I Hate Traction Splints

Once upon a time, the police decided to chase a stolen car. (You can tell how long ago this happened, being that it involves a pursuit.) Inside the car were at least two teenaged boys. The pursuit led into a neighborhood, curving back and forth on small residential streets, but it was a fairly safe chase being that it happened at three in the morning.

Eventually, the chase got a little too fast for the teen driver to handle. The street they found themselves on ended at a T intersection. Apparently the driver couldn’t decide whether to go right or left, so he went straight. Straight into a big-ass maple tree in someone’s front lawn at about 30 miles per hour. The driver and the front passenger immediately hopped out and bolted.

The passenger made it one step. On his second step, he discovered he was the proud owner of a left midshaft femur fracture. He found this fact when he planted his left foot and pushed off, attempting to sprint after his driver friend. The thigh angulated and he collapsed onto the ground. According to the police, the shriek he generated due to the pain was loud enough to break glass and wake dogs several miles away.

He had discovered his busted femur the hard way.

Can't run on that...
© Nevit Dilmen [CC BY-SA 3.0], via Wikimedia Commons

I arrived to find the kid angry and yelling on the front yard. The glovebox inside the car was cracked, so I think he rammed it with his knee, breaking the leg. Aside from the broken femur, I couldn’t find other injuries. He was completely awake and there wasn’t another scratch on him. His femur, though, had developed an extra knee. It was angulated and exquisitely tender. My partner suggested a traction splint. I agreed and asked him to fetch it.

My system uses the HARE traction splint. It is actually the only one I have worked with. It is the traction splint that I learned to use in EMT class in 1994, and it is the only one I have ever put on a patient – imaginary or real.

My partner returned with the splint in the cloth sack. I opened it to find that the HARE was still in the manufacturer’s packaging. It was still shrink wrapped and not assembled. I briefly looked at it, my mouth hung open, I felt irritation rise in my throat, and I tossed the whole mess into a bush in the front lawn with a frustrated two-handed overhand toss. Apparently we wouldn’t be using the traction splint that night. (I don’t know how a traction splint was found in that family’s front yard bush, boss, honestly…)

My partner was used to my drama. He sighed, rolled his eyes, and fetched the splint out of the juniper bush. “Hang on. Slow your roll. Let me put this together. It will just take a few seconds…” he told me. I started an IV while he unwrapped the splint and screwed it together.

It went on the patient with no problem (once it was assembled), but not with the smooth skill that a practiced team of brand-new EMTs fresh out of the National Registry test would do it. If I’m honest, I think we manually pulled traction, realized we forgot a step, had to release the traction to complete the missed step, and then try to start again. Once the contraption was in place, we loaded the kid into the ambulance, I began administering analgesia, and we went to the nearest trauma center.

After I handed the patient off to the trauma team, the attending physician (my medical director at that time) asked why I used the traction splint.

“Because he had a midshaft femur fracture and a traction splint reduces pain, stabilizes the injury, and can help slow bleeding,” I told him, digging up half-forgotten EMT class lessons.

“But it slowed your scene time. Scene times are critically important in emergency trauma,” he pointed out.

“Yeah, but I felt sure the only injury was to his femur. So I felt comfortable taking the extra time.”

“Then why bring him back hot?” he asked.

“Cause it takes a significant hit to transfer enough energy to break a 17-year-old’s femur. That is a lot of force,” was my reply.

“Yeah, that takes a big hit. So we’re back to taking extra time on scene” he pressed. “Either it was a significant energy transfer with a distracting injury, potentially masking subtle life threatening injuries, or it wasn’t.”

I think it finally hit me at that point. What can I say? I am slow to absorb lessons. But he was right. It is pretty difficult to find a balance between “hard enough impact to break a previously-healthy femur” versus “an impact that was gentle enough to ensure the absence of other life threats so I have the time to screw around assembling and placing the infernal device.”

