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Procedure (Boot Removal in suspected fracture) - Page 2

post #31 of 73
11/6/06 at 7:46am
Good thread. Our policy is to remove the boot in most cases. I do have a question though, how do you assess CMS without removing the boot?
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post #32 of 73
11/6/06 at 8:30am
Quote:
Originally Posted by Sideslip View Post
Good thread. Our policy is to remove the boot in most cases. I do have a question though, how do you assess CMS without removing the boot?

Tap tap tap Can you feel your toes? Can you wiggle them? Let me know if they go numb.

Not the greatest, but we are out on a mountainside.
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post #33 of 73
11/6/06 at 7:28pm
What a great thread!

My two bobs worth:

you have a pretty serious mechanism of injury to have an open # Fib/Tib; and I agree with others depending on where the medical center is whether you remove the boot; but there is ,in my opinion, a limited amount of assessment you could do without taking the boot off (three person job I reckon) so if it was a long way to medical center I would prob want the boot off

if it isn't splinted by the boot you might even want to put some traction on it also (our EMTs/ ambo's tell me that a Donway is handy in lower leg # as well as your standard femur) even though I have never seen us do that

Guess whatever you do would need to be justifiable

So yet another opinion!

Great post

Simon
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post #34 of 73
11/7/06 at 12:15pm
Quote:
Originally Posted by cspsskiguy View Post
Leave the boot on & stay away from the boot spreader,unless the bleeding is severe and out of control.Up here in the Great White North plastic can become brittle in the cold.Imagine the damage and pain that could occur if the boot broke,and the spreader slipped.
That isnt going to happen. In order for the platic that modern ski boots are made of to get cold enough to become brittle and brake, it would be so damn cold that you wouldn't be running the lifts either.:
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post #35 of 73
11/7/06 at 7:59pm
We make it a personal call that can be justified. Our closest hospital is 30 min away. I'd try to remove it... At least undo the buckles for the reason of excessive swelling. Aceman
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post #36 of 73
11/8/06 at 3:37pm
Quote:
Originally Posted by mtbakerskier View Post
That isnt going to happen. In order for the platic that modern ski boots are made of to get cold enough to become brittle and brake, it would be so damn cold that you wouldn't be running the lifts either.:

Grant; with all due respect. I see a whole lot of really old ski boots out on the hill. Not everyone is spancered.
Some of the boots I see, break without the help of a boot spreader.
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post #37 of 73
11/8/06 at 4:57pm
Quote:
Originally Posted by bunion View Post
Grant; with all due respect. I see a whole lot of really old ski boots out on the hill. Not everyone is spancered.
Some of the boots I see, break without the help of a boot spreader.
Any boots made in the last 10 years will not break just because of being spread when cold. If the boots are more than ten years old then, thats another case.

Thats a good point thou, because if they are skiing on boots ten plus years old, then they are probally skiing on bindings that are at least that, thus the reason for them having a compound tib-fib wich is a somewhat uncommon injury now that modern bindings are so prevelent.
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post #38 of 73
11/8/06 at 6:21pm
Boot top fractures are common (bnlt) for kids wearing snowblades which didn't have releasable bindings. Also if the boots are over 10... their prolly rear entry.
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post #39 of 73
11/8/06 at 6:22pm
Id do it yourself at the discretion of the EMS, you will probably do it better than they would, but they will know if it will be dangerous.
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post #40 of 73
11/8/06 at 9:48pm
Quote:
Originally Posted by bunion View Post
Grant; with all due respect. I see a whole lot of really old ski boots out on the hill. Not everyone is spancered.
Some of the boots I see, break without the help of a boot spreader.
We had a call for a tobaggan for a skier who's boot had exploded. He wasn't hurt, the boot just broke. Someone else on the radio said "is it an older model yellow Nordica?" It was...I guess there were some bad plastics back then and he had seen it before.
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post #41 of 73
11/8/06 at 10:22pm
Quote:
Originally Posted by newfydog View Post
We had a call for a tobaggan for a skier who's boot had exploded. He wasn't hurt, the boot just broke. Someone else on the radio said "is it an older model yellow Nordica?" It was...I guess there were some bad plastics back then and he had seen it before.
I'd bet money it wasnt bad plastic, but the effect of accumulated UV damage wich causes the plastic to eventually become oxidated and thus brittle. However it takes a LOT of UV exposure to cause this, thus it is highly doubtful to see it in boots that are less than 10 years old. However there is a very slight chance of a "weaker" boot do to problems in the molding process, but this is prety rare.
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post #42 of 73
11/9/06 at 2:41pm
There is some encouragement by the NSP and our Mnt. to remove boots for a variety of good reasons. Protocol aside, On the hill, If I get the patient to confirm CSM, I will leave boot on. I like to get everybody inside as soon as possible and not be the "bad guy who hurt me so much" out in the cold. Once in BFA I like to get the boot off, with help, on our terms. A warm boot in a warm room is just so right!
Situations demand consideration. There are no right answers, just considered decisions.

