Wilderness Medicine Updates

Ep. 29 - Wilderness Orthopedics with Dr. Chris Healy

• Patrick Fink MD • Episode 29

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Wilderness Orthopedics: Managing Trauma in Remote Environments with Dr. Chris Healy

In this episode of Wilderness Medicine Updates, host Dr. Patrick Fink tackles orthopedic injuries in the wilderness with Dr. Chris Healy, an orthopedic surgeon and outdoor enthusiast. They explore the management of long bone fractures, traction for femur, pelvic binders, and the nuances of treating injuries in limited-resource environments. The episode covers strategies for handling common injuries like shoulder dislocations, tibia fractures, knee injuries, and how to prioritize care. They also emphasize the importance of timely evacuation and when and how to safely attempt reductions in the field.

Links:

Donate to the Tina Biddle Memorial Scholarship

Sulcus sign / Squaring of the shoulder

Chapters:

00:00 Introduction and Episode Overview
01:36 Tribute to Tina Biddle
04:09 Meet Dr. Chris Healy
05:11 Ski Patrol Background and Pre-Hospital Care
08:12 Approaching Orthopedic Injuries in the Field
17:50 Managing Tibia and Fibula Fractures
21:40 Understanding Compartment Syndrome
27:50 Femur Fractures and Traction Splinting
36:57 Pelvic Fractures: Identification and Management
38:41 Understanding Pelvic Fractures and Binders
39:53 The Role of Pelvic Binders in Pre-Hospital Care
41:11 Challenges with Pelvic Binders in the Field
43:15 Proper Placement of Pelvic Binders
46:36 Field Management of Shoulder Dislocations
50:43 Techniques for Reducing Shoulder Dislocations
54:17 Managing Upper Extremity Injuries
57:51 Handling Knee Injuries in the Field
01:00:37 Patella vs. Knee Dislocations
01:08:06 Evacuation Priorities for Knee Dislocations
01:10:53 Common Issues in Pre-Hospital Orthopedic Care
01:15:36 Final Thoughts and Listener Engagement

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at wildernessmedicineupdates@gmail.com.

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Patrick Fink MD:

Hello and welcome back to Wilderness Medicine Updates, the show for providers at the edges. I'm your host, Patrick Fink. Today I'm bringing you a wraparound episode and it's all about orthopedics. I've gotten a lot of questions. I've got a lot of questions from listeners about long bone injuries splinting, traction for femur, the use of pelvic binders. Yeah, everything to do with those hard white things inside our arms and our legs, which have a nasty tendency to get broken when we fall. So today I am bringing to you a long conversation with Dr. Chris Healy, who is an orthopedic surgeon in the St. Charles Health System. That's where I work in Central Oregon, in Bend, and the surrounding area. And Chris is a member of the outdoors community. As you'll hear, he has a background. A life really that was formed through ski patrol experience as a ski patroller. And he now works in a hospital doing definitive care of orthopedic injuries. So he was uniquely positioned to come on and answer a bunch of these questions with an understanding of what it means to operate in a resource limited austere wilderness pre-hospital environment, and answer some questions about what really makes a difference, what we can actually do for patients. Before we deliver them to hospital or to EMS before we start, I have a little bit of sad news I learned recently of the sudden and terrible death and and passing of Tina Biddle, who was the ski patrol director at Snowbird. During the time when I was there and just up until December of this year when she died at age 58, leaving behind her husband and a whole ski patrol. And Tina was an amazing woman who really, uh. Set a standard in the ski industry, forged a path forward for women in leadership. And just before I learned that she had died, I was just thinking to myself, it was time to get Tina on the show to talk about what it was like. Making that path for herself and being a leader in what has traditionally been a bit of an old boys club, Tina led from the front. She loved being outside in the mountains. I remember her as strong, responsible, but almost always smiling and she's gonna be sorely missed. I'm thinking of all you guys at Snowbird, all the friends and colleagues there. I know that she's, she's gonna be missed. So if you are a member of the ski patrol community or want to support women in the outdoors, friends of Hidden Peak, the nonprofit that was started by the Snowbird Ski Patrol. Is now hosting a scholarship that was started by her husband Matt Biddle, to honor Tina and her legacy and to allow her legacy to live on by helping to support the advancement of women in the outdoor industry. So if you are interested to donate to that. You can go to friends of hidden peak.org and there's a button for the Tina Tina Biddle Memorial Scholarship on the front page, or I'll put the link in the show notes. So please if you can drop a couple dollars there tax deductible if that matters to you, and support an the memory of an amazing woman and the advancement of women just like her. Now, with that, I won't delay any further in jumping in. Here is Dr. Chris Healy and our orthopedic pope. Why don't we just start with having you introduce yourself. What's your day job and why do you live in central Oregon?

Christopher:

Um, yeah, sure. My name is Chris Healy. I'm a orthopedic surgeon. I've been in practice for a little over six and a half years. I did my orthopedic surgery training in New York and then also did a year of hand and upper extremity fellowship also in New York. And I am originally from and I very much wanted to move back to the west western us. Um, I love to ski and mountain bike and run on trails and just generally enjoy the outdoors. And bend is a really great place where I can be personally and professionally satisfied. So that is why I am here and feel very fortunate to be here.

Patrick Fink MD:

Amen. And for the listeners who aren't privy to our, uh, prior emails, you also did a year as a ski patroller. Is that right?

Christopher:

Yeah, so my background with ski patrol is I think pretty cool. Um, my dad was a volunteer ski patroller at Winter Park for 46 years, so before I was born he started, um, in the early eighties or maybe even late seventies, um, volunteer patrol there. And so I grew up around ski patrollers and from, uh, his volunteer work that meant that our family could ski for free and get free seasons passes each year that he was on. And he just doing it a couple years ago. Um, and so when I was finishing high school and in college, I also joined the volunteer. Patrol at Winter Park and would do it over winter breaks from college. And then I had a year off between undergrad and school and I was on the professional ski patrol at Mount Hood Meadows in Oregon.

Patrick Fink MD:

So you have some perspective as to the pre-hospital care and the limitations. It's not just the, not just coming from that hospital perspective where you have all the, the tools and toys.

Christopher:

Totally.

Patrick Fink MD:

that's,

Christopher:

I

Patrick Fink MD:

I.

Christopher:

remember. Um. Certainly some of the things from my original training when I was a senior in high school, taking the outdoor emergency care certification. and yeah, honestly, like have some really good lessons from that and, uh, now even better perspective, um, just as a clinician who's definitively fixing these injuries and kind of what and what maybe doesn't matter. Um, know when, when you're out in the field.

