career-ending football injury my son’s close friend experienced. That fracture so stumped BLS and ALS crews on the scene that they wasted close to an hour trying to figure out what to do with it.
They ended up over-medicating and under-immobilizing his injury, and they allowed his injury to move unnecessarily. After multiple surgeries and a year of protracted rehabilitation, he ended up with permanent “drop foot.”
While investigating this incident, I found that the crews involved didn’t carry any splints that could adequately immobilize an angulated fracture/dislocation and opted to move it to a “manageable position” and transport it on an unsecured pillow.
My research of this knee injury also revealed that there were virtually no references in EMS textbooks about the peroneal nerve—an important nerve that supplies movement and sensation to the lower leg, foot and toes. When the peroneal nerve is stretched or snapped, permanent foot drop and other debilitating injuries can occur.
After writing about that situation in JEMS, I learned about the versatile, adjustable Reel Splint system and the Minto Fracture Kit used to immobilize the mangled legs of soldiers after improvised explosive device blasts in Iraq and Afghanistan. The reports from the military showed that these splints were reducing permanent damage and shortening rehabilitation time. Ironically, when I severely injured my own knee a few months later, I applied a Reel Splint to my injury and fixated my knee in the exact position of injury, preventing the unnecessary tearing of remaining ligaments.
My surgeon later told me that if my knee wasn’t fixated in that manner and he didn’t have the remaining, undamaged strands of ligaments to use in the reconstruction of my knee, I would have been subjected to at least six additional months of rehabilitation and permanent limitations in that knee’s range of motion.
Today, I often can’t remember which knee sustained the injury. The fact is, we’ve over-hyped and overwhelmed personnel with ALS skills, and underwhelmed and under-educated them in BLS. We have placed substantial emphasis on new ALS treatment and reduced the amount of time (and depth) spent on the basics.
The majority of our calls are BLS, which means the bulk of our patients could be getting inferior splinting in the field. I witness this firsthand as I ride with crews all over the country and review thousands of photos for possible use in JEMS. I continually find ill-prepared or poorly educated crews who can’t think outside the box and create splints.
Sadly, many services don’t equip their rigs with splints that are adequate to immobilize dislocations and long bone or hip fractures, particularly adjustable angle/position-capable splints.
But most alarming to me is the number of critically injured patients, with obvious fractures or dislocations, who are just slid or rolled onto uncomfortable backboards by ground and air crews under the over-used guise of “rapid removal requirements.”
Their fractures are left “loose” and un-splinted throughout their care, transport and transfer to the emergency department or trauma center staff. This not only contributes to patient morbidity, but it also results in poor messaging to, and confusion by, hospital staff who weren’t verbally (or visually) made aware of fractures and their locations.
Read this month’s article co-authored by Edward T. Dickinson, MD, NREMT-P, FACEP, JEMS medical editor, and EMS educator and long-time ski patroller Jon Politis, MPA, NREMT-P. Then, share it with your crews so they redirect attention to the careful splinting of extremity injuries and proper pain management.