September 12, 2007
Posted by Jim Macdonald at 03:39 PM * 207 comments
Let’s talk about skeletons for a bit.
Our bones have all kinds of functions. They provide shape. They provide support. They allow movement. They provide protection. They store minerals. They produce red blood cells.
Those last two functions aren’t so important on a trauma scene. What is important is that broken bones are highly vascular (they bleed), and sharp ends can cut other blood vessels.
If you were to ask me how many bones there are in a skeleton, I’d have to say “Beats the heck out of me.” The book answer is 206, but … well. Throughout our lives cartilage is turning to bone (somewhere around age 60, for example, the thyroid cartilage (the voicebox) starts to ossify). Whether you call bones that have fused one bone or two might be debated. Most people have four bones in their coccyx, but some have three, and some have two. Plus, you can have any number of sesamoids. Those are tiny round bones (the word means “seeds”) that form in tendons to reduce friction. They form in response to exercise. Everyone has at least two sesamoids: they’re the patellas (kneecaps).
Definition time! “Proximal” means “closer to the trunk.” “Distal” means “farther away from the trunk.” (On the trunk itself, “superior” means “closer to the top of the head,” while “inferior” means “farther away from the top of the head.”) “Lateral” means “toward the side” (right or left, away from the centerline.) “Medial” means “closer to the centerline.” “Dorsal” means “back,” “ventral” means “front.”
Bones come in several shapes: long (such as the femur (thighbone)), short (such as the carpals (wrist bones)), flat (such as the costals (ribs)), and irregular (such as the various vertebrae).
Joints too have several varieties: hinge (such as knee), ball-and-socket (such as hip), fused or fixed (such as in the pelvis), pivot (the joint between C-1 (the Atlas) and C-2 (the Axis) for example, which allows the head to turn from side to side), gliding (for example in the wrists), and saddle (uniquely in the base of the thumb).
Ligaments attach bones to bones. Tendons attach muscles to bones. Damage from pulling on ligaments is called a sprain. Damage from pulling on tendons and muscles is called a strain.
Damage to joints takes three forms: Distraction, subluxation, and dislocation. In distraction, the bones that form the joint are still in line, but the surfaces are separated. The binding ligaments aren’t ruptured. Subluxation is an incomplete dislocation; the joint has moved beyond its normal range, the alignment between the joint surfaces is distorted, but the articulating bones remain in contact. The binding ligaments may or may not be ruptured. In a dislocation (the old name is luxation), the joint is completely disrupted; the joint surfaces are no longer in contact. The binding ligaments are usually ruptured.
Just because a joint is dislocated doesn’t mean that one or more of the bones isn’t fractured, too. Without X-rays, you can’t tell for sure. So—hope for the best, but treat for the worst. Assume every dislocation includes one or more fractures.
Shoulder dislocations are fairly common. Falls, where the patient tries to catch himself with his hands, and motor vehicle accidents where the driver is grasping the wheel, are common causes. One common subluxation is “Nursemaid’s Elbow,” where the proximal head of the radius (the lower arm bone on the thumb side) is pulled out of alignment in the elbow joint. You see that in little kids who are holding hands with an adult; when the kid steps off a curb and suddenly all the weight of his body is suspended through one arm. Distraction — you see that in hanging, and when folks get entangled in machinery.
A fracture is when the body of the bone itself is disrupted or broken. Wrist fractures are the most common fractures in persons under age 65.
You can have a lot of fun memorizing bone names. (For example, the mnemonic for the bones in the wrist is “Some Lovers Try Positions That They Can’t Handle” for Scaphoid, Lunate, Triquetium, Pisiform, Trapezium, Trapezoid, Capitate, Hamate. (You can have even more fun memorizing the names and functions of the twelve cranial nerves, but that’s for another post.)
The most common wrist fracture is a fractured Scaphoid. That’s the bone on the thumb side that articulates to the radius (thumb-side forearm bone). The other forearm bone (little finger side) is the ulna. When you bend your elbow, the point of the elbow is the olecranon process on the proximal end of the ulna.
Oftentimes a fractured scaphoid presents as a “sprained wrist” that keeps hurting for four to six weeks. The most common mechanism of injury for a scaphoid fracture is a fall where you catch yourself on your outstretched hand, palm open and down.
There are all kinds of different fractures. You have your transverse fractures — they go from side to side at 90 degrees to the axis of the bone. You have your oblique fractures, your spiral fractures, your greenstick fracture (an incomplete fracture), your comminuted fracture (that’s where the bone shatters), your impacted fracture (one broken end is rammed into the other broken end, resulting in a bone that’s a bit shorter than it should be), and depressed fractures (you see them in skulls, but the sides of long bones aren’t immune) … lots of kinds of fractures. Your friendly EMTs have to know them because the book was written by the American Academy of Orthopaedic Surgeons, and the orthopods think fractures are fascinating. Therefore types of fractures’ll be on the test. But what you have to know in the field is this: It doesn’t matter to you and unless your name is Clark Kent you may not be able to tell.
The happy fact about strains, sprains, fractures, dislocations, all of the jolly trauma to the musculoskeletal system, is that they’re all treated the same way.
The only real categories you have to worry about are Open and Closed Fractures. In open fractures, the skin has been broken. In closed fractures it hasn’t. (Those used to be called “Compound” and “Simple” fractures. That’s old terminology. We don’t use it any more.) If the injury is bleeding, treat the bleeding first. Remember, bleeding falls under Circulation, and Circulation is C in the A-B-Cs.
Joint and bone injuries:
How to assess a hard-tissue injury: Look and feel for DOTS.
That is, the signs and symptoms are: a body part is
- Deformed,
- Open,
- Tender, and/or
- Swollen.
Deformity is generally obvious. If a guy has two elbows, one of them half-way down the forearm, you can figure there’s a fracture. If the shoulder has a step-off you can figure on a dislocation. A joint that’s locked in position is often a dislocated joint.
Open means an open wound. If someone got hit hard enough to break the skin, assume that the bone underlying that point is also broken. A guy chopping firewood hits his leg with his axe, assume fracture. A guy playing baseball gets hit on the arm hard enough to break the skin, assume a fracture. (Or, if you see bone ends sticking out … well, what do you think?)
Tender means “If you press on it and the guy says, ‘Ouch!’” (or “$*^#*^@!!!!!”) then it’s tender.”
Swollen means … well, swollen. That can be from bleeding around the injury site, or it can be from fluid going into the inter-cellular spaces around the injury site as part of the body’s immune reaction. In general, the body reacts to trauma by swelling at the site. The classic lump on the head is an example. Swelling can threaten the viability of the limb, through something called compartment syndrome. The various muscle groups in your limbs are inside of tough fibrous sheathes, or compartments. Fluid going into those compartments can have enough pressure that it overcomes blood pressure, creating, in effect, a tourniquet. This has all of the problems of a tourniquet that you applied, only without being as obvious, and not as easy to take off. You really do want to limit swelling as much as you can.
If a patient tells you “I broke my arm,” believe him.
The signs and symtoms go together so often that we abbreviate them: “PSD” for Painful/Swollen/Deformed. (“Hey, Bill, what to you have?” “Guy over there’s got a PSD left wrist….”)
A fun project for a rainy Saturday afternoon! Get a fresh turkey at the market. Using a pair of pliers and a hammer, break its thigh bone. Using your gloved hand, check what that feels like through the flesh. That’s what a broken bone feels like to you the provider (it feels considerably worse to the patient).
What to do about all these injuries: Throw rice at them. The mnemonic here is RICE. That stands for Rest, Ice, Compression, and Elevation.
Rest means that you don’t try to use the part any more. Muscle movement can make bone ends grate on each other (the word for broken bones grinding together is “crepitus,” and it feels nasty under your fingers; the patient can feel it too). I’ve seen people walking on broken legs, though. Part of that is because shock means that it stops hurting. Part of that is distracting injury. If a guy’s got a very painful injury one place he might not even notice a less-painful injury somewhere else. So, get the guy lying down and not moving. Fortunately you’re already doing this because you’re already treating for shock.