Cal
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post #43 of 73
11/9/06 at 4:56pm
Thread Starter 
This has been such a good thread, I'm glad I started it. It has brought us all together for a reason, caring. It also shows individual Patrols do things differently and really it's the situation that warrants the proceedure. Every situation and injury is different. I have no doubt that there is right way to do things in the field and in the Shack. It's up to the Patroller to decide what's best. Paid or volunteer, I have no doubt the injured skier will be in good hands.

I'd like to see more questions like this one. Dig into your past experience and come up with a scenario and a how would you do it question. I've got some strange incidents I'll post if no one else does. Whoever does though, please start a new thread.
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post #44 of 73
11/12/06 at 2:47pm
I think this is a great thread!

MEDICAL PROVIDERS! REMEMBER:

First, do no harm.

Medicine is a team sport.

It is a team sport. Are youtthe best at something? Maybe you should do it. Maybe you should talk to your team.

Talk to your medical director. Talk to the transporting EMS medical director. Talk to the flight nurse. Talk to the receving facility MDs.

Around here, you have at least 3 mountains with Level V trauma centers at the base othe hill staffed with MDs (Keystone, Breckenridge, Copper Mountain). I would think that for those patrols they would almost always leave the boot on.

Other hills have first aid rooms and use their local EMS agency for ground transport to the local ED (or flight for life if needed/available). It becomes more complex.

In general the question that should be asked about removing boots... Is this necessary? Will this do more harm than good? Am I the best person for the task? IS IT GOOD FOR THE PATIENT?

Maybe the boot needs to come off... but maybe it needs to come off with more safeguards than you have whether that is a saw or a spreader. Maybe that won't be available in a timely fashion...

On the note that the ED may not know what to do with the ski boot, when I worked on an ambulance I regularly took pts from a patrol FA room to the local ED (level IV trauma center with 3 beds)... I was regularly asked, as a known skier and rental tech, to remove the pt's boots because the ED staff didn't know how to do it and they didn't have a saw.

I showed them a few times... I told the ED they should stop by a ski rental shop. Honestly, nobody knows how to take off ski boots more gently than a good rental tech at a ski shop (second place goes to children's ski instuctors).

Just some food for thought...
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post #45 of 73
11/12/06 at 3:58pm
Thread Starter 
Good post. What gave me the reason to start this thread was another thread about Bob Barnes friend who broke his leg at Keystone. I was kind of shocked to hear the Patrol at Keystone removed his boot(open fracture tibia). Especially now that you tell me that Keystone has a Trauma Center with MD's on duty.

I'm not going to question the reasoning because I wasn't there. It's their call. I just think it was an unnessary risk and alot of extra pain to put the guy through. That's all I'm going to say on the matter.
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post #46 of 73
11/12/06 at 6:38pm
I meant to write Winter Park, not Copper Mountain (Copper Clinic does have MD's I think but they are not rated as a trauma center).