The HARE traction splints require two trained people working together, take quite a bit of time to place (what, like two minutes, minimum, right?), they are difficult-to-impossible to get on a patient while driving, are a treatment we don’t practice and aren’t good at, and they often extend past the end of the bed (ever see someone hit the splint when closing the door?). Traction splints were invented to treat fractures, not for field stabilization¹. Show me a study that shows the efficacy of traction above splinting; I bet you can’t.² I don’t see how the logic for the routine placement of prehospital traction splints holds up very well.

So I am not a fan of the prehospital use of traction splints.

1. Bledsoe B, Barnes, D. Traction splint. An EMS relic? Journal of emergency medical services. 2004;29(8):64–9.

2. Gandy WE, Grayson S. Sacred Cow Slaughterhouse: The Traction Splint. EMSWorld. 2014. Accessed Jul 23, 2016. http://www.emsworld.com/article/11542786/traction-splint-evidence-and-efficacy 

That Poor Little Liar

A couple of years into my career, I decided to increase my life insurance I get through work. As part of that, I needed to have a blood test – apparently if you test positive for heroin, you may need to pay a higher life insurance premium. Not a big deal; I wasn’t going to test positive for anything except levels of nicotine and caffeine that would kill a small toddler. The life insurance company would send someone by my home or work to draw blood. So this was no problem at all. Nice and convenient.

I was working deep nights at the time, so I would get off work, go home, and be in bed by about 8am if I was lucky. One night, I ran a sweet highway grinder. I don't remember the specifics, but there was stuff on fire, a semi-truck of rattlesnakes overturned, and a tornado hit a school bus. All at once, if my memory serves me correctly. Whatever actually happened, it was an event big enough to be on the news the next morning. I was first on-scene and ran the call pretty well, I thought. Two other ambulances from my agency showed up and transported patients, as well. I intubated two patients before the second-in units got on scene. I remember that specifically because I wanted to get both tubes; the next unit had a medic I didn’t like to share with (still don't). Between that and a ton of other calls that night, I was exhausted at the end of that shift and crawled into my bed.

Three hours later, my wife woke me to come downstairs. The mobile phlebotomist had arrived to our home for her visit. I threw on a t-shirt and a pair of sweatpants, went downstairs to the kitchen, and took a seat at the kitchen table. My plan was to stay conscious for the three minutes it would take to draw a tube of bloods, then go back to bed without fully waking up. The phlebotomist was a chatty lady, though.

“This isn’t my normal full-time job, you know.”

I grunted in return.

“Yeah, I am actually a paramedic.”

Grunt.

“Did you see that huge thing on the highway last night? With the rattlesnakes and the tornado? I ran that.”

Weird. I thought that was me. But I was tired and didn’t especially care, so I grunted noncommittally at her again.

“Yeah, it was a tough call, but professionals just get the job done,” she explained to me. “I’ve been doing this too long to let things like that trouble me.”

I upgraded from grunting: “That must be a tough job. I bet you’re proud.”

“Yeah, it is tough. I do this [draw blood in people’s kitchens] for a break. Wow, you don’t have very good veins, do you,” she told me. It was news to me. I like to think I have fine veins, thank you very much.

My wife walked into the kitchen at that point and overheard the last part of the conversation. “What do you do?” she asked the phlebotomist.

“Paramedic,” the lady replied. This should be good, I thought to myself.

“Oh? My husband is a paramedic too! What a coincidence!”

The phlebotomist turned to me. “Really? Where do you work?”

I nodded my head at the jacket draped over the back of the chair I was sitting in.

Seriously. No exaggeration. It was obvious...

“Denver,” I told her.

My houseguest turned white and began to stammer something.

My wife turned to me. “You were on a highway thing with rattlesnakes and a tornado last night too, weren’t you? Did you see each other? Or were there two crashes?” my wife inquired, innocently.

The odds of a successful first-time venous draw was diminishing by the second. The phlebotomist was pale, stammering, and had a distinct tremor in her hand. She gulped air and tried to focus. Stabbing someone in the arm is a great distractor. I offered to stick myself, being that I had poor vasculature.