Ice means a cold pack. If you’re using genuine ice, put it in a plastic bag and wrap that bag in a towel before placing it on an injury. You don’t need to add frostbite to the guy’s other problems. Ice reduces swelling and reduces pain. Reducing pain is a good thing.
Compression means wrapping with an elastic bandage (an Ace bandage, for example). The compression reduces swelling, limits movement, and keeps the parts aligned. All good stuff.
Elevation puts the injured part above the heart. This lets gravity help in reducing swelling and reducing pain.
After that comes Splinting.
Splinting provides the support that the bone formerly provided, but is no longer capable of giving. It stops further damage from occurring. Even if the bone isn’t broken, a splint at the site of a deep laceration will limit movement and help prevent more damage. Splinting also reduces pain.
Danger Will Robinson alert: You can kill people by splinting them, even if you do perfect splints.
If you get distracted by a fracture to the point you forget to check your patient’s airway, breathing and circulation, that guy will be dead. Fractures can be grotesque to look at, but they probably won’t kill the guy today. A blocked airway will kill him in the next five minutes.
If you have an open fracture and it’s bleeding, control the bleeding first before you consider splinting.
On to splinting. You can use almost anything quasi-stiff to make a splint. You’re building an exoskeleton. Rolled up newspapers, a copy of National Geographic, a pillow, a tree branch, and umbrella — anything. The rule for splints is that you want them to be BUFF. That is, Big, Ugly, Fat, and Fluffy. A narrow splint that cuts into the guy’s flesh isn’t going to help. You can pad the splint with the patient’s own clothing (you cut it off the injured part anyway, when you were examining it). I carry SAM splints, and suggest you put ‘em in your own first aid kit.
First thing to do: Manually immobilize the part. The patient is probably doing this himself, but you can have a bystander help with holding the bone or joint steady. Next, check movement, circulation, and sensation distal to the injury. Can you feel a pulse? Can the patient feel you touching him? Can the patient wiggle his fingers and toes? If you can’t feel the patient’s pulse in the affected limb (but you can in the other, unaffected limb), what you do next will depend on how long it’ll be before you can get the guy to definitive care (that is, to an emergency room). If it’s going to be over an hour, consider applying gentle, in-line traction until you can feel a pulse. But for heaven’s sake, be careful. Pulling the guy’s arm off is usually considered bad form.
For a broken (sprained, dislocated) joint, immobilize from the bone above to the bone below. For a broken bone, immobilize from the joint above to the joint below the injury. That is, for a broken forearm, you immobilize the wrist and the elbow. For a broken hip you immobilize the pelvis and the knee. You need a minimum of two ties on the splint above and two below to immobilize each part. I like to wrap the entire length of the splint with roller gauze to make sure the part is immobilized. Use wide, soft material to tie the splint in place. Triangular bandages are perfect for this. Strips of cloth (cut from the patient’s clothing if necessary) are great. Wire or fishing line is right out.
After you’ve applied the splint, check the patient’s circulation, sensation, and movement again. If you could feel the guy’s pulse before you applied the splint, but you can’t feel it now, you might have the splint on too tight. You don’t want to cut off circulation. If you’ve lost the pulse, or his hand is suddenly numb, or some such thing, take the splint off and reapply it.
And keep checking airway, breathing, and circulation.
Human necks are delicate and lots of important things go through them. Any time you have a serious mechanism of injury (e.g. high speed automobile crash, fall over three times the patient’s height), or any time you see any injury above the collarbone, assume the patient’s neck is broken until Mr. X-ray tells you different. What to do then: Hold the patient’s head steady in a neutral, in-line position until the nice ambulance guys get there. (Note: there are protocols for clearing the cervical spine in the field. Don’t do it unless you do this kind of thing a lot, are supremely confident, and have a desire to see yourself in court explaining your decision.) I have personally had a patient with a fractured C-2, who had suffered a fall from a standing height, whose only signs were a small abrasion on the point of the chin and in the center of the forehead.
How to hold c-spine: Stand or kneel behind the patient (after explaining what you’re going to do and getting his permission to do it), spread your fingers, rest the little-finger side of your hands on his shoulders, and with the tips of the fingers hold his head up and pointing straight forward.
If the patient is unconscious you can skip the “get permission” part.
If you are the first one on scene at an automobile accident, after calling 9-1-1 and setting out flares, pretty much 100% of what you’ll be doing is holding c-spine, assuming that airway, breathing, and circulation are okay. Note: Training bystanders to hold c-spine is fast, easy, and frees you up to do other things.
Special cases:
Let’s work from the bottom up. First:
The femur is one of the largest and strongest bones in the body. It takes significant force to break one. Once it’s broken, there are several life-threats present. One is the embolus. You have large veins present in the leg. Fat, marrow, or a blood clot from the injury site can get sucked into one of the large veins and carried to the heart or lungs. Your pulmonary embolus can kill you dead, fast. Second is bleeding: the femoral artery, a blood vessel the diameter of your thumb, runs along the bone along the medial aspect. If sharp bone ends cut that artery, you can bleed out very rapidly.
The large muscles of the leg (quadriceps, biceps femoralis) contract on injury. (The only trick a muscle has is to contract.) That makes the sharp ends of the bone override, and increases the danger of cutting a major vessel.
Internal bleeding at the injury site, apart from the femoral artery, can also cause significant blood loss. As the leg muscles contract the shape of the leg changes with the thigh getting shorter and wider, providing more volume for the blood to go into.
The field intervention for all of this is the traction splint. Without traction splinting a fractured femur is 80% fatal. With traction splinting, it’s only 20% fatal. There are several kinds of manufactured traction splints. No one expects you to carry one in the trunk of your car on the off-chance you’ll be first on scene where there’s a fractured femur. Instead, let’s talk about an improvised traction splint.
Here’s one way to improvise a traction splint: Gather together a stick that’s longer than the patient’s leg, a coffee cup, some cord, and some strips of cloth.
Check circulation, sensation, and movement in the foot on the injured side. Cut or tear away the clothing from the injured leg. (That’ll give you your cloth strips right there.) This intervention is only for an isolated mid-shaft femur fracture. Hips are different, and a fracture that involves the knee is something else again. Tie an ankle hitch around the ankle of the injured leg using a strip of cloth, a triangular bandage, or something else wide and soft. (Cutting off circulation is a bad idea.) Take the patient’s shoe from the affected side and put it, sole up, into the patient’s crotch. Put one end of the stick (umbrella, ski pole, what-may-have-you) into the shoe. Lay the stick along the length of the leg. Put the coffee cup over the other end of the stick. Tie the cord to the ankle hitch, then put it through the handle of the coffee cup. Pull on the cord, using the handle of the cup as a pulley. Continue, gently, until the injured leg is the same length as the uninjured leg. The patient will usually tell you that the pain has diminished when you have it right. The usual amount of traction is around 15 pounds. Tie off the cord to maintain tension. Tie the stick to the leg using more strips of cloth. Check circulation, sensation, and movement in the foot again. Continue to recheck the splint at regular intervals.
The pelvis is also a very strong structure that requires significant force to fracture. Again, bleeding is a major risk. Any movement in a fractured pelvis risks further injury, including cutting blood vessels. So, you want to keep it from moving.
Assessing the pelvis: Press in, press down, and pull up on the wings of the pelvis. Press down on the pubic bone. Any movement, crepitus, instability, pain or tenderness suggests a fracture.
What to do: Check circulation, sensation, and movement in both feet. Take a sheet. Fold it until it’s approximately four inches wide. Run it from side to side under the pelvis (to do this: run it under the small of the back, or under the thighs, then work it until it’s in place). Take the folded sheet around in front of the pelvis and tie the ends together with a square knot. Insert a stick into the knot and tighten down as you would a tourniquet until snug. Recheck circulation, sensation, and movement.