Patrick Fink MD:

So let's, let's dive into that.'cause I think that that perspective is gonna be super useful. I, I was just recording a podcast about how some things in wilderness medicine have really, or just pre-hospital care, have really evolved, like the care of, uh, spinal injuries and, and the dogma around spinal mobilization. But I feel like if I went into the textbook that I have behind me on emergency care and transportation of the sick and injured, that probably not a lot has changed in pre-hospital care of orthopedic injuries. But at the same time, despite that, people have the same questions over and over and over about how to approach this stuff. And I think it's just because there's a variety of limbs, there's a variety of bones, there's quite a, a number of different injury patterns that we might encounter. So let's just from your perspective as the orthopedic surgeon who is receiving these injuries and treating them definitively. How do you want people just approaching an injured limb in the field in terms of evaluating that limb for injury and going about identifying potential issues? What is your general approach?

Christopher:

My general approach is do what you can to

Patrick Fink MD:

I.

Christopher:

the patient comfortable and stabilize the injury so you can get that patient to. A clinic inside or emergency room or a hospital sooner rather than later. that very much depends on where you are in the outdoors when the injury happens. So if you are at Mount Bachelor or Winter Park or Mount Hood Meadows and there is a clinic at the bottom of the hill and it's staffed by an emergency care physician or an urgent care physician or pa and you can get that patient downhill within, you know, 30 ish minutes, my advice is generally speaking, just get the patient indoors so they can be in

Patrick Fink MD:

Being a lump

Christopher:

and, um, evaluated quickly. Now,

Patrick Fink MD:

out in your

Christopher:

a multi-day backpacking trip and someone falls and you know, there's. A concern for a broken leg or something. Obviously that, um, advice will change. But, you know, if, if the audience mainly today is for people working in the ski patrol industry or, um, even some like wilderness medicine or search and rescue, where like generally speaking, you're gonna have that patient, you know, into a hospital within hours, generally speaking, it's just do what you can to make them comfortable and we can dive into specific injuries on how best to do that. Um, but I would say that level of assessment that you need to do in the field, from my perspective, is pretty minimal. I mean, get a lot more information from an X-ray or a CAT scan, um, than you can glean from, you know. Someone's shoulder when it's blowing 50 miles an hour and it's snowing and you're freezing and the patient's freezing. my advice is generally speaking, just to get them inside quicker.

Patrick Fink MD:

Let's say that just for the sake of argument, we can't go inside immediately. What is, what are the things that you want to identify right up front? The issues that could potentially require either, you know, really expediting evacuation or different treatment for that patient that says, this isn't just like a routine, I don't know, SPR sprain or strain. This is something that needs to be a, a priority injury.

Christopher:

Totally. I think, you know, it's helpful if, if you witness the injury and you can see what

Patrick Fink MD:

What the benefit

Christopher:

was and if it was something really high energy and. fall and like a visible, you know, deformity like at the time of the injury.

Patrick Fink MD:

and that's something that

Christopher:

to, um, be much more aware of. I think if you, you know, show up an injured skier on the side of the hill and they're

Patrick Fink MD:

said rising.

Christopher:

pain and you can't find a peripheral pulse and it's a clear dislocation, like, you know, that's something you probably want to be a little bit more worried about. Generally speaking, fractures, um, while they are very painful, you know, once the damage is done, um, there's not a whole lot that you're gonna be able to do right there to make them significantly more comfortable. But a dislocation, certainly you can make them more comfortable by, reducing the joint. I.

Patrick Fink MD:

Yeah. So let's start a little bit with the idea of of fracture. So if you identify someone who has a visible deformity in terms of managing that in the field, general principles, is it safe to return that fracture to anatomical alignment? Can I try to straighten out a limb?

Christopher:

Yeah, I think it's, it's fine to try and do that, especially if you're gonna be putting them into a Sam splint or, you know, a long leg splint. fine to pull some traction on the limb and generally speaking, try and make the arm or leg straight. Again, traction, just direct axial traction, like pulling in the direction of their

Patrick Fink MD:

Their.

Christopher:

is very safe. I don't worry about more damage being done by you trying to gently realign the limb, um, like causing more damage that's gonna make it. for me to do surgery or, um, cause the patient more pain, uh, in the long run. So speaking, I think it's totally fine to, um, gently try and realign. Now I will say like, you know, you the field without the advantages of able to provide sedation or give good pain medications, like your ability to actually like redo something, um, to more anatomic alignment is pretty limited. And I think once you start like actually having to care of these injuries and the emergency room or the operating room, um, you realize how much force is often required in order to correct a deformity. So I would just caution that, you can try and make something straighter, uh, but I wouldn't go nuts. Hero with it. Does that make sense?

Patrick Fink MD:

Totally. Yeah. I would echo that from my own experience in the emergency department and through my training that like the difference between the emergency medicine intern and the orthopedics fellow is how hard they pull and just the amount of force required to reduce some of these injuries is like, there's a reason that a lot of orthopedists are like big, you know, burly dudes. I get, I get. Sweaty sometimes trying to reduce stuff in the er. Um, some of, some of our, you know, listeners, some of our operators may, you know, have access to ketamine or other such things. So it's really not beyond the pale, um, in the, in the right context, particularly for prolonged care. So let's say there's a deformity, but it's accompanied by open fracture, there's bone end sticking out. Is that something you wanna leave poking out, or are we trying to reduce that underneath the skin?

Christopher:

I think it's great to try and reduce it underneath the skin. Um, again, like pulling straight traction is probably gonna be the best way. If you want, you can try to, you know, maneuver the armor leg to help get the skin kind of up and over. You can kind of imagine it as you need to like lever the, skin back over the bone. Um, in order to do that, I will say, you know, oftentimes, like you can try and do that, but if you're not putting the splint on properly or. Um, know, keeping it reduced, it's gonna wanna fall right back out. So I think like open ankle fracture where like the foot is clearly pointing the wrong direction and you pull on it and you get, you know, skin back on top of the bone and the foot is better aligned is great. Um, that's probably gonna be like the easiest thing to correct, but a mid shaft tibia fracture, you know, is gonna be a little bit harder. Again, just straight traction is gonna be the best. Um, I also think if say you are on the ski hill and it's a boot top injury and you can see the bone out, um, my advice would be to, you know, traction, try and get it a little better aligned, put some. Saline soaked gauze over the wound. Wrap it with an a wrap, a splint on and just get them downhill promptly. I know there's probably some questions about when boots, ski boots should be removed in the field, um, not. Generally speaking, I would wait to do that until you can get the patient some good pain medicine, unless it's gonna be like a really prolonged Like I remember a time when I was at Mount Hood Meadows and we went out of bounds into, um, a nearby canyon to a patient who likely had a femur fracture and it was gonna be like, you know, a two hour slog, like to get'em out to a place where a helicopter could land. You know, that might be a reason to like try and get a ski boot on, but if you're in bounds, um, you know, I think there's probably very few reasons to try and remove a ski boot while you're in the field.

