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Procedure (Boot Removal in suspected fracture) - Page 3

post #61 of 73
1/23/07 at 8:52am

With new found 1st hand knowledge-----

I agree with Lars on this damn near 100%. I felt as much before, but having just watched Bonni go through an Open fracture within the boot --- I am thouroghly convinced now that sedation is necessary and removal should wait until then--- in all but the most severe bleeding cases or those with extensive transit time to higher level care.

Schweitzer's patrol did a fine job.

Quote:
Originally Posted by Lars View Post
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 #62 of 73
1/26/07 at 8:24am
I am sooooooo glad no one tried to take off my boot before I was THOROUGHLY MEDICATED.

Schweitzer's ski patrol is not allowed to administer even an aspirin. I waited for the EMT and got an IV going in the ambulance over an hour after the accident. Only then would I have agreed to let someone without a handful of morphine vials near my boot.

Any Hot Dog Patroller who wants to take off a boot from an open fracture to 'ease the pain and swelling' had better reassess who he really wants to be more comfortable, because you aren't helping the patient.
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post #63 of 73
1/26/07 at 2:11pm
Quote:
Originally Posted by Bonni View Post
I am sooooooo glad no one tried to take off my boot before I was THOROUGHLY MEDICATED.

Only then would I have agreed to let someone without a handful of morphine vials near my boot. .
One Orthopedic surgeon told me "there are only two times to take off the boot, when full of adrenaline, or full of morphine." That said, I've been told in one place that boot removal is in the protocol, so get on with it. Feel free to refuse that part of the treatment.
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post #64 of 73
2/4/07 at 1:06am
If I read this thread correctly, we started out with a spiral fracture of a fibula, but not the tibia. A spiral facture of the fibula (the smaller bone in the leg) used to be the most common fracture in skiing. It generally occurs in a slow rearward twisting fall, which is the type that most beginners use to make.

An open (skin break) compound fracture of the tibia (big bone) and fibula is an altogether different animal. I would agree with pretty much everyone else here that boot removal should wait for serious anaesthetics, and that the goal of the patrol on the hill should be to stabilize the condition of the patient and get them down asap.
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post #65 of 73
2/8/07 at 1:34pm
Quote:
Originally Posted by Bonni View Post
Schweitzer's ski patrol is not allowed to administer even an aspirin.
After my recent experience, I'm gonna do my darndest to never ski anytime anywhere again without some percoset with me. Some of the stuff you can do to yourself hurts a lot.

As for boots, I think we've already reached the concensus that "it depends". Something to consider is that boots are heavy, sometimes uncomfortable, and sometimes can be pretty cold, and can hold that "coldness" in for a while. In most cases where it can be done without further damage, we do it. CSPS training now includes boot removal, with practice. I certainly appreciated having my boots taken off, but I'm sure I wouldn't have been as happy had it been a boot-top.

Andy
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post #66 of 73
2/8/07 at 3:15pm
Quote:
Originally Posted by Bonni View Post
I am sooooooo glad no one tried to take off my boot before I was THOROUGHLY MEDICATED.

Schweitzer's ski patrol is not allowed to administer even an aspirin. I waited for the EMT and got an IV going in the ambulance over an hour after the accident. Only then would I have agreed to let someone without a handful of morphine vials near my boot.

Any Hot Dog Patroller who wants to take off a boot from an open fracture to 'ease the pain and swelling' had better reassess who he really wants to be more comfortable, because you aren't helping the patient.
Welcome to liability 2000. No one under ALS (paramedics), including EMT-B are allowed to dispense medication, including aspirin. If a patient walks into first aid for an aspirin, I have to tell them it's available at the cafeteria cashier. If I'm in the ski patrol room at the summit, I point them to the shelf and to help themselves to the 500 count bottle, but will not get them for him. We can call for ALS for "pain management" though, and ALS will be waiting at the bottom of the hill if the pain is that bad.
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post #67 of 73
2/8/07 at 3:32pm
Again, results may vary.

