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 Glasgow 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
