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Consider this Case Study

Terry Dinerman trauma-list@trauma.org
Wed, 5 Jun 2002 09:58:42 -0700


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Stephanie Stafford-

Case in point regarding vascular Doppler in the field:

On my last shift I attended a 34 y/o male bicyclist who, while on his =
customary pre-dawn ride,  hit a hard to see gate and fell on his =
extended right arm. He was rewarded with a severely angulated, fractured =
/ dislocated right elbow. (Probably snapped the humeral head off).  He =
was wearing his helmet tho.  (Said he bikes for his health!) =20

Cleared C-spine according to our protocol, discovered no other notable =
injuries during the full exam,(some minor road rash / lacs) splinted the =
arm from shoulder to fingertips (no radial pulse was noted before or =
after splinting), moved him to the rig, started IV NS for analgesia, =
administered 4 mg Morphine for pain, obtained vascular Doppler of distal =
fingertips indicating circulation present, transported to local ED.  =
Local ED MD confirmed Doppler, and diagnosis via x-ray. Local ortho and =
vascular specialists were contacted and Pt was transferred from local ED =
to Houston (75 miles) for open reduction at a specialist ortho hospital. =
=20

The only time I feel may have been lost was the few moments taken to =
hunt for a pulse after no palpable radial pulse could be found. The limb =
was still warm and pulsatile (via Doppler) and I started an IV and =
administered analgesia prior to departure, since our roads are rough and =
the ride would have been quite an ordeal for the Pt, who otherwise =
reacted strongly to even slight movements.

If the limb was non-pulsatile, I would have opted for air transport to =
the specialists in Houston, rather than a stop for diagnosis and =
stabilization in the local ED.

All the Doppler did was give me a better picture of the conditions =
extant, and allow me to make a more appropriate transport decision. =20

Likewise, if a Fetal Doppler indicates fetal distress, I opt for air =
transport to specialized treatment.

A moment to choose the most appropriate treatment venue for each patient =
cannot be considered time wasted, a more thorough clinical picture =
grants the luxury of more informed decision making and generally =
produces a more desirable outcome in the patient.

I would prefer to see the above patient treated by specialists who treat =
thousands of cases yearly, in an operating room especially equipped and =
supplied for the task, than hope the local venue can handle it. =20

He'll be back on his bike that much sooner, with less severe post =
incident rehabilitation issues if the initial treatment is handled =
appropriately.

Regards-

Terry Dinerman EMTP
  ----- Original Message -----=20
  From: stephanie staford=20
  To: trauma-list@trauma.org=20
  Sent: Wednesday, June 05, 2002 3:54 AM
  Subject: Re: Consider this Case Study


  are they used on the rig or in the field?  does this ever slow down =
response time and get patient to hospital later?=20

  stephanie stafford=20

    Terry Dinerman <dinerman@computron.net> wrote:=20

    Rowley-

    Thanks for the advice, the crowd seems to be in agreement on this =
one. =20

    The Doppler's are getting positively cheap around here, the two =
units we have deployed (one with a tight beam head for vascular use the =
other with a wide field for fetal heart rate) are simple and rugged and =
cost less than $150 each.  They give good results with inexperienced =
users.  All our long bone fractures are treated to a Doppler exam to =
confirm less than palpable pulses and our preggers get a fetal heart =
rate.  If you want a manufacturer, send me a e-mail and I will provide =
the information.

    Regards-
    Terry Dinerman EMTP
      ----- Original Message -----=20
      From: Rowley Cottingham=20
      To: trauma-list@trauma.org=20
      Sent: Wednesday, May 29, 2002 6:49 AM
      Subject: RE: Consider this Case Study


      It's a no-brainer, as you guys say. My only concern would be that =
28% of
      patients vomit with opiates, and you need to be prepared for that
      possibility with the changes of advanced pregnancy pressing on the =
stomach.
      Also, monitor her pulse rate and width extremely carefully because =
of the
      haemodynamic changes associated with advanced pregnancy - they =
behave a bit
      like children with a rising pulse followed by abrupt circulatory =
collapse.

      I am deeply impressed you have a doppler on ambulances!

