Hip Fractures

A hip fracture is not a prehospital emergency.

Let me repeat that.

A hip fracture is not a prehospital emergency.

I couldn’t believe it. But there is was written in bold. Not just a stray sentence by listed as “an axiom.”

A hip fracture is not a prehospital emergency.

For those who know this or have had least read this claim, it may not be news, but I found it shocking. It did explain much, however.

As some of you know I recently took a second job as a prehospital coordinator at a local hospital. The job, while taking me off the streets during what would have been my overtime shift hours, has been very enlightening. I am learning some inside system management I had missed. Let me tell you how I found out about this.

Out of curiosity I began tabulating all the drugs one of our medic services has given over the last year. I learned how to do an Excel spreadsheet and it was pretty easy inputting and I was fascinated by the results. Without going into all the numbers, these were the drugs given most(in order):

ASA, NTG, breathing treatments (albuterol and combi-vents), dextrose, epinephrine, atropine, zofran… The list went on and ended in the low single digits with drugs like metoprolol and dopamine.

As a big advocate for pain management, I was surprised to find morphine much lower on the list than I would have expected. So I started to trying to figure out why it was so low.

I considered several reasons:

1. The time and hassle element of exchanging used narcotic kits
2. The old school handed down over the ages philospphy of you have to prove to me you’re in pain before I will medicate you.
3. Lack of knowledge about pain’s destructivness.

But before I could make too many assumptions I did realize that for all the run forms that did cross my desk, there were very few that were glaring examples of people needing but not getting pain management, which led me to suspect that either people were made out of rubber in this area or maybe the medics were simply not getting dispatched to pain management calls.

This service is an ALS intercept service only. When I looked into the issue from the dispatch angle, I found my answer. ALS is not dispatched on low falls, where most fractures occur(due more to frequency of low falls over mechanism).

This isn’t to say a basic ambulance couldn’t call for a medic for pain management, but in an area of scarce medic resources, they may not be prone too. Besides splinting is a basic skill.

That same day I found an old book in my desk at work, called Emergency Medical Dispatch, and was flipping through the pages and then that’s where I saw it.

A hip fracture is not a prehospital emergency.

I made a copy of the page and approached several doctors with it. Can you believe this? They couldn’t.

This explained why when working as a paramedic on an ambulance, I often get sent lights and sirens for a fall with a head lac (fall with injury to a dangerous area) but am never sent lights and sirens to a fall with hip pain. As the only ambulance in town we are sent to all calls(And I have no problem going non-lights and sirens — safety first, but at least I am sent). That’s why I give more morphine in two months than a medic intercept service might give in a year. I work in a town full of old people and they are always suffering low falls and nearly every low fall that comes in with hip pain turns out to be a hip fracture with a person in pain. And all those broken ankles and shoulders and arms and wrists. I give them Morphine.

Sir William Osler, the founder of modern medicine, called morphine “God’s medicine.”

I can see why.

For years I used to pick these people up, throw them on the stretcher and bounce them through the city to the hospital, while they cried out in pain. This was in the pre-pain management era when you had to have bones sticking through your skin to get a doctor to give you the order to give morphine. But times have changed.

All those studies came out that showed how people were being under medicated and left in pain, and how pain is itself destructive to the body, how it often leads to chronic pain. One of our hospitals started requesting a pain scale on every patient we brought through the doors. Our pain control orders became standing and then increased in the amount we could give on standing orders. Up to 15 mg for a 100 kg patient, 7.5 for a 50 kg patient.

And I have to tell you, once you start practicing pain management as a tenet of your paramedic practice, it quickly becomes one of the most rewarding aspects of the job. I medicate people with hip fractures where they have fallen. While the medicine is starting to work, I make them comfortable with pillows and blankets. If after ten minutes, they need more medicine, I give it to them. By the time I am moving them, I am their new best friend or their favorite son or grandson. And not only are they grateful, their family is grateful because their relative who was suffering before them, is now calm and pain-free and the event is less hard on all of them. What power we have as medics to make people feel better, to relieve suffering and agony. And if it means listening to a patient sing an off-key “The Farmer in the Dell” so be it.