As to the incident you are referring to, I wasn't there and couldn't possibly second guess their decisions with what I know. That said, Keystone's patrol proabably has the most experienced providers and the best care of any patrol in the state,
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post #47 of 73
11/15/06 at 12:17pm
I had a pair of tecnica TNT Racings do the same.: I loved those boots. Didn't need a ride though.
Quote:
Originally Posted by newfydog View Post
We had a call for a tobaggan for a skier who's boot had exploded. He wasn't hurt, the boot just broke. Someone else on the radio said "is it an older model yellow Nordica?" It was...I guess there were some bad plastics back then and he had seen it before.
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post #48 of 73
11/17/06 at 11:02am

For what it is worth

I am not a patroller or emt, but lived through this. I broke my fib and had a chip out of it plus double break of the tib. This was a long long time ago and boots were eaiser to remove, but they removed the boot and put on a splint. Doc was happy and no problems 35 yrs later.
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post #49 of 73
11/18/06 at 3:10pm

boot removal with three patrolers

Recently I helped instruct an OEC course. We practiced boot removal, and found that three patrolers can do a much better job than the usual two. One stabilizes the leg, one spreads the opening flaps, and one rotates/removes the boot.
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post #50 of 73
11/22/06 at 12:39pm

jarski

If you don't take the boot off, the hospital will probably cut it off with a cast saw
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post #51 of 73
12/5/06 at 2:29pm
Thread Starter 
Just to let you know how a recent accident by noodler at Winter Park and how they handled the rescue. This goes a long way towards my train of thought and proper proceedure.

Quote by noodler:

I guess I didn't pray enough (see my sig). I was so worried about all my little aches and pains that I didn't consider the effects a major accident would have on my season. In over 30 years of skiing I've never broken anything. This past Saturday at Winter Park I shattered my lower right leg.

The day started out great with about 6-8" of fresh snow - powder runs on Jane and nice big soft moguls. I was trying out my new Elan MO2 skis which had just been re-ground flat so that I could reset the base bevels to 1 degree (I'll discuss the skis more in a gear thread). At about 11:00 a.m. we needed to head over to the main Winter Park area so that one of the guys I was riding with could pickup his season pass. So were were heading down Cranmer working our way down to the main lodge. We had been skiing powder and cut up on blacks all morning and the skis felt fine. Cranmer was my first go at a blue groomer for the day, but in retrospect the surface wasn't very firm. It was a "soft" groomer and had a kind of "groomer cut-up" on top of firmer snow. Even so, I felt pretty comfortable picking up the pace and wanted to see where the speed limit was for the MO2s. I was cranking out some pretty fast GS style turns with lots of angulation and hip drop (my impersonation of racer style) - that's when my day all went wrong.

In the middle of a high-speed right-hand GS turn I caught the outside edge of my inside ski. As my body kept going right, my right leg went left. I'm pretty sure I was doing about 45-50mph at the time of the crash, but unfortunately my GPS had run out of battery power about 2 runs prior (I have a pretty good feel of my skiing speeds since getting the GPS).

When the downhill forces blew through my right leg I was left with a shattered mess. I blew out of both skis and my right leg was just flopping about - I immediately knew I broke it and I knew it was really bad. It took ski patrol about 5 minutes to get to me and another 5 minutes for the meat wagon to get to the accident scene. They assessed me on-slope and then splinted my right leg in the boot. They put me on the sled and took me into the hospital clinic. The ride down to the clinic in the sled was absolutely miserable. It's no fun to stare at the sky when you're cold and in pain.

