Fractured arms

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Compound fracture needs toilet, reduction and fixation under GA or good
regional technique asap. There are few things with a higher priority on
theatre time than a dirty compound fracture. This patient was also losing
muscle and nerve to her compartment syndrome while she was waiting. Don't
give more morphine if you've got respiratory depression. Especially don't do
it when you're busy and everyone's rushing around doing other things. You
may well turn it into an unplanned GA, so you need someone who can cope with
an emergency GA to be at the patient's side.
 Getting another doctor to change the orders of the first one will create
bad feeling in the department (where it sounds as though there's already a
lot of stress), so you want to be pretty sure of your grounds before you do
it. In this case, you have a compartment syndrome, so will not be able to
control pain fully with opiates- it's a trade of between severity of pain
and risk of respiratory arrest. In this case, I wouldn't give more opiates,
but would use other forms of pain control myself. If less opiate had been
given initially, I'd be more inclined to step it up; if I could watch
closely at the patient's side, same goes. Ultimately, its a judgement call,
responsibility falls on one person's head.

Matt Dunn


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