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Thu, 4 Apr 2002 07:18:26 +1200

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Opinions please...
35 year old female fell about 12 foot from rooftop onto out stretched =
arms on grass, paint can fell on top of her.
Arrived at emergency dept crying with pain after 25 mg morphine, arms =
splinted. Paint everywhere.
-----two times colles fractures (right and left), with max. displacement
-----compound fracture dislocation left elbow, involving all three arm =
bones. Paint and grass in large wound.
-----dislocated right collar bone (undiagnosed till surgery due to =
difficulty getting decent xrays.)
---- Haemodynamically stable, pulse 115 BP around 140/80, this then =
settled to around P95, BP130/75
In emergency for 3 1/2 hours waiting for theatre to be free (Sunday =
morning).
Two hours later, she had had further 25 mg morphine and 1mg midazolam, =
showing some sign of resp. depression (RR12), but BP and P gradually =
rising. Orthopaedic Reg. arrived to re-locate elbow (as much as =
practical) and both arms back slabbed to improve pain control... not =
very effective. using entonox gas intermittently with some effect.
Doctor in emergency refused to chart further morphine or other analgesia =
due to pts resp. depression, unmoved by my arguments, despite empirical =
evidence (P and BP rise) and pts distress. Consequently, pt without =
adequate analgesia for around an hour. During this time the department =
"went to custard" (as they say... it was really busy), and no one else =
was able to assist me with pt.=20
I left her at theatre, distressed and moaning in pain, P 125, BP 170/90, =
RR still around 13.
My questions: should I have insisted on more pain relief? Should I have =
over ridden the docs decision and asked someone else? Would a nerve =
block have been effective? (Consensus here on that was that it would =
have too difficult due to pts lack of arm mobility, but her left arm was =
raised above her head to re locate the elbow, could it not have been =
done then?) Would a different analgesic been better?=20
This was a very frustrating case from a nurses point of view, I felt =
hamstrung by the departments busy-ness, the doctors inability to stay =
with the pt and see what I was seeing as her pain rose, and the wait for =
the theatre (out of our control, but also compounded by lack of info =
from theatre staff, who just kept saying "it'll only be five minutes =
more....").
What do you think, Ali.
PS I get on well with the doc concerned, and don't have a problem =
usually with the way he works, and I'm not trying to find a scapegoat, I =
just want to know if I could have done more.

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<DIV><FONT face=3DArial size=3D2>Opinions please...</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>35 year old female fell about 12 foot =
from rooftop=20
onto out stretched arms on grass, paint can fell on top of =
her.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Arrived at emergency dept crying with =
pain after 25=20
mg morphine, arms splinted. Paint everywhere.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>-----two times colles fractures (right =
and left),=20
with max. displacement</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>-----compound fracture dislocation left =
elbow,=20
involving all three arm bones. Paint and grass in large =
wound.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>-----dislocated right collar bone =
(undiagnosed till=20
surgery due to difficulty getting decent xrays.)</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>---- Haemodynamically stable, pulse 115 =
BP around=20
140/80, this then settled to around P95, BP130/75</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>In emergency for 3 1/2 hours waiting =
for theatre to=20
be free (Sunday morning).</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Two hours later, she had had further 25 =
mg morphine=20
and 1mg midazolam, showing some sign of resp. depression (RR12), but BP =
and P=20
gradually rising. Orthopaedic Reg. arrived to re-locate elbow (as much =
as=20
practical) and both arms back slabbed to improve pain control... not =
very=20
effective. using entonox gas intermittently with some =
effect.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>Doctor in emergency refused to chart =
further=20
morphine or other analgesia due to pts resp. depression, unmoved by my=20
arguments, despite empirical evidence (P and BP rise) and pts distress.=20
Consequently, pt without adequate analgesia for around an hour. During =
this time=20
the department "went to custard" (as they say... it was really busy), =
and no one=20
else was able to assist me with pt. </FONT></DIV>
<DIV><FONT face=3DArial size=3D2>I left her at theatre, distressed and =
moaning in=20
pain, P 125, BP 170/90, RR still around 13.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>My questions: should I have insisted on =
more pain=20
relief? Should I have over ridden the docs decision and asked someone =
else?=20
Would a nerve block have been effective? (Consensus here on that was =
that it=20
would have too difficult due to pts lack of arm mobility, but her left =
arm was=20
raised above her head to re locate the elbow, could it not have been =
done then?)=20
Would a different analgesic been better?&nbsp;</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>T</FONT><FONT face=3DArial size=3D2>his =
was a very=20
frustrating case from a nurses point of view, I felt hamstrung by the=20
departments busy-ness, the doctors inability to stay with the pt and see =
what I=20
was seeing as her pain rose, and the wait for the theatre (out of our =
control,=20
but also compounded by lack of info from theatre staff, who just kept =
saying=20
"it'll only be five minutes more....").</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>What do you think, Ali.</FONT></DIV>
<DIV><FONT face=3DArial size=3D2>PS I get on well with the doc =
concerned, and don't=20
have a problem usually with the way he works, and I'm not trying to find =
a=20
scapegoat, I just want to know if I could have done=20
more.</FONT></DIV></BODY></HTML>

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