      -----Original Message-----
      From: trauma-list-admin@trauma.org
      [mailto:trauma-list-admin@trauma.org]On Behalf Of Timothy J Coats
      Sent: 29 May 2002 10:11
      To: trauma-list@trauma.org
      Subject: Re: Consider this Case Study


      Titrate morphine.
      I feel uncomfortable - there is too much agreement here!!!!
      Tim.


      --
      trauma-list : TRAUMA.ORG
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<META content=3D"MSHTML 6.00.2600.0" name=3DGENERATOR></HEAD>
<BODY bgColor=3D#ffffff>
<DIV><FONT face=3D"Comic Sans MS">Stephanie Stafford-</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Case in point regarding vascular =
Doppler in the=20
field:</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">On my last shift I attended a 34 y/o =
male=20
bicyclist who, while on his customary pre-dawn ride, &nbsp;hit a hard to =
see=20
gate and fell on his extended right arm. He&nbsp;was rewarded with a =
severely=20
angulated, fractured / dislocated right elbow. (Probably snapped the =
humeral=20
head off).&nbsp; He was wearing his helmet tho.&nbsp; (Said he bikes for =
his=20
health!)&nbsp; </FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Cleared C-spine according to our=20
protocol,&nbsp;discovered no other notable injuries during the full =
exam,(some=20
minor road rash / lacs) splinted the arm from shoulder to fingertips (no =
radial=20
pulse was noted before or after splinting), moved him to the rig, =
started IV NS=20
for analgesia, administered 4 mg Morphine for pain, obtained vascular =
Doppler of=20
distal fingertips indicating circulation present, transported to local =
ED.&nbsp;=20
Local ED MD confirmed Doppler, and diagnosis via x-ray. Local ortho and =
vascular=20
specialists were contacted and Pt was transferred from local ED to =
Houston (75=20
miles) for open reduction at a specialist ortho hospital.&nbsp; =
</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">The only time I feel may have been =
lost was the=20
few moments taken to hunt for a pulse after no palpable radial pulse =
could be=20
found. The limb was still warm and pulsatile (via Doppler) and I started =
an IV=20
and administered analgesia prior to departure,&nbsp;since our roads are =
rough=20
and the ride would have been quite an ordeal for the Pt, who otherwise =
reacted=20
strongly to even slight movements.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS">&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">If the limb was non-pulsatile, I would =
have=20
opted for air transport to the specialists in Houston, rather than a =
stop for=20
diagnosis and stabilization in the local ED.</FONT></DIV></FONT>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">All the Doppler did was give me a =
better picture=20
of the conditions extant, and allow me to make a more appropriate =
transport=20
decision.&nbsp; </FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Likewise, if a Fetal Doppler indicates =
fetal=20
distress, I opt for air transport to specialized treatment.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">A moment to choose the most =
appropriate=20
treatment venue for each patient cannot be considered time wasted, a =
more=20
thorough clinical picture grants the luxury of more informed decision =
making and=20
generally produces a more desirable outcome in the patient.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">I would prefer to see the above =
patient treated=20
by specialists who treat thousands of cases yearly, in an operating room =

especially equipped and supplied for the task, than hope the local venue =
can=20
handle it.&nbsp; </FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">He'll be back on his bike that much =
sooner, with=20
less severe post incident rehabilitation issues if the initial treatment =
is=20
handled appropriately.</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Regards-</FONT></DIV>
<DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
<DIV><FONT face=3D"Comic Sans MS">Terry Dinerman EMTP</FONT></DIV>
<BLOCKQUOTE=20
style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
  <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV>
  <DIV=20
  style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
  <A title=3Dsstafford1168@yahoo.com=20
  href=3D"mailto:sstafford1168@yahoo.com">stephanie staford</A> </DIV>
  <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
  href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, June 05, 2002 =
3:54=20
  AM</DIV>
  <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: Consider this Case =

  Study</DIV>
  <DIV><BR></DIV>
  <P>are they used on the rig or in the field?&nbsp; does this ever slow =
down=20
  response time and get patient to hospital later?=20
  <P>stephanie stafford=20
  <P>&nbsp; <B><I>Terry Dinerman &lt;<A=20
  =
href=3D"mailto:dinerman@computron.net">dinerman@computron.net</A>&gt;</I>=
</B>=20
  wrote:=20
  <BLOCKQUOTE=20
  style=3D"PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #1010ff 2px =
solid">
    <META content=3D"MSHTML 6.00.2600.0" name=3DGENERATOR>
    <STYLE></STYLE>