Patrick Fink MD:

Fantastic. Yeah. Let's, let's just jump into the tib fib injuries then. Um, since we, we mentioned that, so super common injury pattern in the ski population is a fracture near the, near the boot top. It's kind of the risk guard principle, like the ankle is protected from injury'cause it's essentially splinted inside a hard boot. But, um, striking a buried object or falling with twisting can result in injury to both of the bones at the top of the boot. So you're saying that, generally speaking, you think it's better to leave that foot protected inside the boot? Don't get it cold and get a patient out of the cold environment and into a clinic before evaluating further.

Christopher:

Yeah, I think so. I think, um, you know, the chances of like a really bad arterial injury that like you want to palpate the foot to see if they have a pulse. Very low yield there. Um, so I would say generally speaking, just the boot or keeping the boot on is, is reasonable. Um, think, you know, taking a boot off, uh, especially like if it's a snug fitting alpine boot, it's gonna be pretty damn uncomfortable for the patient. So if you can get them where they can get some IV pain medicine, that's gonna be really much more pleasant for them.

Patrick Fink MD:

Our protocol that I wrote for Mount Bachelor is to leave the boot on unless it's going to be for some reason, some very prolonged slog, or there's something else going on like upwelling of blood from inside the boot where you feel like you need that exposure to appraise what's happening.

Christopher:

Yep. Yeah, I think that's reasonable. I also, you know, boot top fractures are certainly a thing. I think what is probably equally as common of a injury is actually more of like a distal third spiral tibial shaft fracture where you have a tibia fracture, but really the problem is the binding didn't release, um, the ski hit a tree root or something like that. oftentimes, like these ski injuries are actually like more distal fractures than you might think, and the boot is kind of acting as like a little bit of a splint, um, as is, if that makes sense.

Patrick Fink MD:

Yeah, so it sounds like if you want to get the boot off, you think pain medicine is definitely indicated. Any, uh, tactical tips for removing ski boot when there's suspected fracture?

Christopher:

it's a good question. I don't know about the clinic at Mount Bachelor, but it's certainly helpful to have a cast saw, um, in those clinics. Um, that is gonna be something that can help cut through the plastic and like cut through the boot and remove it a little bit easier. You can, you know, certainly, um, undo the bolts if it's, you know, an alpine boot that allows that and disengage the, the cuff from the actual boot. but generally speaking I think like you just need to load them up with pain medicine. Really get in there with your hands and just try and pry it open as much as possible. And also keep in mind that, you know, our ski boots are stiffer when it's cold. They're a lot softer when you're trying them on in the shop where it's warm. Same thing is true for. Like, get'em inside, let that plastic warm up a little bit and it's gonna come off easier than, um, if you're out in the cold.

Patrick Fink MD:

Excellent. Well, I, we had a couple cases last year of tib fib injuries that went on to develop compartment syndrome. Can you talk about that a little bit? Like explain what is compartment syndrome when we should suspect it, and in the pre-hospital setting, is there anything that we can do for those patients?

Christopher:

Yeah. So compartment syndrome is something that is going to likely develop over hours rather than minutes. And what it is, is within. Your lower leg or thigh or forearm, you know, all over your, your extremities. You have compartments where the muscles and tendons and blood vessels and nerves are basically encased or wrapped around with what we call fascia. And that fascia is a tissue that has some stretch, but it doesn't have complete elasticity. So if you have a in your tibia, fractures bleed a lot and gonna be some bleeding underneath the skin within that compartment. And when there's enough bleeding and muscle injury and ooze from the injury that it causes too much pressure within the compartment, that's where you start to get some. Nerve irritation or nerve compression, potentially some vascular compression, although that's a very late finding. Um, but the biggest thing, it is just extremely, extremely painful once those compartments start to get too tight. And the reason why it's so painful is, um, the muscles are actually starting to get some ischemic injury because they're not getting good blood flow because small blood vessels are being compressed too much by all the fluid and blood within the compartment. Um, I don't think there's a whole lot you can do in the pre-hospital setting to prevent that other than trying to get them into the clinic or into the hospital as soon as possible. There are some injuries that are more likely to get syndrome than others. Um, the most common one is going to be really bad. Tibial plateau or proximal tibia fracture, that's kind of the highest risk of getting a compartment syndrome. but I would say getting compartment syndrome has a lot more to do with the injury pattern itself rather than what is done the first hour or two of taking care of that patient.

Patrick Fink MD:

Okay, so it's a, I agree in my experience that like the tibia seems to be predominantly the, the main generator of the compartment syndrome, at least from like a common orthopedic injury. And then the real key to recognizing that is both the injury pattern and this like really seemingly like pain out of proportion to the injury or pain that you really can't control. Some things that came up when we were talking about like, could you manage these in a more prolonged environment? They need to go to hospital, right?'cause there's compromised circulation, there's ischemia developing. While you're working on that, is there value to compression or elevation or anything we can do to preserve profusion to the compressed compartment? I.

Christopher:

Um, that's a great question. I generally, no, you know, you don't want to have something on there that's too tight, um, that is gonna like further restrict any blood flow through those tiny arteries or capillary beds. Um. Getting to the muscle. So I would say generally compression is not gonna be your friend here. Elevation, yes. Um, to try and see if you can get some of that swelling from the injury to go down. I think, more of an important thing. If you are out on a back country ski trip or you're on a backpacking trip somewhere and uh, you know it's gonna be several hours before someone can get to you, um, you know, keeping that limb elevated is gonna be most helpful. Um, but compartment syndrome is, you know, it's not something that develops like within hour or two. It's usually, several hours later, generally speaking, like it's, um, you know, something that I would say like is only happening in like, probably like 20% of all tibia fractures. I don't

Patrick Fink MD:

I don.

Christopher:

there's a whole lot you can do in the field other than get them to a hospital quickly. Um, and I don't think you can really manage it because really the management of compartment syndrome is doing a procedure called a fasciotomy, which is, um, a pretty involved cut to the leg. Um, that takes a lot of expertise to do correctly.

Patrick Fink MD:

Yeah. In contrast to like escar Otomy on the chest for circumferential burns, I don't think I've ever heard of the pre-hospital fasciotomy. I'm sure we could find the, the case report out there, but I would be nervous to undertake that.

Christopher:

Yeah, absolutely. I, I, I don't, I, I don't think there would be many orthopedic surgeons like out there who would wanna do it in the field either.

Patrick Fink MD:

Let's, I know that this is like a mean trick for someone who does like hand and and upper extremity ortho, but let's just keep marching up the leg. Um, let's move on up to the femur. One thing that always comes up is the reason that we need to be concerned about. Like a mid shaft femur fracture. Your classic femur fracture is the potential for significant blood loss. How often does this, do we need to actually be worried about this in terms of like prolonged field care? How often is this an issue, an isolated femur fracture?