So, it just happened, in my coordinator job, I was at a meeting to go over the lastest verion of changes in medical dispatch protocols for one of the areas that we provide medical control. As we went through the dispatch cards we came upon falls and there it was again in the dispatcher notes:

A hip fracture is not a prehospital emergency.

We were trying decide what calls you send medics to and what calls to send responders “hot” or “cold.” So I spoke up on the hip fracture issue. I said you need to at least start medics to low falls with hip pain, but I was unconvincing to the others.

How do we know its a fracture? Maybe its a bruise. Besides, its just a simple fracture. They can always call for pain management. And we’re short enough on medics as it is. We can’t tie them up on a low fall. This is an education, not a dispatch issue.

Some days my mind is sharp and my words are clear and pristine. Other days I am in a fog. I babbled on, but wasn’t clear maybe even to myself. I eventually gave up. I could see I had no allies.

Hip fractures are lengthy calls. I can be on scene a half and hour or more (where I am someone who generally likes to just pick a patient up and do everything on the way to the hospital). And the ride is always slow — turtle speed to avoid bumps in the road, and then there is the issue at the hospital of having to exchange narcotics afterwards.

And maybe you do need to have medics available for “the big” calls.

But here’s what I do know — I give more medicine on low falls than I do on multisystem trauma. And with the big recent study showing ALS makes no difference in major trauma, I can argue, as a paramedic, I make a bigger difference on low fall calls than I do on major trauma. But I don’t think the majority of people in EMS, particuarly are ready to grasp that yet because after all, its there in black and white.

A hip fracture is not a prehospital emergency.

***

Here’s a good article on hip fractures:

Prehospital Hip Fracture Assessment and Treatment

Here’s the link to the OPALS Trauma study that that showed that(in their study): “systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced lifesupport phase, mortality was greater among patients with Glasg
ow
Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma.”

The OPALS Major Trauma Study: impact of advanced
life-support on survival and morbidity

18 Comments

  • keepbreathing says:

    Fascinating. As an in-hospital provider I’d have assumed that a hip fracture, or a suspected hip fracture, would have been an ALS call. Indeed, many years ago when I was training as an EMT-B (never ran on a truck, just took the EMT-B and I courses) my instructor’s truck…an ALS truck…was sent out lights and sirens to a fall from standing with leg pain. I’d never have imagined that a hip fracture was not considered a prehospital emergency. Fascinating.

  • hilinda says:

    Thanks for that entire post.I had been noticing that the calls that are most traumatic for ME are the ones where someone is in intense pain, and as a Basic, I can’t do anything about it. And yes, our ALS backup is sent cold.Most of them, however, are willing to step it up if we give them a patient update with 10/10 pain.I also agree with you that these patients, when they get pain meds, are the ones who are most appreciative, and I feel the best about having been able to actually help someone.Most of the priority system makes some sort of sense… but pain really is given a very low priority, as if it’s unimportant. That bothers me.I tell my friends that if they ever have to call an ambulance because of pain, to tell them that are having difficulty breathing, too.

  • Herbie says:

    Wow.I also sit on scene for hip fractures.1. Start IV.2. Give morphine.3. Place scoop stretcher around patient.4. Secure patient in scoops stretcher.5. Pad the voids.6. Extricate.7. Reassess pain management.The scoop stretcher is great for hip fractures, since you don’t have to move the patient. Between that and using a KED upside-down to help stabilize the hip, and morphine, your patient should have a comfortable ride.

  • Dan says:

    Is there a link to that “big study” that shows ALS doesn’t help in trauma cases?