Flail chest is two or more contiguous ribs broken at two or more places. This produces a section of the chest wall that’s just floating free. You see this in injuries such as when someone’s chest hits a steering wheel. You’ll note that the patient is having difficulty breathing, and you’ll note paradoxical movement: That is, when the chest is expanding while the patient is inhaling, part of the chest wall is going in. When the patient is exhaling, while the rest of the chest is contracting, that part of the chest wall is going out.
What to do about it: First, stabilize the flail segment with your hand. Then, tape a bulky dressing (towel, pillow, large folded cloth) over the area. Be ready to perform artificial ventilation.
The general treatment for anything involving the upper extremities (arms, shoulders) is the sling-and-swathe. For forearms and wrists, put on a splint first. For upper arm or shoulder, just the sling-and-swathe is enough.
First, check circulation, sensation, and movement in the hand on the affected side. Remove watches and rings, since when the hands swell (and they will) those can cause loss of circulation and tissue death downstream. Splint wrist (from bone to bone, metacarpals to radius/ulna) or forearm from joint to joint (wrist to elbow).
To do a sling and swathe: Take one triangular bandage. Lay it on the chest so that the long edge is straight up and down and the 90-degree angle faces toward injured side. Tie a knot in that 90-degree angle to make a pocket for the elbow. Now put the hand from the injured limb in the “pledge allegiance” position (on the chest above the heart). Wrap the bottom point of the triangle up, around the neck and down to meet the other point. Tie them together on the side of the neck. (If you put your knot in the back it’ll be uncomfortable for the patient, and impossible for you to get to once the patient is on a stretcher.) The sling should take the weight of the limb. Now, take a second triangular bandage and tie it over the upper arm on the injured side and under the arm on the uninjured side. The purpose of this is to hold the arm tight against the ribs so it doesn’t go flapping around. This keeps an elbow or a shoulder from moving, and splints the humerus.
Look for Battle’s Sign (bruising over the mastoid process—the area just behind the ear) and/or “raccoon eyes” (bruising around both eye sockets). (These are both late signs.) Look for blood, particularly if mixed with clear fluid, coming from the nose or ears. Look and feel for depressed areas in the skull.
What to do about it: Assume the neck is also broken and keep it stabilized. Keep the patient’s upper body slightly elevated, since the brain is going to swell and you can help a bit by letting gravity move fluid away from the brain. Watch for the pulse to get slower, for blood pressure to go up, and for respiration to become patterned, then cease. (Note: if you see an isolated head injury and blood pressure is going down while heartrate is going up, there’s another injury somewhere that you haven’t found yet. See what you can do to locate it and treat it.)
Take good notes on the patient’s mental status. Particularly note if the patient was unconscious, woke up, then became unconscious again. A neurosurgeon somewhere wants to know the duration of that lucid interval and will thank you if you’ve written down the times.
That’s pretty much it for broken and dislocated bones. I recommend that y’all either take a first aid course, or check out a first aid manual for illustrations and some hands-on play. Unless you’ve made a sling a few times in practice, you probably won’t be able to do one in an emergency situation.
Trauma and You will return in Part Four: The Squishy Bits
Summary:
- Call 9-1-1 (or your local emergency number)
- Scene safe? If not, make it safe. If you can’t, stay out.
- Treat the A-B-Cs.
- Immobilize fractures/dislocations
- Cold-pack the injury
- Treat for shock
- Recheck the A-B-Cs.
Some interesting items:
- Daniel Sickles’ Leg
- FM 21-11 First Aid for Soldiers, Chapter Four, Fractures
- Guided Tour of the Visible Human
Copyright © 2007 by James D. Macdonald
I am not a physician. I can neither diagnose nor prescribe. This post is presented for entertainment purposes only. Nothing here is meant to be advice for your particular condition or situation.
(Attribution URL: http://nielsenhayden.com/makinglight/archives/009238.html)
Trauma and You, Part Three: Sticks and Stones by
James D. Macdonald is licensed under a
Creative Commons Attribution-Noncommercial-Share Alike 3.0 License.
Index to Medical Posts
This one I've had some experience with. It's interesting to note that I no longer have a scar from a compound fracture of my ring finger, but rather from an open fracture. Treatment for it certainly agreed with the BUFF guidelines; I had a whacking great boxing glove over the entire hand for several months.
"Without traction splinting a fractured femur is 80% fatal. With traction splinting, it’s only 20% fatal."
I am just now realizing that my little brother nearly died when he was ten. (He's 38 now, and fine.)
Cracked ribs (they didn't get x-rayed, so I don't know how bad it was): 'rib belt' which is some kind of hybrid of 'Ace' bandage and long-line bra. It hurt less with the thing on, but I wouldn't recommend giggling with broken ribs, and ROFLMAO is right out.
I'm confused by what you say on "how to hold c-spine". You say to stand behind the patient, but I'm expecting the patient to be lying on the ground at least some of the time. This makes standing while reaching down to do this seem ridiculous, and also makes "behind" somewhat unclear. I haven't looked at any of the references in that section, maybe they make it obvious; but delineating the positions better would help a lot (and it'd still be easy to adapt to related positions).
Also (and I may be dangerously stupid here), it seems like standing up isn't a safe position for a person with a possible spine injury. On the other hand having them lie down constitutes "moving them" in some sense, too.
All this reminds me of a section of the early seventh century Alamannic laws: "If anyone breaks another person's head so that the very bone is detached from the head and makes a sound when thrown at a shield across the road, let him pay six solidi..."
I used to have a history professor who liked to use that passage to point out that, unlike modern legislation, medieval laws were not written with the intent that they should be interpreted literally.
Okay, the thing with neck injuries.
Oftentimes the guy will be standing or walking around, or sitting in an automobile. You'll be able to get behind him then.
If the person is lying down, kneel at the top of his head and hold his head and neck in-line with his body.
Getting to a place where you can actually hold c-spine sometimes requires that you pass the EMT Ingenuity Test.
PJ Evans (#3): I hear you. My experience with three broken (not just cracked) ribs included a bout of hiccups.
Not recommended.
Are there multiple ways to pop shoulders in depending on which way they were dislocated, or does one way work for everything?
For my husband's dislocated shoulder, I do the crawl stroke motion:
Upper arm pointed straight out to the side and lower arm pointed up, elbow at a right angle.
Rotate lower arm forward until it's parallel to the ground.
Pull in the direction the upper arm is pointing, and listen for the wet pop and sigh of relief.
Reducing a dislocation depends on where the various bones are before you start. You need to be very familiar with normal anatomy in order to visualize where things are, and where they should wind up.
While reducing dislocations in the field is part of the Wilderness EMT protocols, it isn't something that you normally do in the field, in a situation when you can get the patient to an ER in a reasonable time. Y'see, if the joint is not only dislocated but fractured, you can do additional damage by manipulating it.
With a patient who has a history of repeated dislocations, it's usually easy to move the joint back into position, and the patient can guide you. If it's a first-time dislocation, don't mess around. And do get some formal hands-on training.
The thing about fractures is: I expected them to HURT. When my sister, at seven and again at twelve, fractured a bone, she was screaming bloody murder.
So when I fell off my bike and hit my arm hard, I thought, "Well, I'm not screaming bloody murder, but I guess I'd better go to the ER just to be on the safe side" - and it was broken. Just six months later, I stepped in a hole and twisted my ankle, but I could still stand and walk on it okay. Couldn't be broken, I thought; just a sprain. That was in the summer, and I wasn't insured -- and even though I was ensured then, the broken arm cost me $2000 --, so I didn't go in until the student clinic opened the next week. That was broken too. The ankle, I mean, not the clinic.
Adrenaline can cover up for a lot.