At the clinic they decided to do all of the x-rays with my ski boot still on. My foot was so numb and my toes were really cold, but I could still feel them. They wanted to see the x-rays first to know what they were dealing with before attempting any further treatment (read that as NO pain killers allowed yet). The x-rays showed what they call a "segmented" fracture. I called it a jigsaw puzzle. My tibia was in 4 pieces, my fibula in 3, and there is a large medial ankle fracture. With this information in hand they knew I was heading for surgery so they started an IV for me and hit me with some morphine. After about 15 minutes or so of the morphine they decided it was time to get the boot of my foot. I think I now know what giving birth feels like. Taking the boot of my injured leg was the most intense excruciating pain I've ever felt in my life, but it sure did feel better once they got it off.

It took hours to figure out what doctor was going to handle my case and what hospital I was going to. When they finally figured something out I told them "no" and to go figure out something better. They wanted me to see a guy who was going to put me in St. Anthony's downtown and who wasn't going to operate until Monday. Instead I got them to find a doctor who was at Swedish in Englewood (much closer for my wife) and who did the surgery Saturday night. The clinic wanted to ship me down in an ambulance, but I'm a stubborn fool who decided that I wanted to go back down with my buddies in my own car. So they gave me a big dose of pain killer, instructed my friends on CPR and what to look for to make sure I was OK and we were off. In restrospect I was in shock and made a stupid choice - the ride was fine and they got me to the hospital without any problems, but it was silly for me to add that level of risk to an already bad situation.

At Swedish hospital the doctor reviewed my films and looked at my leg. He decided that it would be best to go into surgery immediately and avoid the possible risks of waiting. In surgery he installed a titanium rod inside my tibia which was inserted through the knee. He also used a bunch of titanium screws to secure the rod, stablize my ankle, and fix my fibula. They haven't shown me the new pictures with all this hardware installed, but I bet it looks pretty cool . The doc said that the hardware will actually make the injured areas stronger in the long run, but if I'm "feeling" them he would remove the hardware in 6 months - my choice. He said that I should actually be able to heal faster with the added support of the hardware and he thinks I'll be up and around in about 8 weeks. Of course there's months of physical therapy to follow so right now I'm pretty much thinking that my season is over.

They released me from the hospital yesterday afternoon and now I'm just trying to figure out how to run my life with my leg elevated.

This was noodler's report not mine but it's very similar to the proceedure followed with my Son's injury at Copper and much the same as Iwould handle a similar accident. Of course, we're all different.
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post #52 of 73
12/5/06 at 4:24pm
Pardon me, but I haven't read through this entire thread yet. I don't generally frequent this forum, but Lars mentioned he was posting my accident as an example.

The main question in my mind (as the patrollers, nurses, and doctors all debated about pulling my boot off) was whether or not the process was going to do additional damage. I made an assumption that these people are all professionals and they deal with these types of injuries frequently. So I trusted them and didn't question their desire to get my boot off without cutting. I never told them to not cut the boot so they must have felt confident they could remove it without further injury - they sure couldn't do it without further pain though!

I'm just glad I wasn't wearing a stiff 2-piece overlap boot. I don't know how they could have gotten something like that off my foot without cutting. It's interesting to note that last season when my son broke his tibia at Copper they pulled his boot off without cutting also. I don't remember that part of his experience very well though now.
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post #53 of 73
12/5/06 at 6:23pm
Quote:
Originally Posted by Noodler View Post
Pardon me, but I haven't read through this entire thread yet. I don't generally frequent this forum, but Lars mentioned he was posting my accident as an example.

The main question in my mind (as the patrollers, nurses, and doctors all debated about pulling my boot off) was whether or not the process was going to do additional damage. I made an assumption that these people are all professionals and they deal with these types of injuries frequently. So I trusted them and didn't question their desire to get my boot off without cutting. I never told them to not cut the boot so they must have felt confident they could remove it without further injury - they sure couldn't do it without further pain though!

I'm just glad I wasn't wearing a stiff 2-piece overlap boot. I don't know how they could have gotten something like that off my foot without cutting. It's interesting to note that last season when my son broke his tibia at Copper they pulled his boot off without cutting also. I don't remember that part of his experience very well though now.
First and foremost, Noodler it is good to hear that you are doing well and on your way to recovery. Good luck with everything.