  • emt.dan says:

    Excellent post. Thank you. Is it just me or is there the capacity for a hip fracture, if moved improperly, possibly sever the femoral and cause massive hummorage– cause large amounts of blood to pool in the pelvis and cause hypoglycemia shock pretty quickly– and its hard to spot the cause…? Wouldnt that be enough of a reason to call ALS…? for the IV and meds, plus being ready to bolus fluids.In my region, just about every hip fx needs to be boarded + c-collar and blocks– even if its a ground level fall. Neither ALS nor BLS can clear spines– and even if we could, there would be distracting pain.

  • Lisa says:

    As both a Paramedic and an EMD-trained dispatcher, I see both sides. In an area with minimal ALS coverage, as you said, the goal is to get the ALS resources to the patients who most need them – life threatening emergencies like chest pain, trouble breathing, unresponsiveness, etc. The reasoning behind making a hip injury a downgraded response is that a hip fracture, while traumatic and very painful, is not considered to be immediately life threatening. I do, however, agree that those patients need good pain control as soon as possible, and I consider myself lucky to live in an area that has all-ALS response. (I started in EMS in an area where ALS coverage was spotty at best, and I took way too many injured patients BLS to the hospital without pain control, or cardiac monitoring, etc.)You’ll be glad to hear that EMD is changing shortly – my understanding is that hip injuries will be lumped in with pelvic injuries, which will upgrade the response (depending on where you live and whether they do EMD).

  • Tom Reynolds says:

    An excellent post.As we use the same dispatch system (I believe) our ‘fall, no injury’ or ‘fall, leg injury’ are non-blue light responses, while the 20 year old who has fallen and bumped his head is lights and sirens.After a while it starts to annoy turning up to the umpteen elderly patient with a hip fracture after they have been waiting for us to deal with all those poor 20 year olds.Morphine is indeed brilliant in such cases, especially given the design of the houses and flats in my area – like you I don’t like hanging around on scene, but in these cases you are absolutely right – more time on scene is better for the patient.

  • VA FireMedic says:

    I defiantly think that a hip fx is an emergency. We dont prioritize dispatch in terms of lights/siren use, but we do dispatch ALS/BLS, and a ground level fall is BLS while a fall from height or fall with head injury is ALS. Even so, when an ALS unit does go to a BLS ground level fall (if it is the closest unit), the medic usually has the BLS driver tech the call.I’ve never been on a call where I’ve either seen or personally given morphine to a possible hip fx. Our protocols give us a max of 10mg, but even paramedics must call for orders for this if it is not an apparent injury (dislocation, compound fx, burn, etc). The funny thing is that we carry 20mg of MS in our boxes, but I’ve never even heard of a doc ordering more than 6mg.I’m all for giving pain meds if needed but its simply harder to do down here…if the doc does give us the order, its usually not enough to help. Ive been given orders for a max of 2mg on a 200lb man, and all that did was make him sick. Luckily we dont carry zofran yet and still have phenegren, thus we could make him sleepy.Another alternative that some agencies are using is laughing gas. It can be self administered and its effects almost immediately wear off after you stop inhaling it. Any discussion in your agency about that? (not that we have it either)

  • Erin says:

    I am glad you wrote on this- when I used to work for a regional dispatch center that is contracted to EMD calls for a handful of towns, I always second guessed the non priority that came up for the “hip injury” secondary to a fall. Working in the field, this EMD protocol never made sense to me. The interesting thing about it though is that if the dispatcher chose “Pelvic” instead of “hip” for area of the body that was injured, the pelvic injury, if I remember correctly, came up as ALS hot because of a severe hemorrhage risk. Sometimes the caller could not be very definitive as to the exact area…all they knew was that they were in pain and it was in that general area.

  • Kelsey says:

    Something I remember from medic school- can’t a pelvis hold like a liter of blood before you have any external indication of trouble? I mean, obviously this applies particularly to pelvic injuries with bigger mechanisms of injury, but shouldn’t we be more cautious? In my service area, ALS ALWAYS gets called on the reds for any orthopedic injury. Our medical director is HUGE on pain management, though.