Sometimes bones don't hurt at all when they're broken, or at least very little -- I had a green stick fracture of my elbow as a teenager (took a header over the handlebars of a bike) and my parents wouldn't believe it was broken because I wasn't hurting enough. X-ray years later established, yes, old fracture there. It hurt, but never beyond an, "Owe, I need ibuprofen!" level.
I also fell off a horse once, with my hand tangled in the reins. When I got up, I had a finger on backwards. I was somewhat in shock (also rang my bell pretty good), looked at the finger for a moment, then grabbed it, twisted the finger around the right way, and pulled on it until the dislocated joint slipped back into place. In my somewhat concussed thinking, my logic was that if I could push everything back together in a hurry it'd heal right away and not be broken and not hurt, and that it would hurt more later if the doctor had to set it. I did mention concussion, right?
The hand doctor advised me later that this is not the generally recommended way to set a broken finger. And that I'd also broken a couple bones in my hand.
It never did hurt much, though I've got a pretty good bad-weather detector in the joints of that hand now too.
A few years ago, I wrote up on my livejournal the worst physical accident I ever saw. Back when I was hang gliding, a guy took a turn too close to the ground, his wing touched, and he became a guy tied to a 22' lever accelerating from a starting speed of >30 mph. (He lived.) The scariest parts: the inhuman noises of pain he made. The way he flopped around when we weren't sure if his spine was damaged.
I don't know, if a badly hurt guy is moving around, how do you get him to stop without hurting him more?
Glad you asked about holding the spine, #4 David Dyer-Bennet; I was confused about that, too. (Barry the hang glider had his head held straight by Ann as she talked him down, kneeling behind him with her hands on either side of his head, like #6 James D. Macdonald says.)
Another interesting hang glider bit: they have their very own fracture: spiral fracture of the upper arms, I believe. When the glider crashes, your body keeps on going, swinging through the triangular control frame. If you're still holding on to the control frame, the force undoes your arm bones like a twisted slinky. They drill it into your head again and again, if you crash, LET GO! Regardless, about 1 in 40 forgets in the heat of the moment.
Me, the worst I ever had was when a bag hanging from the handlebars of my bike swung into the front wheel and I went over the top like something out of Indiana Jones. Landed and took all the force on hands and knees. Did not realize I had hairline fractures in both elbows until that night at dinner at a friend's, when I went white and slid off the seat in a dead faint. Putting on shirts sucked for the next while... "You're not in a cast how bad can it be?" Bah! ;) Anyway, don't ever hang anything off the handlebars of your bike. It is never ever worth it.
Figent Figary, an ER doc in the midwest somewhere, has brilliant posts on medicine in the ER. This one has neat stuff about a guy with shoulder dislocation, but I really recommend you click the "emergency medicine" tag and read them all.
I love these posts. As an x-ray tech (Radiologic Technologist, to be official), I have been amazed at how hard it can be to convince seriously injured people, especially drunks, to lie down and hold still. Folks really do walk on dislocated hips and broken knees.
Then there's the joy of trying to keep someone's neck straight, in C-spine precautions, when they're puking. Airway first, right?
Both scary and gratifying are the fractured cervical spines, discovered three days later, when the patient finally decides to walk into the ER, stiff and sore. No, don't try to stretch out that neck, sir, please hold still. The neurosurgeon is coming to see you RIGHT NOW.
Leva Cygnet #11: When the tombstone fell on my foot, there was never any pain. One of my ankles is bigger than the other now, but it never hurt.
Then there's the joy of trying to keep someone's neck straight, in C-spine precautions, when they're puking. Airway first, right?I'm probably going to regret this, but... how *do* you deal simultaneously with airway problems and neck fractures?
Me, the worst I ever had was when a bag hanging from the handlebars of my bike swung into the front wheel and I went over the top like something out of Indiana Jones.
Handlebar bags are glorious things. So are front baskets, front or rear racks, and all the other assorted objects that let you carry stuff on a bike. If I'm reduced to hanging a bag off my handlebars, I *walk* the bike.
Also, it's kinda horrifying how many people end up in bike/car accidents and walk off the scene... to end up in the ER 2-4 days later. I keep reminding myself "do not leave the scene". Even if it's a low speed collision, there's pretty good odds that the cyclist took damage.
How do you deal with vomiting and suspected c-spine fractures?
1) The patient won't enjoy this at all. The patient will enjoy being dead even less.
2)If the patient is strapped to a long spine board, roll the entire board up on its side. Stand by with suction apparatus.
3) If the patient isn't secured, hold that c-spine with your mitts like you were Scrooge McDuck grasping your last nickle and aim his mouth at the floor. Log-roll the patient along the axis of his spine if you have to. (Get bystanders to help you. This may be a challenge. The lookie-loos tend to back off when the puke starts flying.) Suction is, again, your friend. A big ol' turkey baster will work.
4) If you get puke on you, oh well. When you decided to run over and help that guy you volunteered to get puke (and other substances) on you. It comes with the territory.
5) If his neck is broken and he moves it he may die. If he loses his airway he will die. That's your priority list, bucko.
Chris # 15:
Mr. Macdonald should describe what it's like in the field. By the time I see a patient, he's on a backboard, in an immobilization collar. I don't know yet if there's a fracture or not--that's what I'm trying to find out, by x-ray or CT scan. I yell for help, turn the board while supporting the head, and hold a basin. It's messy. The patient is often fighting the restraints. A few of these in a night is the reason I refused long ago to work any more night shifts on New Year's Eve.
The puking problem is one reason you get behind the patient when you're holding c-spine.
It always gives me a little chill to realise the closest I've yet been to death (and hopefully, it will stay that way for a good long time) is when I was seventeen and broke my right femur while racing my brother home from church. I tripped on the edge of a curb and rolled into the street.
I had also broken my left clavicle in the roll. But when I pushed myself up just a little, I could tell my right thigh was suddenly half as short as normal, twice as big a round, and super jello-y. My little brother wanted me to move--I was lying on the edge of a dark road in the middle of a chilly November night about three houses down the street from my home--but I refused. I made him go find the nearest adult--the church bishop in the meetinghouse. (It took him about fifteen minutes to convince the bishop to come with him. Reportedly what he told the bishop was, "My sister has fallen down and she wants to talk to you." He still gets teased to this day about that.) Fortunately, it's not a heavily travelled road at all, and no cars rounded the corner, and I just lay still until a neighbour showed up. She wanted to move me, and I pretty much refused again. When the bishop and his counsellors and my brother all showed up, moving me was once again mentioned, and me, kicking into Girl Scout mode, mentioned that I thought my leg was broken and I worried about tearing an artery. (When they were talking about moving, it was all, "Oh, you can lean on me if you want." Eeesh. Thanks but no. I'll just lie here off to the side with my leg like jello.) So nobody moved me, and I told them to get their car and come park it with the lights on me, and oh, could somebody cover me with something, I was getting chilly. Anyway, fifteen minutes later, the ambulance and the EMTs showed up. They cut my clothes off of me so they could get enough local meds into me to splint me. My dad showed up about this time, and he rode to the hospital with me. I remember being all weirdly lucid about the whole experience and chatting with the EMTs and joking, and asking questions about my heart rate. I don't know if this was a weird example of shock, or if they were just humouring me and trying to keep me awake.
I remember the ambulance ride in particular because I was concentrating really really hard on being Not Tense. Every time my leg tensed, it hurt to high heaven. Then they got me to the hospital and covered me with warm towels and that was lovely. (I was kinda bummed about having my clothes cut off of me--it was my favourite outfit. My mom tried to replace it but it was never quite the same. Still....better than going into shock and dying.)
It wasn't until after my surgery that somebody finally told me that femoral fractures can be fatal in a number of ways. I kind of knew it before--what with all the Girl Scout manuals I'd read--and I knew it wasn't a good idea to move the injured person if they weren't directly in the line of traffic. But it never really sank in quite until that day.
