Surviving the Medical Meltdown (25 page)

OPEN FRACTURES

Later in the book you will learn home care for routine fractures. But some fractures cannot wait and must be cared for in an emergency
department. An open, or compound, fracture is one in which the bone comes through the skin – however slightly. If not treated with a surgical procedure to open and wash out the wound and remove contaminated bone within six hours, the rate of deep bone infection rises significantly. Seek professional orthopaedic help.

If you cannot get to help, the next best thing is to flush the wound/bone with several quarts of clean or sterile water with a tiny bit of pure soap or antibacterial soap added. Then make sure the limb has good blood flow – if necessary, by pulling it straighter. Next, cover the wound with a sterile dressing with antibiotic ointment underneath and/or Betadine in the dressing. Apply a splint (see
chapter 22
). If you have cipro in your medicine cabinet, this is the time to take 750 milligrams while awaiting definitive care. Children are more difficult to dose. Cipro is not recommended for children. For children, I would use clindamycin as soon as possible when delay in definitive care is established. Clindamycin dosage is 40 mg/kg/day in three to four divided doses (see sidebar). Keep in mind these recommendations are not the standard medical approved therapy. This is the fallback plan when the correct hospital-based physician care is not available.

CLINDAMYCIN DOSAGE CHART FOR CHILDREN

When definitive care is not available and you need to treat an open fracture in a child, consider treating with clindamycin for no more than three days while awaiting hospital care.

DISLOCATIONS

Anyone who has played contact sports has probably had or seen a dislocation – usually a finger or a shoulder. It is often possible to reduce dislocations immediately after they happen while the tissues are still a little numb from the trauma. In general the principle is to reproduce the deformity, then pull straight. For example, if a finger is dislocated and the end of the finger is sticking up at the first joint, you (or usually someone else) pull the finger up more and keeping tension on the finger, allow it to relocate into a straight alignment. In other words, first pull in line with the dislocated part.

Many people have dislocated shoulders, and these are a little more complicated. The easiest thing to do is to lie facedown on a table or high bed, letting your arm hang over the side. Put a rolled-up towel or firm pad under the chest just next to the shoulder, but not under the shoulder. Hold or tape a weight – ten to fifteen pounds – to your hand. Relax and let gravity put the shoulder back into place. Alternatively, this technique can be used with your friend (hopefully he will still be your friend after this experience) doing the pulling instead of using a weight. If you have any Valium (10-to 15-milligram tablet for an adult), take it ten minutes before this procedure to aid in relaxation.

The key to reduction of a shoulder is not brute force but relaxation of the person injured. When I was a first-year orthopaedic resident on trauma call, I walked into the “cast room” and witnessed five big orthopaedic guys – four residents and the chief of the department – pulling on the arm and applying countertraction to the chest of an old man with a shoulder dislocation. More than six hundred pounds of combined muscle could not reduce the shoulder. But the female resident (me) then took the patient to the OR where, under general anesthesia, it took literally three fingers to reduce the shoulder dislocation because the patient was relaxed. I always remember the incident, both for the dramatically easy reduction and because the minute the shoulder dropped into place, the whole floor started waving and moving in a thirty-second earthquake.

If the dislocation is reduced, great! Now you can follow up as needed in the daylight hours with an orthopaedic surgeon. If you can’t reduce it, or are unsure – head for emergency help.

PENETRATING WOUND TO A JOINT

Unless you are a gangbanger and at risk for gunshot wounds, any joint penetrations you get will probably be from the knife slipping or your friendly cat. Any puncture wound to a joint from any cause has contaminated the joint with bacteria, and you cannot treat that at home. Seek help.

CHEST PAIN (POSSIBLE HEART ATTACK)

It is easier to say what is usually not a heart attack, but again, one can be fooled. Generally, if you are in a low-risk group – under fifty, a nonsmoker, without significant medical problems, and do not have classic symptoms – you are unlikely to be having a heart attack. If you can push on your chest wall and reproduce the pain, it is probably not a heart attack. If it goes away with a little antacid, it is probably not a heart attack. However, heart attacks are difficult even for seasoned emergency room doctors to sort out, so when in doubt, don’t hesitate to get help.