She declined my offer and drew my blood. It worked out that she was a brand-new EMT, applying for her first job at a nearby private ambulance company. Poor, dumb EMT. She probably talked up her job as a paramedic to dozens of phlebotomy clients before stumbling into my house.

But, really, I don’t have that much sympathy for her embarrassment. The jacket was right there on the chair.

Community Paramedicine

Picture this scenario: You respond to a 35-year-old male with insulin-dependent diabetes mellitus complicated by alcoholism and near-homelessness. You find him at his home, a daily hotel, without complaints.  Other family members (who don’t live with the patient) visited and called 911. They are worried about him because his home is very unsanitary, and the patient drinks too much. This is the second time this week you have responded on this guy at this address. He never wants help. You arrive to confirm that he is slightly intoxicated, slightly intoxicated, and he hasn’t checked his blood sugar in months. Just like last time. His appearance is generally normal, if slightly dirty and malodorous, and the patient once again has no complaints. His vitals are normal, outside of a blood sugar reading of 188 mg/dL. He is intoxicated, but is in his own home. So you call for community paramedics to add this gentleman and his family to their daily visit list. The CPs can come make sure the patient and his family don’t abuse the 911 system with calls like this. Maybe the CPs can explain to the patient why he needs to quit drinking and check his sugar more often. They can also explain to the family why the patient isn’t a 911 candidate. While calling to set up the CP visit, you tell dispatch to mark this address as one the CPs need to respond to, rather than 911 resources. You leave the patient at home with instructions to wait on the community paramedics. [Clapping-style hand brush off motion.]

Awesome, right? Like a big, amazing EMS dream!

Something came up recently that got me to thinking about community paramedicine; more specifically, how a community paramedic program would work. The scenario above generally describes the way that a lot of street medics envision community paramedics. In short, community paramedics are other responders who take low-acuity calls so the “real medics” don’t have to. They can do suture removals, well-baby visits, and such while waiting for street medics to find patients for them to commun-isize. 

Commun-isize my boring calls, so I don't have to!

This community paramedic model will probably never happen. Sorry to be the one to tell you.

There are two viable options for community paramedicine. Neither involves 911 responses. The first is to operate as an adjunct to primary care in rural areas without sufficient primary care physician (PCP) access. Most rural counties don't have enough PCP/family medicine/internal medicine physicians willing to take on new patients. I see this CP model as a follow-up post PCP visit to answer patient questions, provide follow-up test results, check medication understanding, and such. 

The second option for community paramedics is to reduce hospital readmission rates for specific types of patients. Medicare monitors 30-day unplanned readmission and death rates for COPD, MI, heart failure, pneumonia, stroke, and hip or knee replacement patients. Medicare then links those quality measures (readmission rates) to financial reimbursement*. Thus, hospitals are incentivized to find ways to continue caring for patients after discharge. Like, say, sending a community paramedic to their house to weigh them, run a 12-lead, maybe draw some blood, and check to make sure they are working off their updated medication list. Concerning findings at the home visit would result in a clinic visit, rather than waiting until the problem worsens to the point of needing an ambulance to the ED and hospital readmission. Those kinds of CP actions would potentially enhance the care received and increase patient satisfaction.

The most likely scenarios for a community paramedic call is for a medic to visit a house to weigh a CHF patient. The medic checks to make sure the patient has and understands her meds. Then the community medic goes to a STEMI patient who was released from the hospital two days previously. The main goal of this visit is to dispose of all the patient’s old medications and explain the new ones. Patients are comfortable with their old medication lists and will stick with them, even after a big event changes their prescription list. They need the new list, not the old/comfortable one. Then the medic goes to COPD patient’s house to make sure they are using oxygen. The medic finds the patient’s supply of oxygen to be running low and helps get more delivered. And so on...

Nobody can see the future, so it will be interesting to see if community paramedicine is a fad or an EMS paradigm shift. But it is unlikely to have a large effect the acuity of calls in a 911 system, however it works out.

* Hospital Readmissions Reduction Program (HRRP) in Section 3025 of the Affordable Care Act