BTW, it turned out I'd made a super clean break. There were no weird bone splinters, but there was also nothing for my bone to nestle against like a little puzzle piece and knit back together. So I went into surgery and they gave me a rod and pin. And I more or less had to keep off of it as much as possible for a month and then not run on it for a year. (Biking and swimming were my new forms of exercise, and it got me out of gym for the rest of high school.)
But yeah....that was my (knock on wood) my closest brush with death.
Emily @10: My femoral fracture REALLY hurt. I was crying with pain for a good five or ten minutes after it occured.
Janet @ 7
Not fun with mild asthma either - it's the tendency to cough. I think it was the knob on the gear shift that did it; there was a fairly impressive bruise on my thigh - not painful, but it took weeks to fade, and there was a dent for quite a while after that.
Then there was the time I was riding a bike and clipped the corner of a car. Scraped arm: minor injury. Hit left knee really well. The resulting bruise went around the medial side of the knee in the shape of a Greek e. That was unfun: a couple of weeks of extremely stiff and four months of don't-kneel-on-it.
While we're asking c-spine questions: if you arrive on the scene and your patient is lying there with his head turned to the side, do you straighten it for him and/or encourage him to straighten it before holding c-spine?
I've always assumed that the answer is "no, it's more important to avoid moving the neck than to make it perfectly straight," with a side order of "unless you don't have airway and your patient is dying, in which case you do what you gotta do." But what do I know?
(Note to self: put first aid classes back on the calendar!)
In general, hold the neck in the position found. Airway takes precedence. If possible hold the head in anatomic position, but don't be yarding around on your patient's head to get it there.
Be particularly suspicious of pain, tenderness, and guarding in the neck. Crepitus is a very bad sign indeed.
Early on, the muscles may tighten up and hold fractured or dislocated bones in place. Later, as the patient relaxes or the muscles tire, the neck may become more mobile and compromise the spinal cord.
Retrospectively, I was an idiot after I took a full force knee to the face. I finished the rest of the bout (karate class), went home, and lay down on the couch with ice. Half my face was black and purple (including the solid black mass under the eye), but it never occurred to me that maybe, just maybe, an X-ray and some professional treatment might be in order.
I have a notch on the cheekbone to this day (nine years later), so I'm inclined to think I fractured it, if only slightly. I'd claim a concussion for the stupidity, but then how do I explain that nobody else either at the dojo or at home, thought to recommend a doctor's visit?
Cynthia @24,
I venture to suggest, your accident being nine years ago, that the instructors had yet not been on the kind of coach-training course that I went on this summer, to get my UK aikido coach accreditation.
Where the duty of care by a sports coach was most strongly emphasised, with all the legal consequences and potential penalties laid out for us.
Put simply, it is the coach's responsibility to ensure all appropriate medical treatment for injuries is given or obtained, whether or not the accident-sufferer is saying, oh, no, I'll be fine etc. If they absolutely refuse to co-operate, you need their signature to that effect on your accident reporting form.
These days, without formal coach accreditation by your particular sport or martial art in the UK, you cannot get coaching insurance and without that insurance, no venue should be letting you set up a martial arts or any other kind of sporting club.
Indeed, increasingly, schools, sports halls, leisure centres, church halls etc now require you to provide a risk-assessment for your activity in their premises as a condition of their own public liability insurance.
And yes, it's a pain from the paperwork point of view but the reduction in sports injuries and in particular, long term consequences from them, is worth it.
I shan't get started on the legal headaches of teaching kids nowadays as that's waaaay off topic.
23: Something I've been told repeatedly - when you are first approaching the casualty, do it from the feet end, not the head end. Because you're going to be speaking to him ("Can you hear me?") and if the voice is coming from above his head (assuming he's supine) he'll turn his head to see you and could wrench his c-spine.
James D. Macdonald:
(6) Getting to a place where you can actually hold c-spine sometimes requires that you pass the EMT Ingenuity Test.
Sometimes it requires that you pass the audition for a Cirque du Soleil acrobat.
(19) The puking problem is one reason you get behind the patient when you're holding c-spine.
The other reason is that you then get to point the head at your buddies.
Old Dan Sickles was lucky to lose his leg at Gettysburg--as wounded war hero, he could avoid being court martialed for disobeying orders and almost losing the battle (& the war). Given his pre-war acquittal of murder on the basis of temporary insanity, perhaps the prospect of a court martial didn't bother him, though.
Having a wooden leg didn't stop him from using his position as US Ambassador to Spain to embark on an affair with Queen Isabella II . . .
Osteopathic or Orthopedic Surgeons? Not that both groups don't have a thing for bones, although osteopaths (at least in the beginning) have some very different notions on that topic.
Thanks for another great post!
You missed an acronym: FOOSH (Fall On Out-Stretched Hand, as in how my sister managed to break both wrists at once while cleaning up the church nursery).
Cynthia Wood @24, Juliet E. McKenna @25, about facial fractures and coaches:
I have had two fractures in my life, at least ones which were diagnosed; the first, on my sixteenth birthday, involved a knee to my left eye socket and resulted in an orbital fracture (covering third base, bad bounce on a thrown ball, aggressive base runner). In May, 1968, there was apparently no requirement that PE teachers have any training in first aid; I lost consciousness and woke up vomitting, and my coach yelled at me for faking it.
39 years later, I still have the black eye.
The other fracture? About twelve years ago I shattered the tip of my left ring finger getting it between a cow's head and something hard, and had to have my wedding ring cut off ; today I'm finally getting the ring replaced in time for my 25th wedding anniversary later this month.
The worst musculo-skeletal damage I've sustained, again in PE, same teacher, was a severe sprain of the left ankle which left the joint unstable and prone to reinjury; it's now showing signs of both osteoarthritus and compromized vascular function. We were doing gymnastics, vaulting over a horse, and she made me take off my glasses for safety reasons. Unable to see the ground, I misjudged my landing and came down with my entire weight on the outside edge of my foot. She screamed at me for being fat and clumsy, and was one of the teachers who demanded that I stop using crutches well before the injury had healed. I'm pretty sure that was against the law even then.
Why yes, I have issues.
JESR @ 31
I think you had a teacher who should have been fired and had her teaching credential revoked (permanently) for endangering students. And also been sent for psych observation.
I have another category of broken skin: what the joint specialists called "the worst possible kind of sprain" when I brought a friend to the ER over the summer. She'd jumped up to hit a soccer ball with her head and come down wrong, been carried off the field, and, despite insisting it was just a sprain, was bleeding steadily from a wound on the outside of her ankle. The ankle was incredibly swollen within a minute, which was worrying enough, but we managed to convince her to make an ER visit when the bleeding hadn't decreased despite pressure and ice after half an hour.
The eventual diagnosis was that her ankle had briefly dislocated. A bone had thrust far enough out of alignment to break the skin, then snapped back into place. She had to have surgery that night to repair the membrane that encapsulates the joint, which would be a very bad place to get an infection. She can walk on it now, and the physical therapist says total recovery is certain. If we had let her just go home, maybe not so much.
(The fun part was driving my car onto the soccer field to pick her up.)
Emily H @ #10
Your experience mirrors my own. Broken metacarpal, right hand, extra knuckle and everything. Never a twinge! Not when I half-heartedly tried to put it back into place myself. Not after a trained professional drilled holes in it an laced it back together with a piece of wire.
I always expected incredible pain with a broken bone. The most painful parts of the experience were having the stitches removed and getting the "pimp my skeleton" bills.
Woo! Open dislocations! You treat them out on the street the same way you treat an open fracture: Control the bleeding, then RICE, then splint it.
People's experience of pain varies, from "HOLYCOWOHCROMITHURTSITHURTSITHURTS" to "Gee, that's sure odd."
If you want to read more about traumatic skull fractures, read Lee and Bob Woodruff's book In An Instant. It's about his being injured by an IED in Iraq in early 2006. The book includes photos of what his head looked like without some of his skull. They also included an X-ray of all the crap that hit the upper part of his body. Fascinating and scary reading.
