Pain management in wrist fractures

How do you control pain when reducing wrist fractures?

For those of us in rural settings, we frequently have patients present with broken bones. When we do, the problem is not usually “how to reduce a fracture”, but “how do we manage pain while reducing the fracture”. If you are working in a metropolitan area, you give the patient a little pain medication and send them to the Orthopedist. Well guess what, in the rural setting you are probably going to be as close to an Orthopedic Surgeon as the patient gets.

Now some of the techniques Ralph and I are going to mention might not be within your scope of practice in the state you are working in, so just because you read about it here, DOES NOT give you permission to go try it. You have to remember that I work in frontier rural Alaska and the closest orthopedist is over 300 air miles away.   Also, some of the “details and statistics” I mention come from a variety of places. If you are looking for specific data and the most recent and factual information, you need to research it yourself so you can include specific citations.

Today we are going to talk about “wrist fractures”. These fractures usually occur in two specific populations. The first is youth and result from high energy falls, the second is the elderly and result from low energy falls and are an indirect result of osteoporotic bones. In both groups, the fractures are most commonly the result of a fall onto an outstretched hand.

With any fracture, we want to identify the mechanism of injury and complete assessment of neurovascular status including motor function. ANY FRACTURE WITH NEURO OR CIRCULATORY COMPROMISE IS A TRUE EMERGENCY! These are not the focus of this discussion.

After we have established adequate circulation, motor function (remember there is a BIG difference between “I don’t want to because it hurts” and “I am trying and nothing is happening”), and neuro status, we need an x-ray.  Things that increase the severity of the injury include, but are not limited to: severe comminution, fracture-dislocation, etc.

 

Indications for Orthopedic consultation include: open fractures, fractures that cause circulatory compromise, compartment syndrome, acute neuropathy, palmarly displaced fractures (Smith’s fractures), fracture dislocations, distal radial fractures associated with styloid and scaphoid fractures, or fractures with significant displacement.

Now that we have determined that it is appropriate for us to reduce and stabilize the fracture, how do we manage pain during the reduction? If the usual populations are the young and the old, do we really want to use moderate sedation? I am not sure about you, but I would rather not, despite what Ralph says.

The method of choice for reduction pain management is a “hematoma block”. It sounds complicated, but it really isn’t. The hematoma block can be used with or without systemic pain medication. I am going to summarize the technique from several sources.  Before attempting this, verify it is within your scope of practice and find a mentor that is willing to show you the proper technique on an actual patient.

This fracture was reduced using a small amount of IV Fentanyl prior to performing a hematoma block. The patient tolerated the procedure well without sedation.

Have a great day!

Some things you just can’t make up!

Hello again from beautiful Dillingham, Alaska. I have been back here for a week and am all settled in my apartment. Everyone has made me feel welcome to the point that I really don’t feel like I have been gone for almost three months. As usual, there are several new faces. For a few of the “newbies” this is their first Alaska experience, the rest are like me, here because they enjoy working here. The official term in Native Facilities for what I do is (TDY). There are TDY positions in just about every licensed healthcare position in these facilities: physicians, nurse practitioners, physician assistants, dentist, dental hygienist, radiology techs, registered nurses, and some I probably haven’t even thought of.

I originally planned to blog two or three time a week, but Ralph and I have been discussing some of the things that we have noticed about the newbies. We have been trying to understand the thought processes, or lack of thought processes, for  someone traveling many miles from home to work for several months in a setting they have never been in. In some previous blogs, I have told you how I prepare to go to a new place or state. The research I do about “little things” like: scope of practice, licensing, prescribing laws, and many other “little things”.

Now I am in no way finding fault, Ralph and I are just making observations. We are going to tell you a “pretend story” about Sally (no we ain’t dumb enough to use real names, except our own). We are going to pretend that Sally is a Physician’s Assistant (PA) who is coming to a state that she has never practiced in before. There are a few things that Ralph and I think Sally should have known about BEFORE she got to Alaska.

1)      Sally is coming from a state where she can not prescribe medications (her sponsoring physician has to write prescriptions).

2)       Sally has only worked in a large emergency room and has NEVER practiced rural (much less frontier) medicine.

3)      Sally does not have a DEA number.

4)      Sally does not know that she can only get a “provisional license” in Alaska until she has worked for 160 “directly supervised” hours in Alaska.

5)      Sally does not know what schedules of drugs a PA can prescribe in Alaska.

6)      Sally is going be assigned to a remote village clinic and will be doing and seeing “everything that comes through the door”, but when she gets here, Sally says: “I don’t do OB or skin, who comes and takes care of them?” 

7)      Sally made a statement to us that really upset Ralph: “you are just a mid level, why don’t you know what schedules of drugs I can prescribe?”

8)      Sally didn’t know that Alaska is a ZERO tolerance state as far as drugs and alcohol in the work place.

Now those of you that really know Ralph and I are probably betting about know that we probably said some “un-nice things” to Sally. Well I hate to disappoint you, but for once the filter was working, at least for my “out loud” voice. And other than number seven, our mouths were gaping open too wide to utter a response.

Ralph and I can not even imagine coming here and not knowing the answers to the above questions. It has nothing to do with PA, NP, RN, MD, Rad Tech ……….

IT IS ALL ABOUT BEING A PROFESSIONAL!

You have “paid the price” to earn you license (at what ever level), you say you want to be treated like a professional, yet many evidently do not even know the definition of the word “professional”. In order to be respected, you should earn it by your actions and preparation. Too often healthcare workers want to “talk the talk” about being treated as a professional, but Ralph and I find very few that really “walk the walk” every day.

My response to number seven is:

First, I hate the term “mid level”, but I tolerate it at this point in my career because I have much more important sand boxes to stick my flag in where I can choose to “die on my sword”.  Anyone that puts the word “only” in front of their profession, well I don’t think their opinion of themselves is very high on the “notching stick”, so it is really their problem to address. But I can recommend several good therapists.

Now Ralph’s response to number seven can not be posted here, because this is only a PG site. He did reference sunny beaches, miles and miles of desolate tundra, and something about Sally’s figure cause he kept talking about bodies.

Have a great weekend, and be PROUD of your profession by ACTING like a professional!

Sitting in the Anchorage airport

Well yesterday afternoon and evening was spent getting from Memphis to Anchorage. When we boarded the plane in Memphis for the flight to Minneapolis, the pilot "informed" us that we would be delayed "a few minutes" for a maintance issue. As always seems to be the case, the “bitching” started almost instantly. A “gentleman” (Ralph says he was no gentleman) a few rows in front of me started cussing and using words I had to look up in Mr Webster’s book. He seemed to be fueling the other passenger’s frustration. Now understand that the entire delay was less than ten minutes. The pilot informed us that the “maintance” had been completed and he would do his best to make up some time in the air and have us to Minneapolis on time.

Unfortunately, this did little to quell the “bitching passengers” nor did it improve their vocabulary. Fortunately for Ralph and I there were no small children on the flight. The flight was basically uneventful after that. Our captain, true to his word, had us deplaning eight minutes before we were originally scheduled to arrive in Minneapolis.

Now I do not profess to be the “brightest bulb” on the tree, BUT, I am personally glad someone found the “maintance issue” prior to our take off. I felt sorry for the flight crew because of the verbal comments and snotty attitude that several passengers had during the flight. I wonder how they would have felt had we needed to make and emergency landing because the “maintance issue” was not addressed prior to take off? What if it had caused an in flight emergency or resulted in major equipment failure?

Every time I witness these delays and the passengers reactions, Ralph repeats the words of Ron White in my ear over and over:

“We will be the first ones at the crash site”……

Have a great day!