Second, I did a spiral fracture of my fibula about ten years ago while roller blading. Don't ask, at the time I thought it would be a good training method. It was a slow twisting rearward fall while moving forward, exactly like a beginning skier.

At the time I was with my daughter who was about seven. I knew immediately that my leg was broken because I could hear it snap. Rather than continue on the roller blades, I sat down and pulled them off my self. Then I walked very carefully home, sending my daughter ahead to get my wife. Unfortunately the wife was out shopping at the time, so I ended up driving myself to the ER since I knew I needed help. I think shock helps a lot, but it was actually surprising how little pain I felt. Again, I was careful how I walked and drove and thankfully didn't do any further damage.

It would seem to me that if this is a fracture of the fibula, and there isn't a lot of pain, that it shouldn't be that big a deal to get the boot off, especially if you do it soon after the accident. On the other hand as long as you are not in a super tight boot, like a racing plug, I'm not sure that it would hurt to leave it on since as others have noted it will help to control swelling and act to some extent as a splint.

On the plus side Noodler, I now know when it is going to snow in advance thanks to my weather-detecting ankle. So there may a silver lining in this cloud.
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post #54 of 73
12/10/06 at 8:36pm

Fwiw

Hi everyone -

I've been a member here for a long time, but don't post too often. This thread caught my eye as I have experienced an open tibia fracture inside my boot. (Fibula was shattered as well but, not an open fracture.) Not an experience I would ever want to repeat, that's for sure!

Anyway, I 'knew' as I was flipping thru the air that something was horribly wrong and, rather fortunately for me, there was a patroller not 20 yards from where I crashed. There was quite a gathering of patrollers surrounding me pretty quickly. I recall BEGGING for someone to take my boot off! And repeatedly complaining about the pressure. There was a conference of sorts and I was told "We're going to leave your boot on until you get to the hospital". (The hospital is about a 15 minute drive from this ski area and services about 18 different ski areas, so the ER staff is pretty seasoned in all kinds of ski/snowboard injuries.)

Well, anyway, my boot was left on...much to my chagrin. One thing thing I noticed as I was being transported in the sled was the feeling that my foot was like some sort of bobble head doll...every time the sno-mo slowed and the sled kind of stopped, I got that same feeling. Very weird. Of course, the weird feeling made more sense once it was discovered that I had an open tibia fracture and a severely comminuted fibula fracture.

The on the mountain assessment was a probable fracture of my tibia and fibula and, there was question/concern re: open or closed. However, the severity of the injury was not known/confirmed until my boot was removed in the ER.

I've got to tell you, for all my begging on the mountain to have my boot removed, I realize now that the wiser call was to leave the boot on. I guess the boot was actually stabilizing the fractures (somewhat). Also, having my boot removed while properly sedated...morphine and fentanyl (sp) HAS to be better than going thru that experience on the mountain or in the patrol room...not sedated.

Oh, immediate surgery. IM rod/static in the tibia (cross locking bolts in the top and bottom of the rod) and a molded tubular plate affixed with 6 screws to the two pieces of my fibula. Fractured beginning of April skiing agin the following November (with hardware still in).

Anyway, kudos to all you patrollers for all you do!
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post #55 of 73
12/11/06 at 1:05pm
**I posted about this in noodlers post in the general forum

Broke my tibia and fibula clean through, about 3 inches below the top of the boot. The instant it happened, I knew it was broken. I had these Technica boots at the time that were very difficult to get on and off. (required almost all of my strength to get on and off)