Christopher:

Um, something that could contribute to hemorrhagic shock. You know, you can lose a liter and a half of your blood volume, um, from a isolated femur fracture. And, uh, that's obviously not insignificant, but it's also in the hospital setting. Pretty unusual that we actually need to transfuse or give a patient a blood transfusion for an isolated femur fracture.

Patrick Fink MD:

Uh.

Christopher:

I think also a potential misconception is that, there's a significant risk of an arterial injury with a femur shaft fracture that's really, really unusual. The blood loft comes from fracture itself. Bones are very vascular when you break them. There's lots of teeny tiny blood vessels that get injured and the bone just oozes a lot. So that's where the blood loss comes from, not from like an artery being cut by the edge of the bone. traction might help with stabilizing that. Um. Hematoma or blood clot that's forming around the fracture. And it might help give it a little bit of stability, might decrease bleeding some, but it's probably not making a real drastic impact, especially if it's a case where, um, you're at Mount Bachelor and the patient is likely going to be the hospital within a couple hours of the injury. I think the only times like, uh, traction has been shown to be really helpful is when it's like a prolonged extraction type thing. Um, I don't think there's a whole lot of studies out there demonstrating that it's a real critical or crucial thing to do, um, for a patient with an isolated femur fracture. I.

Patrick Fink MD:

I think what I'm hearing you say about the potential for blood loss, you, you use the word contribute, that it could contribute to hemorrhagic shock. That to me says that like if you're encountering a polytrauma patient who has an obvious midhat femur fracture, has angulation or deformity, and they are in shock that we should, you know, straighten the femur, fine, splint it, but you should be thinking about other causes of shock or other injuries that would be inducing that hemorrhagic shock. Not just the idea that the femur is, is the culprit.

Christopher:

Yeah, I agree. And I think, um, Patrick, you're obviously gonna be better versed of the criteria is for hemorrhagic shock, um, than I might be. But I think you're spot on with, if that patient is really, really shocky, you need to be looking at other reasons for why that might be occurring, whether it's an abdominal injury, a pelvis injury, that sort of thing. I.

Patrick Fink MD:

Definitely. Yeah. And without going into it too deeply, I mean, in the field it's predominantly a clinical diagnosis, right? You have a polytrauma patient who is pale, has altered mentation, has a heart rate that's greater than their systolic blood pressure and some sort of injury pattern that suggests blood loss. That's hemorrhagic shock until, until proven otherwise. Um, which of course, unless you are in a rare pre-hospital system like Australia or Europe where you can deliver blood, it's really about evacuation at that point.

Christopher:

Yeah,

Patrick Fink MD:

So in terms of splinting the femur, you got into that a little bit that it may have use in prolonged care. I'm sorry, traction splinting is what I'm referring to here. When we're putting on a traction splint in the field, how, how much does that differ between like what we're able to achieve with a SL man device, you know, cranking down on a femur in the field versus the kind of traction you do in hospital? Are they even comparable?

Christopher:

generally speaking, no. Uh, you know. You know, yes, it's the amount of force that like you're, you're putting on. Um, but it's also the amount of relaxation that you can get from the patient. um, you know, that's mostly done by the anesthesiologist in the operating room. So with femur fractures, like oftentimes, like you need that patient to really full paralysis, so their muscles are really, really relaxed. Um, so you can apply enough traction to get the bone lined up again, in the field. Like you're just not gonna be able to get the same level of traction. Now, is it helpful and will it make them feel better? Absolutely. I think it's worth a try. Um, but whether you can get pounds of traction or 10 pounds of traction, like I wouldn't stress out about that. I think that those traction devices are. It as good as anything, um, might help decrease a little bit of blood loss and ideally just make the patient a little bit more comfortable. But it's again, not a make or break it thing.

Patrick Fink MD:

What we're doing right now for the patrol setting is. I've come to think of it more as like a splint for this injury. And if you put it on and it's helpful for the extrication in terms of like improving the patient's pain or their positioning, then great, we use it. But if it, if the patient has significantly increased pain with application of the traction, then we're backing off and just splinting them in a position of comfort. Do you see any issues with that?

Christopher:

No. Zero issues with that. I think that's a great way to look at it. I think yes, it is, you know,

Patrick Fink MD:

Provide.

Christopher:

traction, but, um, but probably not a meaningful amount. But it is something rigid along the leg that is gonna help give the fracture some stability. And I would even say like, you know, if you are within a 10 minute sled ride to the base where that patient's gonna be going into the clinic, I wouldn't even bother. I would just, you know, put a long leg splint on them and get'em in the sled and just get them downhill faster.

Patrick Fink MD:

Agreed, a hundred percent. I mean, the ones that we have in the emergency department, which I've used exactly once to send a patient from Redmond to Bend are like a erector set, putting'em together as a nightmare. The Thelman device, if you haven't used it, is super quick. And so our folks who have experience with it, it generally doesn't delay transport, which is fantastic. It's like an entirely new thing to me. Um, but again, I, yeah, I think I agree with you that it shouldn't be delaying transfer to definitive care or prolonging the patient's exposure to the environment. But if you're in a, in a more prolonged SAR context where you're talking about a six, you know, plus hour walkout, then it starts looking like really positive. Potential intervention for, for splinting and getting some relaxation in that limb over time as those muscles fatigue.

Christopher:

Yep. I think I, I would agree with that for sure. Um, I would also that, you know, um, I'm not sure what the mountains have these days, but there are vacuum type splints. Um. I've seen, seen, and I think that's like another great tool to potentially use to stabilize these injuries. You know, it may not necessarily add traction, but um, probably gonna be a pretty helpful tool with just preventing the leg from getting jostled during transport.

Patrick Fink MD:

We have the full body vacuum splints, which are great for splinting, you know, patients with polytrauma or multiple traumatic injuries. But I have also seen those isolated limb vacuum splints, and those are great because. The traditional immobilization is sort of like the two pieces of plywood with foam and a little strap, just like sandwich a leg. That works great if you can return it to some kind of anatomical alignment, but if it's angulated or the patient's in a challenging position, like a hip fracture where they want to be on their side, the the vacuum splint is really superior to trying to make things work with those, those old hard splints.

Christopher:

Yeah, for sure.

Patrick Fink MD:

Let's move up now to the pelvis. So if people often fall and have pain over their hips or over their pelvis, in what subset of patients do we need to be thinking about pelvic fracture and how do we examine that and, and diagnose that potentially?