The classic symptoms of a heart attack include deep chest pressure or pain (often characterized as an elephant standing on one’s chest), sweating, radiation of achy pain to the jaw or arm, shortness of breath, light-headedness, nausea, or vomiting. Unfortunately all or none may be present. We miss many “silent” heart attacks that are totally asymptomatic and are picked up later on EKG. And many heart attacks have only one symptom or are atypical. One symptom I would never ignore is the feeling of doom or foreboding. Some people report a sense of death or doom and were found to have a subtle but life-threatening disorder. I took myself to the ER when I was twenty-two, worried about my heart. In retrospect, it was a lot of subconscious, uninformed fear from my father dying of heart disease two years earlier, combined with pain in the cartilage joints
in my chest – costochondritis. However, you should always listen to your subconscious when it feels seriously threatened.

Nonsmokers under forty generally don’t die from a heart attack. If they have a painful heart condition, it is usually a muscular or ligamentous or joint cartilage–type chest pain, which isn’t a heart attack but which shouldn’t be ignored either. I would be more worried about smokers over forty, anyone over fifty, and anyone with the classic symptoms.

If you do think it is your heart, call an ambulance or have someone prepare to drive you to an emergency room. Take a baby aspirin as soon as you can, as this can prevent clotting within the coronary (heart) arteries and has been shown to decrease damage and reduce the likelihood of death. But only take one baby aspirin. In this case more is not better.

Sadly, sometimes the first presentation of heart disease is sudden death. If someone collapses and is pulseless, institute CPR per the latest protocol. It should be noted that the protocols are written these days not for the optimal result but so that people will not fail to start CPR. In other words, it has become “CPR for Dummies and the Reluctant.” You can review the following CPR illustrations. But in days past we did several things not mentioned here. When we witnessed a person collapsing, we first administered a “precordial thump” – a bang on the chest directly over the heart. In cases of a rhythm problem where the electrical starter of the heart malfunctions, this can restart the heart. It works; and if I drop over, please do that for me.
But
it was taken out of the protocol because people were thumping over and over rather than beginning the messier breathing, pushing CPR. So if you give a thump, ONLY DO IT ONCE; then move on. Similarly, CPR used to include mouth-to-mouth breathing for the patient, to provide better oxygenation. This was taken out because people were reluctant to put their mouths on strangers and so failed to start CPR. But trust me – I have firsthand experience here – it is much more effective to intersperse mouth-to-mouth breaths between chest compressions. The latest
recommended ratio is two breaths per thirty chest compressions, and the chest compressions should be done at the rate of one hundred compressions per minute.

CPR GUIDE

1.
Assess the situation for danger, and if safe, tell any onlookers to call 911 for help.

2.
See if the patient is responsive. Shake gently and ask loudly if they are okay.

3.
If you have been trained and know how to apply a defibrillator ask another bystander to get any nearby defibrillator.

4.
Check for breathing. Don’t do this for more than 10 to 15 seconds. Look for chest rise and/or feel for air movement.

5.
If the patient isn’t breathing, begin chest compressions. Place the heel of your palm on the lower sternum (breastbone). Interlock your fingers of the other hand over the first one and push with both arms outstretched.

6.
Begin chest compressions, depressing the chest two inches for a rate of 100 beats per minute. You can estimate this by pressing to the beat of the Bee Gees song “Staying Alive.”

7.
If possible have another bystander begin breathing at a rate of approximately two breaths per 20 compressions. You can do it yourself as well, but it is much easier with two people performing CPR. (Although they now teach a no-breathing technique, trust me, breathing is better for the victim when possible.)

RECOGNIZE THE SIGNS

Immense pressure on your chest

Sweating