I've only ever broken 2 bones - my collar bone (from falling down a flight of stairs when I was 4) and a small bone in my left foot (while wearing sandals with a tiny sole a few days before the '99 Nebs in Pittsburgh - I wound up in one of those "broken foot shoes" for most of the weekend). I don't remember much about the collar bone other than starting to fall, then, later, having my left arm in a sling and trying to do sewing cards one-handed. As to the foot, I didn't think it was broken as it only hurt when I walked on it. It started to swell a little, so I went to the ER early in the evening. As it was spring, there were about 20 Little Leaguers ahead of me, but so long as I was sitting, I was OK. After about 5 hours, I finally got seen, got an X-ray and went home with crutches.
Delurk-for-embarrassing story time!
Several years ago, my parents and I rented a lakeside house in Maine. As I was getting ready for bed, we heard a camp somewhere nearby singing. My mother wanted to figure out the song, so she went out onto the pitch-black deck ... forgetting there were about three steps down. When the house shook and she screamed, I ran out to find her on her side on the deck. (It later turned out she knocked a few slats out of the railing as she fell forward, but that kept her from plummeting down the drop to the lake.)
In emergencies, I have no brain; I go into "tell me what to do and I'll do it!" mode. My father thinks he knows everything (despite having no training), so he was trying to manipulate her swollen lower arm -- to see if it was broken! -- as she begged him to stop.
I put my hand firmly on her shoulder to try to comfort and steady her and asked whether to call an ambulance or put her in the car and drive to the hospital. Stupid -- always call the ambulance, but see above about the no brain thing. She's an RN, so when she insisted on the car, I went with it, not thinking that the pain would have her confused and wanting to do something rather than lie there waiting.
We sped through the dark to the interstate, and I asked the toll booth attendant where the nearest hospital was (!) -- should we just drive towards Portland? (We were 20 or 25 miles away from Portland.) She didn't know (!), so I went with that plan. About halfway there we saw a police car's lights flashing at the roadside. I don't know if I made the suggestion, but my mother asked please to stop and ask the officer for help.
I naively figured he was assisting a stranded motorist; it was something more like a drug bust, so I'm impressed he didn't pull his weapon when a car stopped behind his cruiser and a woman in pajamas rushed towards him. He called for an ambulance but warned it would be a bit because they were coming from ... the town we had left. Dammit!
I then irked the chief EMT or paramedic (I'm not sure which she was) by following her rig at Boston-area commuting distance. It wasn't intentional -- no brain.
My mother turned out to have a comminuted fracture of the proximal humerus, I think it was. So I was pressing right on the shattered break, but even knowing that, she says my father's fiddling hurt more.
Anyway, the valuable lesson: Always know where the nearest hospital is -- but always call the ambulance. I'm sure the smart folks here know that, but it bears repeating.
And if anyone here was somehow involved ... I'm so very sorry I was an idiot.
Back in 1979 right after that year's OVFF, Monday morning, I was headed to work.(My brain was chanting "I don't wanna go to work.)
I was headed down the stairs from my door, when I parted company with the staircase about 3 steps above the first landing. Knowing I was falling I tried to relax. The space was too close to try any sort of save, and trying to do so would have made the results worse.
I hit the landing with my right leg folded under me. My right ankle was under my left buttock and I heard a "pop" like the sound of two football players hitting each other. (Did I mention I was wearing a backpack too?)
I figured I'd broken the ankle. So I crawled back up the steps, managed to get my apartment door open and crawled to the phone. (The cats thought this was fascinating...)
Did I call 911? Oh no, called my best friend, told her I thought I'd broken my ankle and could she please come drive me to the hospital?
Bless her heart, she left work. In the meantime I realized I was wearing a brand new pair of Dockers, and I figured the folks in the ER would cut them off, and doggone it, I wasn't going to lose a new pair of pants...
I actually managed to get my shoes off, pull off the Dockers and put on a pair of sweatpants, and put my shoes back on! Hurt like hell.
When I finally got to the ER and they x-rayed the ankle, it turns out I'd torn 2 of the three ligaments. They put it in a soft cast and told me to stay off of it for 48 hours. After that I could use a walker. The bruise was spectacular, it really did turn almost black.
I didn't find out until a couple of weeks later that I had jammed 13 vertebrae together. (Remember the backpack?) The chiropractor had a fun time working the spine back to it's normal form.
American Red Cross First Aid Courses
British Red Cross First Aid Courses
SOLO Wilderness First Aid Course
(Ah, Portland. We take people over there from my hospital occasionally, to Maine Med. It's a bit tricky to find if you're from out of town. About a three-hour drive on two-lane blacktop for me; only the last little bit is on the interstate.)
Why are the stories on this thread making me shriek and cringe in imagined pain in a way that the other trauma and emergency posts haven't done?
Yes, I have broken bones before (non-dominant wrist, two separate occasions, playground and backstage falls, and a bone in my foot, stair slippage) but I've also lived through some of the other trauma stuff (heat and cold problems particularly) and those don't nearly make me cringe the same way!
Great information. I just have to read it through my fingers this time.
Ah, Jim... I thought I had forgotten: "On old Olympus'...". It came right back.
Rikibeth @ #40, I'd hazard a guess that these stories describe real tangible pain more than the others have.
My favorite subluxation/dislocation story: My friend Matt tore his ACL. In a rock band accident.
Matt was the bassist for a metal band. They were playing a show one night, to a really excited crowd. When Matt's playing a show, he gets all rock star, jumping around with his bass. This is funny, because ordinarily Matt is a giant nerd, just like me.
The problem that night was that the lead singer had put down an uncapped bottle of water on Matt's amp. It got knocked over. And Matt, jumping around with his eyes closed, slipped in it and landed such that he tore his knee.
He finished the rest of the song, playing his bass, lying on his back in a puddle of water. When the song was over, his bandmates said "Man, get up. The song's over, you can stop being a rock star and playing your bass lying down." He said "No, seriously, I don't think I can get up."
He played the rest of the show sitting in an office chair dragged from backstage. Then, and only then, did they take him to the ER.
He was disappointed when he had surgery and was told he was not getting an ACL from a cadaver. He'd hoped to become part zombie.
Funny this came up. I just had to deal with, briefly, a possibly damaged skull/neck. Bike accident, walked around the corner, one guy lying on ground, unconscious, wrapped around bike, with the other guys (who weighed 75 pounds soaking wet) trying to pick him up.
Story elided. End result. Guy#1 off to hospital on a backboard, with c-collar, etc. Guy#2 walked away carrying his bike.
Mr. Macdonald will now tell you why Guy#2 walked away and Guy#1 was carried away on a backboard, etc.
I've never had a broken bone but I've had some truly spectacular bruises. And I have what I think is a vertical dent in my skull from second grade, when I turned a corner a wee bit too soon.
Of course, I think I probably was in more danger the time I slipped and hit my neck on the monkey bars, but I was a kid then and lighter. The teacher let me off from verbal participation the rest of the day— it didn't hurt to talk but it sounded truly awful.
I think Evil Rob wins for nasty bone injuries, though. He was something like 14 years old and on vacation when he got both hands caught in the scissored joints of a collapsing folding chair— that he was sitting on. They couldn't find the pinky and ring fingers on his left hand on the X-ray, so they splinted them, bound them up, and hoped good things would happen.
This is why he plays guitar. It started out as therapy. He's pretty good at it, and I have great joy in telling the above story to people after they've complimented his playing.
Let's see: believing you broke your arm. When I broke my ankle (nine places in three inches) neither the EMTs or especially the hotel manager believed me. I think it's because I moved it back straight before they got there because it hurt less straight. (I'd also asked the janitor who came to my yells of help to get me a blanket and I used it to support the ankle.) The ER doctor clearly didn't believe me. The X-ray tech didn't believe me until she asked me to roll over and I did and my foot didn't.