In Montana we are allowed to give asprin for cardiac. Other than that, they are able to help themselves to our "supplies"

Our local ambulance service discourages their use for "pain management".

Reasons are: Sometimes we may not get an ALS ambulance due to more pressing cases elsewhere. Sometimes depending on the type of injury and the stability of the patient, the EMT-P may choose not to administer pain meds. Some surgery may be delayed if pain meds are given.
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post #68 of 73
2/8/07 at 5:41pm
Quote:
Originally Posted by 2-turn View Post
Welcome to liability 2000. No one under ALS (paramedics), including EMT-B are allowed to dispense medication, including aspirin. If a patient walks into first aid for an aspirin, I have to tell them it's available at the cafeteria cashier.
That's because apparently, they don't educate you on dispensing medications.

Anyone here who has ASA in their protocol for cardiac should understand exactly why you give it for suspected MI is the same exact reason why you may not want give it for pn management with a longbone fracture. There better NSAIDs to choose from for that application. And if you were going to be dispensing these meds for anaglesia, you would probably know why.
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post #69 of 73
2/8/07 at 8:19pm
I also thought I'd add that PO NSAIDs are not the optimal anaglesic for a longbone fx... IV narcotics please!
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post #70 of 73
2/8/07 at 8:50pm
Damn, just what we need, another reason to carry our own drugs on the mountain. Is that oregano I smell burning in that sled?
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post #71 of 73
2/8/07 at 9:19pm
Quote:
Originally Posted by Summit View Post
That's because apparently, they don't educate you on dispensing medications.

Anyone here who has ASA in their protocol for cardiac should understand exactly why you give it for suspected MI is the same exact reason why you may not want give it for pn management with a longbone fracture. There better NSAIDs to choose from for that application. And if you were going to be dispensing these meds for anaglesia, you would probably know why.
Yes, I know which analgesics do what, I can even spell the word, but I'm still not allowed to give them out. I think it's a state by state thing, but I thought it was also national. We have Ski patrollers(off duty paramedics) on hill who carry real drugs (such as epinephrine) in thier packs for an extreme emergency, but will think twice dispensing while not in a paramedic role(we've had that discussion).
ALS is called it for pain management in extreme cases, such as when the tib/fib makes a 90 degree bend at the boottop, or the femur splits the tibial plateau down the middle like a bamboo pole. (don't ask me how, but I saw the X-rays). I was involved with both, and removed both their boots in the first aid room while the patient was on morphine, and the paramedic watched.
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post #72 of 73
12/15/07 at 7:57pm
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.:
You have never skied at -40, have you? I have, and plastic does indeed become brittle at that temperature. It is far far more difficult to bend, and very often, it will simply break rather than bending. Usually this happens with older boots, but I have heard of it happening with newer models as well. Personally, I believe that the newer boots that cracked also had some form of impact damage, and that damage was probably not visible to the wearer until she or he tried to take them off.

As for boot removal, our protocol here (Quebec) is to leave it on unless you have to control hemorraging. Like others have said, it usually serves as a great splint. We are not allowed to administer any drugs whatsoever, so while we might be better at removing boots, hospitals are far better at sedating patients.
Game set and match to the hospitals.

If it were my leg, I would wait to arrive at the hospital.

Dean.
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post #73 of 73
12/16/07 at 8:17pm
Our protocol is to NOT remove a boot for anyone getting transport. We remove boots often for other injuries. Sprains, tweaks, etc. We just do a good job of it. Way better than parents or friends.

I hope all of your protocol is developed with consultation with local ER / ALS. Stating that you are "probably" better at boot removal than your trauma ER? You should know. Maybe THEY would like some training.

Get everybody on the same page. Above all do what is best for the patient.

We ARE unique, I believe. From phone contact to ER door, average eight minutes. So this is not the only thing that differs for us.
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