Christopher:

Yeah. I would probably worry most about a pelvic fracture in someone who is older and just falling onto their side in like really hard snow. Pelvic fractures, um, in young patients take a lot of energy. Um, not that they can't happen, skiing or snowboarding, but it's a much, much more common thing, like from a really bad car accident. Um, you know, the patients with pelvic fractures, they may localize the pain a little bit differently than with a hip fracture. You know, I think if like patients are localizing pain more to their sacrum or their iliac wing, um, is a good clue that it, the pelvis could be more involved. Whereas, like someone saying like, it's really more groin pain, I'd be worried more about a hip fracture. think this is probably honestly a more common injury like in the icy parking lot than it is on the ski hill. Um, I. I think, you know, for examining them, you know, just palpating different areas of their pelvis. Um, and keeping in mind that, you know, the iliac wing and the greater trochanter are two different bones. One is the femur, one is part of the pelvis. Um, so just making sure your palpating in spot is, is important. Um,

Patrick Fink MD:

just, just to jump in there for the audience, Chris, like the, the iliac wing, I would orient people to like put your hand on your flank on the soft part of your abdomen and then slide down onto the top of the pelvis, like kind of your middle school, like slow dance, hand spot. Um, and then the femoral trocanter in contrast is like, take your hand on the side of your leg and run it up to the first kind of bony prominence at the, at the top of the leg before it angles into the hip. And that's where you're finding that that trocanter.

Christopher:

Yeah, totally.

Patrick Fink MD:

So you're saying, okay, pain over the, the trocanter or that, that kind of upper leg area. We're thinking maybe more hip fracture if you're pushing on up on like the slow dance region up in the iliac wing, maybe we're thinking more pelvic fracture. A lot of the coaching for pre-hospital or EMS management of pelvic fracture is early recognition and application of a pelvic binder or pelvic splint, particularly in patient with polytrauma. What do you think, or what's, what's your take on the benefit of pelvic binders broadly? And then we can get into the, the nitty gritty about where to put them.

Christopher:

Yeah, so pelvic binders, you know, really the utility of a pelvic binder is in a patient who is potentially having hemorrhagic shock from a high energy pelvis fracture where there's a lot of. injury or bleeding within the pelvis. And the idea of the pelvic binder is are closing down the space within the pelvis to help that hematoma from expanding. you know, I think the, the issue with pelvic binders is it's very hard to diagnose what, what type of pelvic fracture a patient may have without having some imaging. So the most common types of pelvic fractures are, you know, from falling on your side. those tend to be lower energy things where bleeding inside the pelvis is not a giant problem and actually applying a pelvic binder might make the patient more uncomfortable. As long as you're not doing it too tight, not gonna cause any significant harm. But it also is. Maybe something that's just not super useful. Um, really like we use pelvic binders in polytrauma patients. Like once we know type of pelvic fracture it is from an x-ray or a CAT scan, and then we're using them like as a temporizing measure until we can get them to the OR for definitive fixation. oftentimes these patients are really sick in multiple injuries and really only putting a pelvic binder on when something else is taking precedent and prolonging our ability to like get them to the operating room. I think putting a pelvic binder on in the field, um, is like pretty yield and not super duper useful, especially like on the ski hill I think. One of those full body vacuum splints is probably gonna be more helpful than anything. Um, but uh, again, like I don't know that it's that critical.

Patrick Fink MD:

Okay, so I'm hearing that like there are certain injury patterns, namely open book pelvic fracture, which once diagnosed on with imaging can be, temporarily, can be temporized with a pelvic splint until you can manage it definitively, but potentially other injury patterns like sheer injuries or those more minor injuries that you were talking about, you're sort of intonating, I'm, I'm assuming you're talking about like a fracture to the acetabulum or the pubic synthesis where applying that binder, it may just result in increased pain without bringing you any benefit.

Christopher:

Yeah, exactly. Like if it's an lum fracture or a lateral compression type pelvis fracture, you might just be compressing something that doesn't need to be compressed and you're just rubbing fractured edges of bone together, which is gonna be super painful.

Patrick Fink MD:

Yeah, and I, I have always, when I've taught pelvic binders, I, I teach the placement of it as a trocanter binder, meaning that, like the common error when placing a pelvic binder is to put it on too high to put it up in the up in the slow dance position, and it needs to be, to be effective in the, in the right injury pattern needs to be over those femoral tro caners. Incidentally, probably the most painful place to put it, if you have misdiagnosed a femoral neck fracture or an acetabular fracture, and it's really a problem of, of the hip or lower pelvis.

Christopher:

Yeah. Yeah. So I think. The overall lesson is, yes, put it lower than you think it needs to be. if you're out in the field, I wouldn't go crazy making it super tight, especially if it's making the patient more uncomfortable.

Patrick Fink MD:

Yeah. To,

Christopher:

you know, we worry about pelvic finds being on for too long, like more in the hospital setting, um, being applied incorrectly. Um, I don't really worry about that too much in the field. That would be more of a concern, like, you know, say someone gets injured and evaluated at a really rural and you know, they get transferred and just the provider there like puts it on too high or something.

Patrick Fink MD:

yeah, to my mind, their use now in pre-hospital care is for the unstable. Polytrauma patient with an unclear source of hemorrhage where you're just, you're putting band-aids on all the things until they can get to definitive care. I have seen, I have seen this on the ski hill in someone at Snowbird who unknowingly skied off like a 40 or 50 foot cliff and then landed in, in fairly shallow snow, and they ended up having a, an open book pelvic fracture. Were quite unstable. Um, but I, I think that your average, like fall in the parking lot in my experience, or even like in the park, ends up being much more often a acetabular fracture or pubic synthesis where they just jammed their, the, the ball of the femur into the, into the hip and caused pain.

Christopher:

correct. I will say, you know, I, I'm not obviously in the emergency room as often as you are, um, but some of the pelvic binders that I think I am seeing coming in from the field actually look pretty good to me and that they're fairly long and broad, um, and probably not super likely to. A pressure injury if placed a little bit incorrectly. So that's kind of a positive.

Patrick Fink MD:

Yeah, I think that there's basically like two commercial types and there's kind of the broad, um, what's the word I'm looking for, kind of lace up type, which tends to be 12 inches, probably in height.

Christopher:

Mm-hmm.

Patrick Fink MD:

And then at bachelor we're using the SAM product, which is, it's probably eight inches, maybe less. It's a little bit of a narrower thing. So there, there is the potential there if it's in the wrong spot. But, um, that device also has built in guidance as to how tight to make it, you pull it till it clicks. Um. But that's neither here nor there. Let's, let's move on to your wheelhouse. Let's go to the shoulder and the upper arm. So, shoulder dislocation is super common in both skiing and mountain bike falls. You know, Deschutes Countys recently responded to a snowmobile or with a dislocated shoulder. If you have a suspected shoulder dislocation in the field, what do you think about reducing that in the field?

