Splinting

I am today as excited about being a paramedic as I ever have been in my nearly twenty years with the rocker on my shoulder. This morning I came in and checked my gear and ambulance thoroughly. I paid particular attention to the splinting gear located under the bench seat. (There was a traction splint, an old rusted wire ladder splint and several cardboard splints of various sizes and shapes.) You see, what really has me excited is a chance today to splint a patient’s broken limb.

I have been in recent years a strong advocate for pain management. Treating and easing pain has become for me the reason to be in EMS. It is something I can do on the job every day. Cardiac arrests and major trauma — what many define as our landmark calls — are certainly not every day occurrences. Pain management is something we can do every day — something that really makes our patients feel better and thankful for our care.

Last week I had the opportunity to use Fentanyl for just the third time. We have only been carrying the drug for two weeks. I responded to an elderly male, who had fallen in his bathroom and broken his leg — likely his tibia and fibula. After a quick assessment I immediately gave him 50 mcg of Fentanyl IM into his right shoulder. (He was a dialysis patient and has very poor veins, so I made the decision to go right for the IM and get some relief to ease his 10 of 10 pain).

Within minutes, I could see a some relief crossing his face, although he reported the pain was still high — now an 8. Given where he lay, moving him to the stretcher was fairly difficult, but we put a pillow under his leg as we supported it and gently lifted him up. He did grimace, but felt slightly better once we had him supine. I elevated his leg, applied ice packs and padding, and then gave him another 50 mcg of Fentanyl while my partner shoveled the snow from the man’s patio so we could get the stretcher out without too much jostling. In the ambulance, I was able to get an IV — a 24 in the underside of the wrist — and give another 50 mcgs of Fentanyl IM. This last dose seemed to really do the trick. The ride into the hospital was largely pain free. He was down to a 4 on the pain scale, but then just as we arrived at the hospital, he said the pain was returning. Having already hit my standing order limit, I briefly considered calling for another dose. Fentanyl, while working quicker than morphine, does not last as long. But I punted, thinking having already given 150 mcgs to a 70-year-old man, they may not approve my request for another 50 seeing I was in their parking lot already. (I know I should have called anyway.)

At triage, I told the PA who examined the patients along with the nurse, that the patient had a likely broken leg, had gotten 150 mcgs of Fentanyl, which was wearing off and would likely need another dose. She agreed and placed the order. Placing the order however, still does not mean immediate relief. Once we got our room assignment, we took the patient down the hall and gently moved him over, and again, set his leg up on a pillow and some bath blankets. I could see in his grimace that the pain was getting much worse.

I went to the EMS room and wrote my report, and when I returned with it, I looked in the room to say good bye to the patient and it was then that it struck me. Here was my patient, laying in bed despite the 150 mcg of Fentanyl — the hospital ordered dose had yet to be dispensed — and he was still in considerable pain. I looked at his broken leg and it all came to in one big realization. Where was the splint? Sure there was a pillow and ice and some padding, but there was no splint. No secure immobilization to prevent the tiny bone ends from rubbing tissue should the patient try to reposition himself in bed.

Somehow over the years, my splinting had deteriorated from dutiful by the book EMT care to basically putting the broken bone on a pillow and trying to keep the patient still. Perhaps if I had done what as a new EMT so many years ago I had done, the patient would have been more comfortable. Now, I am not saying take away my morphine and Fentanyl and just give me a pile of splints and cravats, but I am saying I recognize a clear area for improvement.

In subsequent days I have sought advice from my peers and from MDs. I have read book chapters on splinting, Googled “splinting,” and just this morning, watched quite a good series on splinting on EHow: First Aid for Splints & Bleeding Wounds: Video Series

Here is one on How to Apply a Shoulder Sling.

This stuff is awesome. My sling and swathing needed a tuneup and I have been grabbing every EMT that walks by and subjecting them to “”Hey, Do you mind if I sling and swath you?”

They think I am crazy. Maybe I am. My dream this morning is to become a Gran Leggo Master of Splinting, a Frank Lloyd Wright of the trade. When I bring a patient into the ED, not only do I want to have given them analgesia, I want to have splinted them with love and care and no spaces in the padding. I want to be able to say to the triage nurse: “Behold, my splint!”

Behold, my sling and swath!

12 Comments

  • jam says:

    Thanks for posting this and your series on pain management. As a relatively newer medic, I’ve made it a goal to make pain relief and comfort a priority. Wish more in EMS were as self aware and committed to learning as you are. Keep it up!

  • Bill Young says:

    This is an awesome post on the importance of pain management. I have always taught my students that if you arrive at the hospital, with a patient still in pain and pain medication left in your drug kit (pending respiratory status, of course) that you were garbage for a medic. Keep the great message going!

