In The Field

police helicopter rescueShoulder dislocations don’t always happen within easy reach of a hospital. So what are the challenges and issues specific to field medicine and how can you get you and your patient out of trouble?

Gerard Fennessy describes his experience with “in-the-field” shoulder relocations.

My initial experience with shoulder dislocations began as a junior registrar in Emergency Departments, using the traditional traction/counter-traction techniques. It wasn’t until I was faced with dislocations on a daily basis as skifield doctor  on Mt Ruapehu, that I decided to learn more about shoulder dislocation. In my reading I came across Neil’s articles regarding the Cunningham Technique.

Following this, and for several reasons specific to our location, we changed our practice on the skifield to try to limit traction/counter-traction, and focus on non-sedating, non-traumatic relocations. One of the main reasons for  the change was our reluctance to use sedative medications in an isolated centre, 2 hours away from the nearest hospital and medical backup.

Although we occasionally used IV analgesics and sedatives when they were needed, we realised that all sedatives have potential problems. There was also the added workload of keeping people in the centre following sedatives, and ongoing monitoring requirements.

General Issues

Shoulder dislocation can present with several difficulties in the field. There will, of course, be arguments for either immediate relocation, by a skilled and suitably trained operator, versus extraction, analgesia, transport, investigation (x-rays) and treatment at an appropriate facility.

Primum Non Nocere – “First of all, do no harm”

In the instance of relocation in the field, “primum non nocere” – “first of all, do no harm” needs to be considered alongside the potential benefits of doing so to the patient.

The major harm that could be done is worsening the injury due to lack of proper examination, investigation and treatment. For example, should an inexperienced operator attempt a manoeuvre that involves traction/counter-traction, the risks are not simply limited to patient pain. There is the real risk of injury to the joint capsule or rotator cuff muscles or for worsening of injuries such as fractures, or mistaking a fracture of the humeral head for a dislocation.

The major benefit to the patient is immediate pain relief once the shoulder is back in. Relocation may also allow easier transport of the patient (who may be in a difficult-to-reach area, or may have other injuries such as to long bones, head or neck). There is a trend towards an increasing relocation difficulty with increasing time from dislocation, as well as rare but potentially longer term complications associated with prolonged dislocation, such as neuropraxia.

A non-sedating, non traction/counter-traction relocation technique such as the Cunningham Technique balances these risks.

Proximity to Medical Services

Proximity to medical services is an issue throughout Australasia, where ambulance services may be staffed by volunteers, or located a significant distance from the injury. The first responder might be a paramedic, a ski-patroller, a remote nurse, or someone with limited medical knowledge. The closest hospital to Mt Ruapehu Skifield, for example is a 60+ minute round trip helicopter flight (in good weather) or a 2 hour ambulance ride.

This is not including the time from injury to scene arrival, packaging and transport to a first aid facility – often this could be 4 hours from time of injury.

Upskilling of Paramedical Staff

Another reason we started using this technique, was to up-skill our first-responder ski patrollers and clinic nurses to become proficient in managing a condition that they commonly saw, and could treat effectively and safely, particularly when the doctor was unavailable or a delay was inevitable.

This allowed several relocations to happen “in-the-field”, on the side of a snow covered mountain, by the ski patroller, without requiring medications or monitoring and allowing easier extraction. This was particularly helpful to those that were injured “off-piste”, or had fallen into an area where extrication was difficult or impossible without helicopters or more staff.

Recurrent Dislocators

Further, a proportion of our patients were recurrent dislocators, so the relaxation inherent in the Cunningham Technique not only enabled the patient to take control of their own injury and pain, but also empowered them for the future. Several of these were also shown an auto-reduction technique, (the Boss-Holzach-Matter technique), in an effort to provide them with skills to relocate their own shoulders if they ever dislocated in future.

Sedation and Analgesia

Analgesia and sedation, even in a hospital setting, is not without risks. Achieving adequate analgesia or sedation for a successful traction/counter-traction technique usually involves moderate potential for airway compromise. These drugs include nitrous oxide, methoxyflurane (Penthrane(AU), Penthrox (NZ)), morphine and other opiates, midazolam, and ketamine.

Using IV/ IM opiates or ketamine, which have moderate sedative properties, should be done with adequate monitoring. It also requires the availability of reversal agents, airway trained staff and emergency airway equipment.

Others, such as methoxyflurane or nitrous oxide are arguably safer, requiring a patient to breathe, but are expensive and fiddly to use. Nitrous oxide, for example, is heavy to transport, even in small size A cylinders. At high altitudes and lower temperatures, the nitrous oxide/oxygen mixture tends to separate, reducing its usefulness in places such as skifields. There is also a potential danger of using pressurised cylinders. Methoxyflurane on the other hand comes in small glass vials, and caps that need to be unscrewed – something that is not particularly easy in a blizzard!

Oral drugs, (such as NSAIDs or compound analgesics) are slow acting and thus not useful acutely, and should be avoided due to the risk of aspiration if further sedation is needed.

Monitoring

Traditional patient monitoring in the field is difficult, if not impossible, and expensive. Pulse rate and respiratory rate can be easily determined, but may expose the patient unnecessarily to the elements. Saturation probes do not work well on someone who is peripherally cold – this is common due to the environment or immobility due to injury. ECG and blood pressure monitoring also require specialised equipment, the provision of which may only delay transport and/or treatment. Most electronic monitoring solutions also require a quiet, dry, clean environment, which may not impossible in the rain, snow or beachside. Lack of monitoring effectively precludes the use of most sedatives on the field.

X-Rays

Although we had x-rays available to us, a proportion of people declined to pay for the x-ray, and there would be times when x-rays were unavailable. A non-traction/counter-traction technique is arguably safer for these patients.

Other thoughts

In-the-field relocation may be hindered by the inability to provide an environment where the patient is psychologically prepared for the relocation, which is integral to the Cunningham Technique, or indeed any procedure that requires patient co-operation.

My experience with this technique has strengthened my belief that traction/counter-traction should not be used as a primary reduction technique. It has also highlighted to me that there is a lot of psychology involved in pain relief with all injuries, not only shoulder dislocation. The importance of engaging the patient, talking with them, and allowing the patient to take control over the pain is something that I will take with me to all my patients.

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