Christopher:

Um, I think generally speaking, it's fine to try. I think the key is that you have to be pretty sure that it's a shoulder dislocation and not something else, like a proximal humerus fracture. Um, this is an instance where like, I do think it's probably pretty important to get the jacket off and really look at the shoulder if you're considering. reducing it because a shoulder dislocation, um, and I'm talking about anterior shoulder dislocations, which are by far the most common. Um, there's gonna be a very clear soca sign and a very clear squaring of the shoulder, um, that is gonna clue you in that that shoulder is dislocated and it's reasonable to try and reduce it. Um, I think proximal humerus fractures, especially in patients over 60, are much more common than a shoulder dislocation. unless you can really be pretty confident that it's a shoulder dislocation, trying to pull on a broken shoulder is gonna be extremely painful for the patient.

Patrick Fink MD:

Definitely. That's always my concern in patients in the emergency department is I don't really want to, it's, it's great to try to reduce these injuries when they're fresh and before the muscle spasm has made it progressively harder to achieve that. But poor form, if you're pulling on a, on a broken humerus,

Christopher:

Yeah.

Patrick Fink MD:

I have the benefit of imaging, but I think in the field history is probably, in addition to the exam you just talked about, is probably 80% of what helps you figure out dislocation versus fracture. Right? Like it's often someone who's dislocated before and then they fell. With the arm in some kind of extended or externally rotated position where they got sent into an involuntary backstroke, if you will, and, and had a, have an injury pattern that they're familiar with versus I feel like the most common mechanism for the proximal humerus fracture is a direct blow to the shoulder. So they went over the bars on their mountain bike or collided with a tree on the snowmobile or fell on the ice in the parking lot and land on that shoulder. Would you agree?

Christopher:

Yeah, generally speaking I would agree. I think you can get both from falling onto an outstretched arm. Um, but I think you're spot on with the history. You know, patients who have dislocated their shoulder before remember what it feels like unfortunately, and I think they will often be able to tell you, yes, that's the problem. It felt like did this, you know, six months ago and it feels the same. Um, I think, you know, shoulder dislocations, like even in a muscular patient, like it's gonna be pretty obvious when you actually look at your shoulder. And I think if anyone has questions about what that might look like, Google Sulcus sign or Google anterior shoulder dislocation and just. Refresh yourself with some actual pictures of what it looks like with someone with their shirt off. Um, and it's pretty obvious.

Patrick Fink MD:

I agree with you. It's obvious in our skinny trail runner population, sometimes in our more generously proportioned patients, it can be a little harder to figure out clinically.

Christopher:

Yep, yep.

Patrick Fink MD:

Now, this might be a, a loaded or a pointless question. Do you have a preferred technique for reducing the shoulder?

Christopher:

Yeah, I do. Um, I pretty much use traction and counter traction. Now that can be tough to do, like if you're by yourself. Um, obviously like if I'm reducing a shoulder, I usually have, the benefit of assisting me in the, in the ER or something. Um, but also when I was a resident, like often I was doing that kind of thing by myself. Um, you know. Pulling traction on the arm and you do need quite a bit of traction. Um, while having either someone else stabilize the axilla or upper chest wall while you're pulling is gonna be the safest and leaf likely to cause a problem, uh, or make something worse. You can fracture a shoulder or proximal humerus while trying to reduce shoulder dislocation. If you are too much rotation. unusual, but it can happen and some overzealous, you know, orthopedic residents or ER docs like it. It has happened and it definitely can happen, but it's really unlikely to happen if you're just pulling straight traction. And that's gonna be the most likely thing to get, get it back in. Um, if you're on the scene quickly and like, you know, it hasn't been where it's been dislocated. so if you can imagine like putting a sheet or something in someone's armpit and one person pulls on the sheet and the other pulls on the hand, um, that's what you're trying to do. You can do some gentle circular motions of the arm and that will help loosen it up and get it back in place. Um, in the field I would not try and do a lot of or external rotation, because you could risk, uh, fracturing the arm.

Patrick Fink MD:

And just to make this easier to visualize,'cause unfortunately we're on radio, like internal and external rotation. We're talking about bringing that arm up into like a, I'm throwing a football position and then keeping that arm there and dropping the hand down. So the elbow stays high, hand goes down in like a, I don't know, high fiving motion. That's your internal and external rotation, right when your arm is up, adducted.

Christopher:

Yep. That's a great way to think of it. Um, and sometimes internally and externally rotating is the way that you're gonna get a shoulder back in place. But what you could not appreciate, like just on a physical exam, um, of a patient, is that sometimes there's a dent in the head of the humerus and it is engaged or locked into the of the shoulder. if you don't know which way to twist. You could just be making it worse and it would be super painful.

Patrick Fink MD:

Is that a bank card or a hills sax.

Christopher:

A hill sax

Patrick Fink MD:

Hills sax.

Christopher:

Yeah.

Patrick Fink MD:

I had one of those. It was great prepared surgically. It feels great. Um, so in the. Shoulder dislocation, like early reduction may be helpful provided that you can identify the right patient for that. In terms of or remaining orthopedic injuries of the upper extremity, I think of maybe reducing finger dislocations as something easy and achievable in the field. Are there other injury patterns that you would identify that are like important to say, Hey, this is something that stands apart from, I've sprained my wrist, I've broken my forearm, I'm gonna be splinted in a position of comfort. Are there other kind of high priority injuries of the upper arm or, uh, sorry, the upper extremity.

Christopher:

Um, no, not really. I think finger dislocations, you know, and I'm talking about PIP joint dislocations are fairly common and generally speaking, yes, very easy to reduce, um, they're not. And the most common types are easy to reduce and just pulling on the finger is gonna get them back in place. there's also some more subtle dislocation types that on it can actually make it worse. Um, so again, this is a, a thing where an orthopedic hand surgeon, I don't really worry about a paramedic or a ski patroller, like trying to pull on something and making it dramatically worse. Um, but if it's not working, stop doing it. Um, because sometimes there are stuck in the joint and the only way that you're gonna get it reduced is. Making an incision and getting those stuff, that stuff out of the way.

Patrick Fink MD:

Okay, so for the remainder of our main orthopedic injuries of the upper extremity, like a both bone forearm fracture. A fracture to the the elbow. This is predominantly a matter of like splinting in a position of comfort, slinging the patient and assisting in their evacuation.

Christopher:

Totally. Yeah. I think, you know, elbow dislocations, um, much, much less common than a shoulder dislocation. is something that, um, you know, I think if you have some experience, uh, being able to evaluate it and know that injury, reducing that in the field would be a reasonable thing to do. But generally speaking, everything else, I think you, you splint it, you sling it, and just try and get them to the hospital sooner. Um. Wrist fractures or both bone form fractures. I think if you are trying to gently realign the deformity so you can get them into a splint, I think that's okay, but I certainly wouldn't, know, expect anyone other than an ER doc or an orthopedist to like really do a true reduction maneuver in the field.

Patrick Fink MD:

And you can attest to this as much as I can, that a both bone forearm fracture really does not like to stay where you put it. And so spending a bunch of time on this is probably not well spent.'cause you're, unless you have, you happen to have like a plaster splint with you, it's probably gonna go where it wants to over the course of the next hour.