  • Michael says:

    ….Only to have them cut it all off in triage and then send you to the room sans-splint anyways. Happens every. single. time.

  • Matt says:

    You’re awesome, Peter.

    If you want a ton of splinting practice, have you considered taking a wilderness medicine class (WFR or WEMT)? Surely you wouldn’t get much out of the discussion of, say, diabetes, but you might benefit from a ton of skill practice in things like spinting. (I don’t work for any schools or anything–just passing it on.)

  • medicscribe says:

    Thanks for the comments. I have been reading some wilderness books, which do have excellent material on splinting. I may try to take a wilderness course should one be offered around here.

    Michael- you are very right about what happens in triage and I think because triage always undoes our splints, I ended up not splinting as much, ending up with just laying the bone on a pillow, which is how triage leaves it. The problem of course is when people reposition themselves post triage. I will be curious to see and comment on what happens when I bring in one of my splints now. They undo it, will I resplint them or not? I must be sure to bring tape and cling into the ED with me.

    Bill, I like your saying about the patient being in pain and the medic still having pain meds in their kit. I may use that in a pain lecture.

    Thanks again for the comments,

    Peter C

  • Cs says:

    Is splinting just like a LSB and is soon removed by the ED. Yes. We use it for transport and let the hospital do what they need to. Question…drugs or splint first?

  • Renee says:

    Since my company is one that provides BLS level EMS at events, I deal with a lot of trauma. Splinting is one thing I do all the time. My opinion: SPLINT FIRST. Many times, splinting takes the pain down considerably. Ice second. Between the two, pain management is more likely to be successful with less medication.

    There are exceptions to this. I had one at a soccer match a few years ago. Pre-teen with a distal femur fracture / knee dislocation (yep, both). No way was I moving or splinting this kid until the medics got there and got his pain under control. He had a good strong pedal pulse, even with the knee dislocation (BTW, the arriving paramedics concurred with my decision to not splint him until he was medicated… AFTER they tried to splint him and realized why I had not. He got IV access and pain meds, then was splinted, and was a lot more comfortable.).

  • Renee says:

    And when it comes to the ED, that’s them. That should not affect our decision to make our patients as comfortable as possible.

  • doobis says:

    I like to be generous in PN management when justified, but I am not the “candy man” and will not give narcotics to every little complaint people call 911 over. I cannot justify taking an ALS rescue out of the system to dope up everyone that has the complaint of PN and I think it is reckless to expose them to narcs when they can do without as with minor to moderate PN. Of course, a broken leg is certainly justifiable. I have noticed that at the 150 mcg of Fentanyl, most PTs tend to get that glazed look across their face and the PN is gone. If it is a longer xport, I will give additional doses to counteract the roughly 45 min half life.

    I look forward to looking over the splinting videos later this week.

  • B says:

    Mike- I’ve also seen plenty of crews take their splints with them when they leave.

    I do agree with you though, splints, wound management, head blocks- it all comes off in triage. Apparently we’re too stupid to tell when something’s broken. Triage nurses must have the x-ray vision that we lack.

    Peter- do you have the IN option for your Fent? That way you wouldn’t even have to stick them for that initial pain relief.

  • KanukMedic says:

    Great post. Couple of points though worth noting. First: Its an EMS urban myth that Fentanyl doesn’t last as long as Morphine. Fentanyl has faster onset and has similar duration. Some evidence says that Fentanyl tends to work better for extremity pain versus abdominal pain like renal colic Ref:Fleischman RJ, Frazer DG, Daya M, et al. Effectiveness and safety of fentanyl compared with morphine for out-of-hospital analgesia. Prehosp Emerg Care. 2010;14:167–175.

    Second: Maybe it was the slower onset of the IM injections catching up with the last one IV that made the difference for your patient. Hard to say. Fentanyl can also be given Intranasal (and bucally) which has a faster onset that IM but unfortunately that route is not always permitted in all services. Third: My ER experience is the same as yours. If at all possible I give my last analgesia dose as I am offloading onto the ER bed knowing that the patient will be bounced around some more plus may have to wait some time for additional meds to be delivered. Sometimes the pain level at that point is 2-3/10, down from 9 or 10 but I know that this is temporary and will ratchet back up once I leave the busy ER. I always check with the receiving Rn or MD when I do this and my offer has never been declined.

  • jam says:

    Kanuk- that’s another good point. I try to think about what the pt. Will experience in the next 10-30 minutes while they wait to be registered, evaluated, had more pain control ordered, etc. All depends where you work and the ED you transport to. I’ve given morphine while the patient was on the ED cart waiting to be evaluated… but that was on a very busy day.

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