Uneasy Rider

   There are calls where the complexity of patient care cannot easily be predicted. "Person injured in a bicycle accident" is one of them. Attack One is dispatched with that information, and nothing else, to a rural road, where the crew prepares to find a major trauma patient. They are instead fortunate to find a single victim, helmet in hand, his intact bicycle a few feet away. As the crew arrives, he is talking with a single bystander who came upon the rider and parked his car to shield the man from traffic as he waited.

   The victim is on his knees, moving his head from side to side and trying to find a position comfortable for his obviously injured right shoulder. He is wearing the gear of an experienced cyclist, with a rugged helmet and expensive but now damaged biking suit, and taking a drink from his water bottle. He thanks the crew for arriving promptly and reports that his right shoulder is hurting badly, but he believes that is the only damage he sustained.

   It is about 0800 hours and still cool, but he is sweating profusely...or is he diaphoretic?

   The man is 45 and says he was in the middle of his "sprint workout" when he hit a large pothole. He ejected over his handlebars and landed on his right shoulder. His helmet hit the ground, but he denies any head or neck injury. The helmet bears a confirmatory scratch down the right side. He denies shortness of breath, abdominal pain, nausea or leg pain. He says he's sweating because he'd been working out so hard before the accident occurred. He remembers all details of what happened. The bystander confirms the victim was alert on his arrival, and was asking for his water bottle because of his workout.

   But his right shoulder is a mess. He's torn his shirt, obviously broken his collarbone, and may have dislocated his shoulder. He's found a position on the ground where the bone edges of the broken clavicle don't grate against each other, and that allows him more comfort.

   The crew clears the cervical spine per protocol and determines the man does not require immobilization. They offer to support his arm for comfort while he rolls over, and have a sling available to immediately immobilize his injured shoulder. They prepare to put a chemical ice pack on his arm. But the bystander offers a bag of ice from a cooler in his car, which can deliver a colder compress for longer. The crew asks the man to prepare that for the patient. One of the EMTs then supports the patient's shoulder as he rolls upward and is placed on the cot, and in one motion they cut off and remove his shirt and tie the sling in place. They ask him to find his position of comfort and put the bag of ice on his shoulder in whatever way best reduces his pain.

   The crew completes its head-to-toe evaluation, loads the patient into the medic, and again asks him to find a position that minimizes his pain. He adjusts his sling and the bag of ice, and the crew moves to close the door.

   "Wait!" the patient cries. "You have to put my bike in here with me! That's a $6,000 bike--you can't leave it on the side of the road. Put it on top of me if you need to!"

   The bike is, in fact, still on the road, and this is a problem. The bystander has a small car, law enforcement hasn't yet arrived, and there are no houses nearby to store it. The patient has no friends or family within 30 miles of the scene. That makes it impossible to reassure him the bike could be safely left for pickup by the side of the road. But there's also no way the bike will safely fit in the passenger compartment.

   "Sir," the paramedic says, "we have a policy that says we can't transport bicycles on the roof of the ambulance. But we can have your bike taken to the hospital on the canvas hose cover of the first-response fire engine. Would you agree to that?"

   The patient does, and the bike goes to the hospital on the engine. The emergency department staff is prepared for both arrivals--while the patient is in the ED, the bike will be locked up at the EMS entrance by hospital security.

   The man remains mostly comfortable on the trip to the hospital and arrives in the ED stable. The crew shares his history with the emergency staff, and he compliments the paramedic for excellent pain control, but asks the nurse if he can have some pain medication, as the shoulder is getting more uncomfortable.

   His evaluation reveals only a fractured clavicle and a number of abrasions. The shoulder is not dislocated. The patient's pain is ultimately treated with narcotics and a formal sling, and he and his bike return home safely.

Case Discussion

   Pain management is an essential element of emergency care. Pain is the primary symptom for the majority of patients receiving EMS care, and we now have a widely used scoring system to gauge pain. Hospitals are held accountable for providing pain control, and some regulatory bodies have even proposed pain score be regarded as a vital sign.