Christopher:

if has an extra elbow in the mid form where it's not supposed to be and you wanna try and gently push on it to make it more straight, totally fine, but don't kill yourself.

Patrick Fink MD:

Okay, then let's jump from the upper extremity down to the knee in, you know, perfectly reasonable order. Um, uh, injuries to the knee are super common, right?'cause it's a very mobile, or not mobile, but it's subjected to a, it's easily subjected to a lot of force. Let's just start with broad principles. In terms of orthopedic injuries to the knee, if a patient can walk to assist with their evacuation, can we let them do that?

Christopher:

Yes. Um, short answer, yes. I think most of the time, you know, a patient being able to walk is suggestive of a ligament injury like an ACL tear or an MCL tear, where, you know, the bones actually providing the, the structure and ability to bear weight are okay, even some like very minimally displaced. Tibial plateau fractures. Like if the patient can bear some weight, fine. And that bearing of weight is not going to significantly make the fracture worse or take it from something that likely is not going to need surgery to something that is,

Patrick Fink MD:

Okay, so there's no red flags you would, you know, find on evaluating the knee that would make you say, look, you can bear weight, but I don't think you should.

Christopher:

um, I agree with that. I would let the patient judge how much pain they're in and if they're able to do it and if they can take a couple steps or even just bearing weight just to kind of help transfer from, you know, a wheelchair into the car. Like those types of bearing weight are not consequential, not going to make an injury even if there is. Some type of fracture significantly worse. Does that make sense?

Patrick Fink MD:

Yeah, no, that's great because if, if the patient can participate in their evacuation, it can save an absolute nightmare of a carryout. Um, for example, I noticed. You know, a few months ago when I was there at Smith Rock on the backside of the Misery Ridge hike, they now have stored like a few sets of crutches. And so if you have a patient who can use crutches and can, you know, do some toe touch, weight bearing, or what have you, to crutch themselves out, that saves probably 20 people from having to come in to help with a, a carryout. So that's a, it's a pretty huge benefit.

Christopher:

Yep.

Patrick Fink MD:

Now, let's think about the, the two, you know, dislocations of the knee. One common one uncommon. Just orient the listeners, will you to patella dislocation versus knee dislocation and when we're gonna suspect one versus the other.

Christopher:

Um, so a patella dislocation much, much, much more common injury than a true knee dislocation. So the patella or the kneecap sits within a groove the end of the femur, that groove is somewhat shallow. So if you have some underlying ligament laxity, um, on the ligaments kind of holding the patella centered within that groove, it can dislocate. And that's can be from a twisting tight

Patrick Fink MD:

I back.

Christopher:

or like a laterally directed force. Um. This type of injury much more common in like someone cutting while they're, or twisting really quickly while they're playing soccer or football, um, rather than like a hard fall onto the knee. you know, I actually don't really know like how common patellar dislocations would be skiing, but probably not super common unless like that patient has had this injury before. Um

Patrick Fink MD:

I've seen it. I've seen it in people who have had it previously,

Christopher:

mm-hmm.

Patrick Fink MD:

it's definitely more, it's like equally common in the lodge when they slip on a wet floor as it is out on the ski hill. And then the episodes I've seen on the hill have actually been like a snowboarder taking a sapling to the side of the knee, like an actual lateral blow where they probably also tore their, you know, MCL to go with it.

Christopher:

Correct. Yeah. So, you know. I agree, like some degree of on the lateral side of the knee as well as like a valgus directed, um, forth from like a bad twist. And that's gonna, you know, a lateral dislocation or like the patellas flipping to the outside of the femur rather than the inside of the femur is gonna be the most common. It's very obvious when you like actually look at the knee, like the patella is sitting out and it's stretching the skin a lot. And that is something that, you know, if you can just help the patient straighten their knee and put a little bit of forth on the outside of the patella and push it back where it looks like it should go, an easy thing to do and it's gonna make them feel a whole lot better very quickly.

Patrick Fink MD:

Yeah, I find these very visually striking in that the patient is usually very uncomfortable and they're holding that knee inflection, and then you go and expose the knee and the kneecap, the patella is grossly deformed. And I, I feel like it's one of those situations where the, the deformity is really out of disproportion to the severity of the injury, where this is something that can be readily fixed. But as you said, like straightening the leg while pushing the patella back towards the midline.

Christopher:

Yep,

Patrick Fink MD:

And the biggest hurdle that I have with that usually is just getting the patient to trust me that this is gonna go okay. That it takes like just a moment of their relaxation to get this reduced.

Christopher:

yep, yep. Um, yeah, it's not subtle. it's a pretty obvious thing.

Patrick Fink MD:

Also, I've found that in, even in settings where folks don't have protocols to, you know, reduce these in the field, it often ends up getting accidentally reduced as they're getting moved into a toboggan or moved onto a gurney.'cause that leg gets essentially straightened somewhat and boom, there it's been reduced.

Christopher:

Exactly. Yep. I think that's totally accurate.

Patrick Fink MD:

If your four hours walk out and it has been reduced, can they walk?

Christopher:

Yeah, I think so. I think that's like a case where, you know, just making sure or encouraging them to like, keep the leg more straight and, you know, kind of like imagine a walking on a peg leg, um, is gonna be fine. But yes, you know, there presumably there's no fracture or injury to like weightbearing things with that injury. So it's fine for them to, to walk and again, the

Patrick Fink MD:

Damage.

Christopher:

from the injury itself and that patient may need surgery in order to those ligaments. Um. And having them walk or bear some weight, like to get them back to their car or to the clinic or whatever, is not going to like make something significantly worse.

Patrick Fink MD:

Can you contrast that now for us with the A true need dislocation?

Christopher:

Yeah. So a knee dislocation is where the tibia from the end of the femur. That is a way, way more high energy mechanism. That's, you know, the classic, um, injury pattern or mechanism for that is someone sitting in their car having a head-on collision and the dashboard hits the top of the tibia bone and pushes the tibia behind the femur bone. so. takes a ton of force. You have to rip or tear multiple ligaments in the knee. You know, typically it's A-C-L-P-C-L, a lot of capsular injury it's just a super high mechanism thing. And something I would more expect in a bad car accident, really bad fall from height, um, or motorcycle accident. Um, these are probably a little bit more similar to shoulder dislocations in that like if you get to it really quickly, um, you might be able to reduce it closed in the field. Um, but once things start tensing up, like it takes quite a bit of force to reduce these um, often something that is gonna need quite a bit of anesthesia to, to help with.

Patrick Fink MD:

So generally we're not going to be able to reduce it in the field. Are you recognizing this on the basis of just deformity at the knee, like the, there's deformity there, things aren't in alignment yet. The patella is in the midline.