Dislocating shoulder by falling on outstretched arm. They teach you not to do this in OT. You're taught to automatically drop what you're carrying, cover your face with your hands, and bring your elbows in front of your chest. This is why I don't carry things often. It's a lot faster getting my hands in place and just falling if I don't have to drop things.
Flail. I got this by coughing too hard. Now I have codeine to take as soon as my coughing can't be controlled by hard candy.
I've had a lot of painful things happen but the worst was getting potassium IV. It feels like acid in your veins.
I'll read through the whole thread later, but I just want to say that what Jim said is really good basic aid. From personal experience: RICE made a serious bruise-trauma (nothing broken) into something that basically fixed in a week (though a year later there's still occasional pain).
Well, if nothing else, this thread is making me vow to actually go to the doctor about my right thumb. I fell on my hand a couple months ago (softball), and jammed my thumb. While it's *mostly* better, if I try and bend it any more than "normal", it hurts a *lot*, and occasionally I tap the knuckle and almost shriek in pain. Also, pushing "down" on my thumb with my pointer-through-ring fingers is fairly excructiating. I've been pretty much just ignoring it, hoping it will go away. You guys have convinced me that's not the smartest thing I've ever done...
Um, that's the worst story I got. I know, I'm a piker :-)
David Bishop #48 - jammed fingers are annoying as hell. I've been nursing one along since Febuary - not as sensitive as yours, but not right either. Somehow I can't bring myself to go to the doctor because my finger hurts when pushed sideways. I've learned somewhat better since my day of knee-in-face, but not totally.
I think I may be so persistantly ignoring this because it's my finger of doom - aka my wedding ring finger. The finger that needed the ring replacement, that caused my Dad to shove me in an MRI, that found the pituitary tumor, that turned my life upside-down. My subconscious says bad things happen when I bring that finger to the attention of doctors.
OK, so now I have the evaluation criteria. How did I do when faced with a broken finger on a child?
Fiona fell in the shower, naked. I was wearing underwear and a shirt, but no trousers, because I was helping her. She got up crying, with her right pinky finger sticking out. Deformed.
Her cries started at startlement and quickly turned to pain. She held the wrist of her right hand, and I carefully touched the finger and the attachment to the hand.
I thought it might be dislocated (there is a family history of loose ligaments. At one point we had three shoulder subluxions in the family at once), but it didn't feel, on the brief touch, like something I could just "put back".
I had her wiggle her fingers, and noted that she couldn't move the pinky. At this point, I thought, broken. So did we RICE it?
Um...no. Rest, of course, but we clean did not think of ice. Compression was not going to work - it was not a wrappable structure as it sat there. And again, we didn't think of elevation.
She stopped crying very quickly, and claimed that the pain was much less. We got her dried and dressed (which involved getting a sleeve on her - I suppose we could have left that arm out of the sleeve, but we just worked the hand carefully through.
Then, of course, we did the absolutely right thing and sought medical attention. It was a partial (greenstick) fracture of the inside of the lowest long bone in the finger. They put a cast on from fingertip to elbow (it was night shift in the ER; they were not being delicate and artistic). A few days later, they swapped it for a joint above to joint below number, which meant that she didn't even lose wrist mobility.
The smaller cast came off on Tuesday, and she's already almost back to full mobility.
dan @ #41: I prefer "Oh, once one takes the anatomy final, a good vacation sounds heavenly."
Caroline @ #43: I've torn both my ACLs. First one was a shopping accident (I turned a shopping cart full of gravel and concrete pavers over on myself); second was in the middle of my black belt test when my teenaged daughter did a sweep that dumped me but didn't clear my foot off the mat. I then tried to finish my test (board breaking) and found out why people don't customarily break boards while standing on one foot.
Still haven't had surgery. Neither orthopedist ordered an MRI (x-ray only) so I don't know the extent of the tears. First doc wanted to do surgery--"otherwise the knee will eventually fail". I asked what difference there was in prognosis with immediate surgery vs. when the knee fails--he said none. I told him I'd be back when the knee failed (12 yrs. and counting).
With the 2nd knee, the other doc said "what did you do to rehab the first one? Go do the same thing for this one. Do leg presses till you're blue in the face." I liked him a lot better than I did the first doc.
Marilee (46): I've had a lot of painful things happen but the worst was getting potassium IV. It feels like acid in your veins.
Really? It felt like any other IV to me. But I still have a port from having chemo, so the IV was never in surface veins. That could make a difference.
------------
No broken bones, but I did sprain my foot when I was a kid. ("You mean you sprained your ankle." "No, I sprained my foot.")
I feel so inadequate... I never broke any bone - mine or those of others- although I once slammed a fingertip into my car's door. Not even a partial fracture though. But my nail fell off. Does that count?
Several years ago, I did the standard Fall On Out-Stretched Hand. When I got up, I thought I'd sprained/strained my wrist. Ran out, picked up an Ace bandage, wrapped the wrist. Didn't seek medical attention.
I kept it wrapped for weeks, because it hurt less when there was pressure on it. I'm pretty sure it was a fracture; a couple of times a year, I'll overwork that wrist and it'll hurt like hell.
Serge, I'm the same. I don't do much of anything. I have a weird nervey thing in one finger from too much tiny-fiddly-scissoring a few months ago, I lost a toenail once, and I have half a fake tooth, but my sister's the one with the medically interesting leg-- we think it started with a bone bruise from skiing and went on from there. And I still feel bad for swooshing past her the first time instead of stopping and making sure she was okay.
Diatryma... About 8 years ago, I was on my bicycle and took a curve a bit too fast. Bike went flying sideways and I landed hard on my knee, or rather just below. It hurt like Hell. Did I go to the doctor? Of course not, not even when, while doing leg presses, I could feel my tibia popping around a bit. I stopped doing leg presses for a long time, but that was it. I fully recovered. Still, thinking back, that was stupid of me.
Lila @ 51: Probably for the best. Matt said that recovering from knee surgery was the worst pain he's ever been in, and he hopes never to feel that much pain again. (The biggest problem was that he wasn't told to start taking his painkillers before the anesthesia fully wore off. By the time he could feel his knee, it was too late -- the painkillers didn't touch the pain.)
Serge @ 53, it's okay, I've never broken a bone either.
For some reason, this was the post that made me really decide to get some first aid training. Maybe it seems the most do-able.
Serge #53: I broke my right arm at seven. I have a scar on my right knew as a result of a fall when I was 14 (it isn't smart to run downhill while carrying a sackload of dung if you're going to trip over a tree-root and have your knee land on a rough rock), and I have a scar inside my right elbow as a result of an accident when I was 19.
Marilee @46: sometimes the doctors don't believe the grownup telling them their son's arm is broken. My son was about 5 when he fell (it was a classic jump for something he couldn't reach, and then the FOOSH). I palpated it right away and felt no deformity, so we RICEd him. Two days later, he slipped in the school hall and did another FOOSH. This time palpation elicited pain, so I sent him to get radiographed. My partner said the doctor palpated and didn't think it was broken, but she told him to radiograph it anyway. It was indeed a mild fracture, not even completely through the radius. He wore a cast for 5 weeks and has been fine for the past 6 years.
The only broken bones I've ever had were fingers and toes. The fingers came from getting my hand caught in a closing car door. Two fingers were fractured in the proximal bones, but nothing else. The bone calluses were kind of cool. I've had a toe fracture from stubbing my foot on the couch, which resulted in a spectacular bruise. Once a horse tripped over his own feet, and broke my foot, which was terribly unfair of him. None of them really hurt very much, but as mentioned, this is a very individual response.
I wonder how Abi's daughter is doing. I presume her finger is still in a cast.
Serge @61:
See the last line of comment 50. Fiona's hand is no longer in a cast, and her finger is already almost back to full mobility (she can't quite make a fist yet).
The current worry is the barfing, feverish 6 year old son, though. Fun times!