    <DIV><FONT face=3D"Comic Sans MS">Rowley-</FONT></DIV>
    <DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
    <DIV><FONT face=3D"Comic Sans MS">Thanks for the advice, the crowd =
seems to be=20
    in agreement on this one.&nbsp; </FONT></DIV>
    <DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
    <DIV><FONT face=3D"Comic Sans MS">The Doppler's are getting =
positively cheap=20
    around here, the two units we have deployed (one with a tight beam =
head for=20
    vascular use the other with a wide field for fetal heart rate) are =
simple=20
    and rugged and cost less than $150 each.&nbsp; They give good =
results with=20
    inexperienced users.&nbsp; All our long bone fractures are treated =
to a=20
    Doppler exam to confirm less than palpable pulses and our preggers =
get a=20
    fetal heart rate.&nbsp; If you want a manufacturer, send me a e-mail =
and I=20
    will provide the information.</FONT></DIV>
    <DIV><FONT face=3D"Comic Sans MS"></FONT>&nbsp;</DIV>
    <DIV><FONT face=3D"Comic Sans MS">Regards-</FONT></DIV>
    <DIV><FONT face=3D"Comic Sans MS">Terry Dinerman EMTP</FONT></DIV>
    <BLOCKQUOTE=20
    style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; =
BORDER-LEFT: #000000 2px solid; MARGIN-RIGHT: 0px">
      <DIV style=3D"FONT: 10pt arial">----- Original Message ----- =
</DIV>
      <DIV=20
      style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: =
black"><B>From:</B>=20
      <A title=3Drowley@rowleys-host.compulink.co.uk=20
      href=3D"mailto:rowley@rowleys-host.compulink.co.uk">Rowley =
Cottingham</A>=20
      </DIV>
      <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A =
title=3Dtrauma-list@trauma.org=20
      href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A> =
</DIV>
      <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Wednesday, May 29, =
2002 6:49=20
      AM</DIV>
      <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> RE: Consider this =
Case=20
      Study</DIV>
      <DIV><BR></DIV>It's a no-brainer, as you guys say. My only concern =
would=20
      be that 28% of<BR>patients vomit with opiates, and you need to be =
prepared=20
      for that<BR>possibility with the changes of advanced pregnancy =
pressing on=20
      the stomach.<BR>Also, monitor her pulse rate and width extremely =
carefully=20
      because of the<BR>haemodynamic changes associated with advanced =
pregnancy=20
      - they behave a bit<BR>like children with a rising pulse followed =
by=20
      abrupt circulatory collapse.<BR><BR>I am deeply impressed you have =
a=20
      doppler on ambulances!<BR><BR>-----Original Message-----<BR>From: =
<A=20
      =
href=3D"mailto:trauma-list-admin@trauma.org">trauma-list-admin@trauma.org=
</A><BR>[mailto:trauma-list-admin@trauma.org]On=20
      Behalf Of Timothy J Coats<BR>Sent: 29 May 2002 10:11<BR>To: <A=20
      =
href=3D"mailto:trauma-list@trauma.org">trauma-list@trauma.org</A><BR>Subj=
ect:=20
      Re: Consider this Case Study<BR><BR><BR>Titrate morphine.<BR>I =
feel=20
      uncomfortable - there is too much agreement=20
      here!!!!<BR>Tim.<BR><BR><BR>--<BR>trauma-list : TRAUMA.ORG<BR>To =
change=20
      your settings or unsubscribe visit:<BR><A=20
      =
href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/3D"http://www.trauma.org/traumalist.html">http://www.trauma.org/trau=
malist.html</A><BR><BR></BLOCKQUOTE></BLOCKQUOTE>
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href=http://www.trauma.org/index.php/community/list/url/http:list.ftech.net/pipermail/trauma-list/2002-June/3D"http://rd.yahoo.com/welcome/*http://fifaworldcup.yahoo.com/fc/en/=
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