   This case demonstrates the availability and utility of multiple modalities for pain control. Pain management certainly can be provided by narcotic pain medications, for EMS providers who have those drugs available. But even other EMS providers have extremely effective measures available for most patients, and these can represent important first steps in pain management. These include:

• Positioning the patient to minimize pain. That often means sitting them up or elevating an injured extremity.
• Padding the injured body part, taking care not to compress nerves or blood vessels. EMTs must be comfortable utilizing a variety of boards, stretchers and padding materials.
• When an older patient must be transported on a long backboard, soft padding will increase comfort and prevent injury to thin skin.
• Support devices, such as slings, pillows, blankets and rolled-up sheets.
• Cold compresses, including ice packs or appropriate-size bags of ice.
• Driving the vehicle with the patient's comfort as a priority.
• Reducing patient stress with a calm demeanor, comforting words and appropriate smiles and humor.
• Comfort items, especially for children.

   For selected painful processes, there are medications and procedures that reduce pain significantly:

• Angina patients get oxygen and nitroglycerin.
• Sickle cell crisis patients get oxygen and intravenous fluids.
• Most protocols for local partial-thickness burns utilize cold water on small areas.

   Finally, some systems are utilizing non-narcotic pain medicines and sedatives to reduce pain and increase comfort during emergency patient transport. Those include acetaminophen, ibuprofen, ketorolac and nitrous oxide.

   For certain patients, pain can be reduced by use of prescribed home medications prior to transport. For example, patients with serious and terminal illnesses often have pain medicine prescribed and available, and medical control can guide crews in working with family or home care providers on the use of those medicines.

Initial Assessment

   A 45-year-old male injured in a bicycle crash.

• Airway: Intact and uncompromised.
• Breathing: No distress, can speak in full sentences.
• Circulation: Patient is sweating, with normal capillary refill and pink skin.
• Disability: Alert and oriented; no neurologic deficits. Remembers all details of accident.
• Exposure of Other Major Problems: Obvious right clavicle fracture, abrasions to shoulder and possible dislocation of the humerus. Strong distal pulses, good movement and intact sensation both before and after splinting.

VITAL SIGNS

AMPLE ASSESSMENT

• Allergies: None.
• Medications: Vitamin supplements; daily aspirin.
• Past Medical History: Prior orthopedic fractures related to biking. No heart or lung problems.
• Last Intake: Breakfast at 0530.
• Event: Painful injuries from bicycle crash.

Customer Service Opportunity

   Management of patients' personal property--items like bicycles, wheelchairs and luggage--is an issue for EMS agencies across the country. There are significant logistical issues related to safely transporting large pieces of personal property with patients. Most ambulances are completely packed with equipment and cannot be rigged to transport property. If the patient is critically ill or injured, there is little time to consider such ancillary items.

   Agencies should therefore have plans to move and secure patients' personal property, and hospitals should have policies that allow them to secure items until patients or their family members can claim them. Many large items can be moved in law enforcement or fire department vehicles. Some will also fit in EMS supervisor vehicles.

   Items that are the most challenging include motorized wheelchairs. These are quite heavy, very expensive, and cannot be transported in or on most EMS, police and fire department vehicles. Almost no 9-1-1 ambulance can safely lock down and transport a person in a motorized wheelchair in the patient compartment. EMS agencies should have plans for moving these valuable assets established with mass-transit providers, ambulette agencies or even volunteer agencies that transport wheelchair-bound persons and have vans and staff that can accommodate chairs. Then patients can be managed safely and expediently, and crews can assure patients their chairs will be moved with them to hospitals in a safe manner.

   In all circumstances, EMS providers must be able to deliver excellent patient care, and be prepared to manage important belongings that must later be returned.

   James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in Ohio. He is director of clinical operations at EMP Management in Canton, OH, and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton. Contact him at jaugustine@emp.com.