  • TOTWTYTR says:

    I think that people are mistaking “emergent” and “urgent”. Hip fractures, whether they are femural head or true pelvic fractures from low height falls are certainly urgent, but are likely not emergent. Whether to medicate for pain or not is a system decision influenced by a number of variables. PCs comments and those over at Respiratory 101 inspired me to write a companion post at my blog. Those who are interested can find it at Hip Fractures and ALSAs to OPALS, they spent a lot of money to tell us something that we already knew. Major trauma requires airway management, rapid transport, and an OR. Apples and Oranges.

  • Anonymous says:

    It is shocking and unfortunately true. We found that little old ladies were waiting for ambulances dispatched non emergency. Fortunately, our chief had us just disregard the bravo code. We simply treat it as an emergent code

  • kylie says:

    I’ve been asking for years why us basics can’t have nitrous oxide for pain management. Isn’t self administered nitrous safe and effective? What’s your take on this Peter?

  • PC says:

    Thanks for all the comments. I plan to investigate this whole issue more. I thing an issue like this causes us to look at ourselves in the mirror and ask what is EMS about? Is it about being available for the big one or is about taking care of our frailest citizens when they are in excruciating pain? Ideally EMS should be both things. I would really like to see some breakthroughs in pain management that would enable basics to be able to provide better pain control. I don’t know that much about the nitrious oxide to say, but I think this whole area of pain management and prehospital priorites needs to be explored more.Thanks again for all the comments and look for a new column in a few weeks hopefully adding some more thoughts on this whole issue.Peter C

  • Life Of An Emt says:

    wow you have really made me re-think the possible hip fx calls I have to go on as a basic truck. Where we live we are strapped for medic’s we do priority 1 to the call. which I am glad that you did this post. I recently had to take a trauma pt on a long haul no I.V of course because I am a bls unit. but they did have him hep locked alot of good that does me. but anyway I had a 42 y.o.m involved in MVI he was intoxicated at the time of the accident. it wasn’t my call so I didn’t not get to see the vehicle nor the damage but after getting him to the er where he was examined their findings was that he broke his Acetabulum. which I never heard of until this call and really had no idea until you did this post of the seriousness of this type of fx. the pt had been in the er for over 6 hrs. before i get the call to tp to lsu – shreveport. the tp time is appox 1 hr 45 min give or take depending on traffic now that is almost a total of 8 hrs since this person last possible drink. they did not give him any pain medication because of his alcohol levels when he first got there. nor did they give him any before the trip is there a rational explanation for them doing this that i do not know of? i would of thought with the amount of time that had passed he would of been able to recieve something for pain but I would of atleast thought they would of ran an IV. the initial report that was given to the recieveing facility was IV fluids. Not a hep lock that the pt pulled out. That was a lovely call all the way around. Not only did I have to listen to the poor pt screaming in pain, but I also had to take a chewing for him pulling it out and not being able to put one back in. also the c-collar and spine board was removed from the pt in the hospital so the cheek that wasn’t chewed on initially got gnawed on too.

  • Witness says:

    I just looked it up in my EMD cards, and right there – “Ground-level falls in elderly patients commonly result in hip fractures, which are not prehospital emergencies.”Seriously? That’s insane.

  • Anonymous says:

    Do you medicate a person with a lower leg fracture before you splint the extremity? BLS befoe ALS. Most if not all of these elderly pt have no natural padding. Stay away from the scoops and hard backboards. Immobilize these patients on a full body vacuum mattress in a position of comfort and then reevaluate for pain management. Most of the time they will not need it. Follow some of these patients through the system and find out how many ended up with pressure sores after laying on a scoop or backboard for 2 and 3 hours. Sitting on your stretcher with the effected leg slightly bent will make your customer much happier.

  • Auto Angel says:

    Buy branded ortho mattress with free 24 hr delivery.

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