Christopher:

Yeah, patella is in the midline. Um, if you can imagine the medial side of the knee, um, or the medial femoral condyle, of the inside part of the end of the femur bone is going to probably be sticking way far in front. And you're gonna have this kind of extra double joint at the knee where like the knee is flexed and bent over. But then there's kind of a going backwards, um, with a big soft defect where you would expect the top of the tibia bone to be.

Patrick Fink MD:

Okay. And in my mind this is has, it's been grounded into my head that this is a priority evacuation injury because of the potential for arterial injury. How often do those two actually go hand in hand?

Christopher:

Um, that's a good

Patrick Fink MD:

Shoot.

Christopher:

question. I think like, um, you know, the amount of time where like that patient is actually gonna need some type of, um, vascular repair is probably like 20% of the time. You might notice some degree of like, absent pulses, you know, more like 10 or 15% of the time. Um, but it is like amongst upper or lower extremity injuries there's gonna be vascular compromise. This is top of the list. So I absolutely agree with you like it is. Something that you don't want to dole with at all and you know, and you would want to get that patient reduced a hospital very quick or as

Patrick Fink MD:

so if, if I was gonna give the listeners a take home here, it'd be that, you know, this is not the patella dislocation. This is a very high energy mechanism of injury. You motor, you know, dirt, biker, snowmobiler versus tree, for example, and you're seeing deformity, it's probably not something you're able to reduce. You probably should be exposing the foot to evaluate for pulses if, if you can protect the foot after you do that. And then if you suspect this injury, it's something that should be escalated. Like this is a, if you have the choice between the walkout and the helicopter, it's a helicopter. If you know, if motorized means whatever is kind of the fastest way to get that patient out is worthwhile in this setting.

Christopher:

Yep, absolutely. And this, um, know, if there is a vascular injury, like that can be a devastating thing. Um, you know, certainly really high risk of getting compartment syndrome of the lower leg this injury. And, um, you know, that is if the compartment syndrome is bad enough or it is not taken care of quickly enough. Like this is a case where like a patient could lose their, leg, um, because things necros distal

Patrick Fink MD:

On that cheerful note.

Christopher:

again, it's just like a serious injury that you would wanna take care of soon.

Patrick Fink MD:

Mm-hmm. On that cheerful note, I want to give you the opportunity to tell us if you have any sort of like. Pet peeves or issues, common. Common problems that you see come in from the pre-hospital setting when it comes to care of orthopedic injuries that our first responders could orient to and, and perform at a higher level.

Christopher:

Um, I'm sure that would be helpful feedback, but honestly I really don't. Um, you know, they're, we see patients who get hurt on the ski hill and they get taken care of really quickly. And we also see patients who fall at home and they think that they can walk it off for several days and they show up, you know, a couple weeks after the injury and it's kinda like, have you been living with this? I bet that really hurts. I can't really think of anything super significant that I've noticed as a orthopedist that like, I wish something had been done differently. Um, think generally speaking, you know, it's probably like the comfort level of first responders, like realigning fractures, um, or reducing dislocations is accurately Um, and I really wouldn't expect, like with that level of training to be able to do those sorts of maneuvers that, you know, at least for me, like, took years to master. Um, so I, I really don't, I think, you know, keep in mind that like. Of these things like cannot be definitively fixed until they're in the hospital setting. And so just keeping in mind that, you know, them to the hospital sooner, around later is really the most important thing.

Patrick Fink MD:

I agree with you completely. I think that, you know, building a building experience with managing and reducing orthopedic injuries has, at least in my career, taken me, you know, years going on a decade. And there's still so much that, you know, that is not in my brain. So my confidence in the management of these injuries is lower. And in the pre-hospital setting, I feel like the things that we can do are recognize a few simple things, which if reduced or addressed early are pretty harmless and let a patient walk out instead of a complex evacuation. And then otherwise, it's predominantly that kind of core, recognizing splinting pain control and treating other traumatic injuries without being distracted by that, you know, wrist injury. I.

Christopher:

Yep, totally. I remember when I was taking my OEC course, um, years and years ago, uh, one of the instructors, um, who was not a physician or in clinical practice in any way, um, but he had been in a ski patroller for years and years. Um, his advice was, remember the ABCDs, but don't forget, d and d stands for delivery. Um, and I think that's just a funny thing that I still remember to this day. Um, but it's really true, like, you know, just get them to the hospital if it's something really bad.

Patrick Fink MD:

Yep. When I took my EMT basic course at the University of Utah, it was a BC diesel for the the ambulance drivers. Well, thanks so much, Chris. That was a, uh, real. Pop per roundabout and despite, you know, your hand and upper extremity fellowship, we put you through the paces on really everything. So I really appreciate your time and expertise and I'm sure that the listeners are going to derive a lot of benefit from this. I hope that in the future if folks come back with more questions or we have something to really drill down on that we can invite you back.'cause I think you're actually, you're really great at explaining a lot of these concepts.

Christopher:

It's not rocket science, that's why, um, orthopedic surgeons exist in medicine. Yeah, happy to answer more questions or come back if, if more things come up.

That's it for this episode with Dr. Chris Healy. Thanks so much, Chris, for coming on the show. I hope that all you listeners liked that one. We really covered most of the body, head, shoulders, knees, and toes, fractures and dislocations, care of open and closed. I think Chris really brought it down to earth and gave us some tactical, grounding principles that we can use, treating our patients, whether you're on the ski hill, working in search and rescue, or in a austere. Expedition environment, you know far from definitive care. If as you listen to this episode, you had questions that came up for you or things that weren't clear, please, please, please send those along to Wilderness Medicine updates@gmail.com. As several listeners now realize listening to this episode, I do get around to all those questions. I bring people back on to try to address those if I'm not the right person to do it for you. So if you have follow ups, if you have clarifications, if you want to go deeper on something or if there's some other topic you wanna hear about, please reach out. I'm always happy to hear from you. I had love it. If you would support the show by giving us a five star rating on Apple, on Spotify. Drop a comment in there about how much you like the show. That kind of stuff helps us reach out through the algorithm and reach more people, grow the show, and deliver this content to more ears. That's the best way that you can support it. And the second best way is if you share it with someone you think would like it. So click the share button on this episode. Send it outta your podcast app and send it off right now to someone who you think would appreciate this. Maybe someone who would disagree with it, who wants to argue with me, who has more questions, whether that's another SAR member, a doc in your group, someone you go. Snowmobiling with your cross country ski partner, your fellow K Knowles instructor. Please share it with them so it reaches more ears, reaches more people, and we get more questions to bring more interesting content to you.'cause I like doing it and we learned so much along the way. I appreciate you all. Until next time, I'm your host, Dr. Patrick Vink. Stay fit, stay focused, and have fun.

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Patrick Fink MD, FAWM

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