Oops. Missed your earlier post, Abi. So Fiona can't do the Power Fist yet. As for your son, has anybody figured out his problem? By the way, it's weird, thinking that people around here now have kids who were born in the 21st Century. When those kids hit puberty, will they make fun of their parents for being born in an earlier century? But I digress.
Serge #59: True, and I wasn't anywhere near Dungeness either.
Abi #62: Ah, the joys of having small children! (I remember ear infections with a shudder...)
Mary Aileen @52: But I still have a port from having chemo, so the IV was never in surface veins. That could make a difference.
I wonder if you had an experience similar to mine with that? Depending on where the port's placed, I guess. I underwent chemo from 1987-89, and I had a dual port catheter installed for the purpose into some blood passage in my chest. I don't know about potassium, but I quickly discovered that Heprin (anti-coagulant I had to inject in each port) made an unpleasant cold feeling at the back of my throat, ketamine had to be injected slowly or I'd gag on my way out, and IV-style Benadryll would make me gag to the point of vomiting no matter how slowly it went in. Surprised the heck out of me; I had been under the impression that one shouldn't be able to feel stuff going into the veins. Maybe it was because the insertion point was so close to the heart? How does that work?
When I give platelets, I sometimes get an effect from the citrate anticoagulant. The easiest part to notice is the tingling lips-- citrate binds calcium ions, which leads to the tingling. I think there's an effect for fingertips, but I'm usually not paying attention to them. Yesterday, I noticed that my throat felt sort of weird, and the backs of my eyes, if that makes any sense-- sort of muzzy-wrapped, so while things felt the same, the signal to the brain was being lost. I think a lot of that was me being tired and a little bored from sitting in the same chair, wrapped in warm blankets, for an hour. The effects go away if I drink a bit of milk to replenish the calcium in my blood.
Since I am fairly suggestible, I think the throat and eyes might be in my head. They might be tied to the chilliness, too.
No broken bones for me, but I did badly sprain/strain my left ankle many years ago...diagnosis uncertain because I never had anything but wilderness first aid. I was on an Outward Bound trip - third day, late in the afternoon, and we were doing the first rock-climbing bit. I got about three feet up the last face, and then slid down the face and landed with all my weight on my left foot, which wedged sideways into a crevice. Ouch! Didn't appear to be broken, though, and I was wearing hiking boots with ankle support. So I struggled back up (about 8 feet) to the top, and rapelled down (whee!). After soaking it in the creek, the instructor bandaged it up, and we had a decision: go back with one of the instructors (2.5 days hike), or continue forward with the group (4 days hike). In the morning, we decided that it really probably wasn't broken or fractured, just muscle/ligament/tendons, so I kept going with the trip, after it got taped up. I pretty much kept up with the group, though I begged out of one rock scramble, and I got to pass on the 5-mile run at the end of the trip. :) By the time I got back to civilization, it didn't seem like there would be much that modern medicine could do for it, so I just used an ACE bandage for a few weeks. It's never been quite the same since, though - most of the time it's just fine, but I have an odd ability now to trip over very small objects on flat surfaces when I hit them wrong with my foot, and I end up stepping on the side of my foot - ouch!
Now, my sister had a broken leg when she was 6 or 7 - classic skiing accident on the "last run" of the day, about 3:30pm. And my brother broke his arm when he was about 3 - the story's long, but basically he fell out of the back seat of a car when the door opened [1974ish - no car seats then!]. The car was slowing down to a stop sign in a residential neighboorhood, and he fell out and must have caught most of his body weight on that arm first. No other injuries, except for some scraping on his hands. It was technically a fracture - it didn't break all the way through, probably because he was so little and light.
Diatryma (67):
When I was a platelet donor, I always felt it in my belly first. Chewable Tums (provided by the Red Cross donor center) worked well for me, I tend to be warm most of the time, so rarely needed the electric heating blanket turned on, even though the blood was coming back a good deal cooler than it went out.
Movies not to watch while giving platelets: Reindeer Games (the scene with the darts — not what I want to see while I'm pretending that there aren't these humongous needles in my arms).
Somehow, my FOOSHes have never resulted in anything broken; somewhere I learned how to roll and wind up on my bum. One did end up getting me 3 months of PT for a frozen shoulder; this was the time I was out walking on a cold night, tripped and fell into a mud puddle. My treatment was to walk the five blocks home, have a stiff belt of scotch, and take a hot bath. In retrospect, probably the wrong thing, but the idea of ice after a 40F night was rather unsettling. (Had I known, I would have traded an hour of frozen shoulder on the spot to several months of frozen shoulder later.)
Several weeks later I discovered I could no longer scratch my back, and that I couldn't fasten my bra in the normal way. I got X-rayed to make sure that nothing more than outraged muscles was going on (it wasn't) and embarrassed everyone when I got stuck taking the Xray gown off.
Moral: For Ghu's sake don't forget the ice part.
My "I think I may have broke it" story:
When I was 22, I was on a dig in the Skagit Valley. The field school was run on the theory that every job on a dig is essential, so we cycled through excavation, lab, survey, and cooking crew. The second week I was on cook crew, three of us wasted time trying to find a third leg of lamb (from one lamb) in a cold-room meat-locker. Coming out into the humid air, my glasses frosted over, and I missed the turn going down the long, narrow, steep, unlit staircase and fell down eight steps, landing with all my weight on my right knee cap. When I got up, it was swollen, extremely painful, and could be moved past its normal range of motion, with a distinct grating feeling as if there was bone-on-bone contact.
The dig director had no patience with injury, and had already sent one person home after he hurt his leg. So I didn't report the injury, immobilized it with, first, my heaviest hiking socks and some safety-pins, and then a wide elastic bandage, and toughed it out. The last two days of cook crew weren't fun; I rested some over the weekend (where "rested" includes having to walk a block to the latrine and two blocks to the cook tent, not to mention a quarter mile down to the Skagit to soak the sore knee in glacial meltwater). The last three weeks of the field schoolI bulled through walking five miles a day, under pack, over uneven terrain between camp and site.
When I was forty, that stupidity was delivered to my door postage due. It pretty much has hurt every minute of the last fifteen years.
Nicole (66): I have a single port just under my right collarbone. I don't remember any odd effects from any IVs going in, but Heprin (sp?) always makes things smell of vomit for about 24 hours afterwards. *Not* what I needed when I'd just had chemo!
The last time I had to be retrieved by an ambulence, the lovely folk who stopped to help me were so confused about what to tell 911 that I ended up doing the whole accident description, location, injuries, condition of patient ... and then finishing with "I'm sorry - I think I need to sit down now, before I fall down".
Having an arthrogram for my separated shoulder still rates as one of my most painful experiences (and - well - I've injured enough parts to not look forward to damp days). The MRI after was almost relaxing, and definitely musical.
Caroline @ #57, when I had two knee surgeries to repair a severed patellar tendon (long story told here) I remember that it wasn't the surgery or the days afterward which hurt so much, it was the PT on the exercise bike. Getting that pedal over the top and on its downward stroke the first time was up there with the other big pain sensation I've had: gout.
Cynthia #49: The finger that needed the ring replacement, that caused my Dad to shove me in an MRI
Probably not entirely on topic, but would you mind terribly unpacking that?
Caroline @ #57, we are constantly nagging our patients to take their painkillers BEFORE the pain gets bad. There's a strain of Puritanism down here or something. You're right: once you're really hurting, it's too late for the drugs to help much.
If you were to ask me how many bones there are in a skeleton, I’d have to say “Beats the heck out of me.”
Once upon a time I went to a foot doctor and he told me the reason I have flat feet is that I have an extra bone in each foot that weakens the whole structure. I am a mutant! Though I still haven't heard from either Dr. Xavier or Magneto. *pout*
I did feel slightly better though when I heard about a lady who'd found out, via an unrelated x-ray, that she'd been born with just one kidney.
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