I was only 12 at the time and was begging for them to somehow cut the boot off, because I knew what lay ahead of me if they were going to remove it the traditional way. In the ambulance, 3 guys pulled the boot apart and it was a truely awful awful experience, worse than the break itself by far.
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post #56 of 73
12/12/06 at 5:38am
Quote:
Originally Posted by mtbakerskier View Post
That isnt going to happen. In order for the platic that modern ski boots are made of to get cold enough to become brittle and brake, it would be so damn cold that you wouldn't be running the lifts either.:
My sister's Lange cracked from a minor fall this last weekend. To be fair, it's a few years old, she bought used, and there's no telling whether it sat in the sun, got dropped, etc. Cracked in two places and a big chunk fell out.
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post #57 of 73
12/14/06 at 11:53am
First of all, there seems to be a growing number of spiral fractures happening within the sport again. Granted, the numbers are still not as great as the typical knee injury, but growing, none the less. But the reasons behind that are for another thread.

As I documented here last Nov, I also suffered the same break- spiral, tib/fib, boot top, open fracture, at Copper Mtn.

The last thing I remember prior to realizing my boot was off, was explaining to someone exactly how my boot was set up. (Brand new Nordica Dobermans, multiple power straps, custom buckles, foamed liner, etc)

Though the pain from the muscular contractions of the gastroc was significant prior to the boot removal, I think I was pretty fortunate! After giving me a cocktail of morphine and valium, they gave me 2 hits of a drug called VERSED. It is an amnesiac, causing short term memory loss.

As cgeib can attest (he was in the next room), it took 5 people to remove my boots. And from all accounts, I was in a great deal of distress as they did so (read- swearing like a bloody sailor). So apparently the pain was still there, but I have absolutely NO recollection of it at all.

The next thing I remember, Tsavo and KLKaye were there, we were chatting, and I suddenly realized my boot was no longer on. Whether is was my fun cocktail or what, the pain was greatly reduced.

I fully expected to hear that they had cut the boot off as I had authorized them to do, but was suprised to find they had removed it manually. Apparently the Copper Mtn Clinic does not have (or didn't at the time) the tools necessary to cut a boot off. (I guess I'm kind of happy, it saved me a good pair of boots which I will use after the hardware is taken out of my leg.)

During surgery a few hours later, it was found there was some vascular damage which needed to be repaired along with reduction of the fracture. But whether that occurred as part of the original incident, or as part of the boot removal process, is not known.

That's my story, and I'm sticking to it! You may decide how this fits in with the discussion of this thread. Either pro or con of the topic. But as far as I'm concerned, it worked.
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post #58 of 73
12/14/06 at 12:11pm
Thread Starter 
Which goes back to my original shock of any Patrol removing a boot of a spiral or open fracture patient. No way in he!! would I attempt to do so. Putting anyone through that without sedation or without the help of emergency room personell is mindboggeling. It also seems to me that Copper Patrol and facilities are top notch. I know the fine job they did with my Son will stick with me a long time.

I don't know what the consensus has been here but from my personal experience and from the testimony of a few here it's better to leave the boot on till the patient is sedated and in an emergency facility. Of course, every Patrol is different, but should they be?
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post #59 of 73
12/14/06 at 10:54pm
Quote:
Originally Posted by Lars View Post
I don't know what the consensus has been here but from my personal experience and from the testimony of a few here it's better to leave the boot on till the patient is sedated and in an emergency facility. Of course, every Patrol is different, but should they be?
I think the consensus is that every case is different. Location/severity of injury, any bleeding that needs to be controlled inside the boot, ETA to the first aid room, ETA to the hospital, local protocol and who's better equipped to do it, all play a part in the decision on when a boot gets removed.
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post #60 of 73
1/18/07 at 8:07am
Very Nice post Lars!

The one thing everyone needs to do is practice! Removing a boot with three people is preferred if the decision is to remove the boot. Practice as the remover, and the stabilizer. And more importantly let someone else practice on you. The best way to learn to remove the boot and cause as little stress to the area as possible is to be the patient and actually feel what goes on when someone is yanking on your foot. If done right its incredible how easily a boot can be removed.

Just my 2 cents

Kurt
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