# Lifting patient with possible dislocated shoulder



## QRScomplex (Jul 17, 2016)

This was a call I had at the BLS level and am curious how others would approach this. 

We were toned out for a 65yo female who had fallen with a possible fractured hand. When we got there the patient was laying supine in the upstairs bedroom of a s 2 story home. She had apparently stumbled, hit the dresser on her way down with her left shoulder and was unable to get up on her own. Patient had been down for more than an hour as she wasn't able to reach the phone. No loss of consciousness or syncopy prior to fall. No other injures and c-spine cleared. CSM's present in all 4 extremities, patient alert x4, normal vitals. Not on any medication and only allergy was to oxy and could not take any narcotic pain killers. Due to the last we called of ALS for pain management. 

The issue was getting the patient up off the floor and onto a stair chair to get her downstairs and onto the stretcher. 

We ended up wrapping her in a sheet to keep the left arm as immobile as possible but any pressure to the shoulder or arm caused severe pain (7 out of 10 when not moving 10 out of 10 if pressure applied). Patient was approximate 190lbs. Attempts to manually lift her up failed due to he pain and the patient ended up maneuvering herself to her knees with some assistance to keep her from tipping back and the stair chair placed behind her. She was able to get into the chair with assistance. 

My question is, are there other ways that services approach these types of lift situations either with lift assisting devices or other types of lifting aid's and if so what do you all do?


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## TransportJockey (Jul 17, 2016)

I would use a scoop stretcher


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## QRScomplex (Jul 17, 2016)

TransportJockey said:


> I would use a scoop stretcher



My initial thought was safety using a scoop stretcher going down stairs but I suppose with enough guys that would be a non-issue. Thanks for the feedback!


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## MonkeyArrow (Jul 17, 2016)

Honestly, I would just profusely apologize and attempt to move/lift the patient as quickly as possible. It's going to hurt for a few seconds but it's the most efficient way.


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## SpecialK (Jul 17, 2016)

Combi-carrier would be best because she doesn't have to move much, and can put the entonox cylinder between her legs.


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## NomadicMedic (Jul 17, 2016)

Scoop stretcher and a paramedic with fentanyl.


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## QRScomplex (Jul 17, 2016)

DEmedic said:


> Scoop stretcher and a paramedic with fentanyl.



Do paramedics carry pain meds that are not opiate-based? She refused any narcotics which is why we called off ALS. 


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## NomadicMedic (Jul 17, 2016)

QRScomplex said:


> Do paramedics carry pain meds that are not opiate-based? She refused any narcotics which is why we called off ALS.
> 
> 
> Sent from my iPhone using Tapatalk



Not anything I'd give to her. However, people who don't want to take opiates seem to change their tune when they're being man handled down a flight of stairs. And she's "allergic" to oxy? I hear that a lot. When I ask what happens invariably I'm told, "well, I get a little sick to my stomach, get dizzy and kind of loopy". I'm always like, that's the expected action not a side effect. Do doctors ever explain what patients can expect when they take opiate based medication?  It's not like taking an APAP.


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## TransportJockey (Jul 17, 2016)

QRScomplex said:


> Do paramedics carry pain meds that are not opiate-based? She refused any narcotics which is why we called off ALS.
> 
> 
> Sent from my iPhone using Tapatalk


Some. I used to carry toradol and some places carry ketamine too


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## QRScomplex (Jul 17, 2016)

I'll have to think twice about ALS then in future situations. Thanks guys for the feedback!


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## WolfmanHarris (Jul 17, 2016)

We carry keterolac as well. I'd consider 30mg IV for pain. If the injury is isolated I'm inclined to assist them to standing and help them walk down the stairs. Stair chair or scoop are both going to place pressure on the shoulder. Pop in a lock, push keterolac, maybe combo with Morphine or fentanyl as carried, then splint/sling and walk out of the house to the stretcher.


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## DesertMedic66 (Jul 17, 2016)

WolfmanHarris said:


> We carry keterolac as well. I'd consider 30mg IV for pain. If the injury is isolated I'm inclined to assist them to standing and help them walk down the stairs. Stair chair or scoop are both going to place pressure on the shoulder. Pop in a lock, push keterolac, maybe combo with Morphine or fentanyl as carried, then splint/sling and walk out of the house to the stretcher.


This. Walking may be the most painless option for this patient. Pain meds, splint the area, walk the patient if stable on her feet


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## NomadicMedic (Jul 17, 2016)

I guess I missed that part that said she was able to walk. In that case, ABC. (Ambulate before carrying).


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## akflightmedic (Jul 17, 2016)

QRScomplex said:


> Do paramedics carry pain meds that are not opiate-based? She refused any narcotics which is why we called off ALS.



You are asking about a better way to lift/carry/position a patient who is heavy (190 pounds), has a flight of stairs involved, already injured and elderly....and part of the plan was to wave off ALS due to patient denying any pain control (at that time)? Was any consideration given that more manpower or a different perspective would be a benefit? Just sayin...you had tools at your disposal and decided to not use them.


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## Tigger (Jul 17, 2016)

Some places (like here) allow for field shoulder reductions. While I am not going to use a recently reduced shoulder as a lifting point, it would likely help with the pain and extrication process.


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## StCEMT (Jul 17, 2016)

Her legs work, so I am not gonna carry her downstairs. I will apologize for the discomfort and stand her up. Depending on available meds, maybe some before moving her. Immobilize it once she is off the floor.


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## DrParasite (Jul 17, 2016)

WolfmanHarris said:


> We carry keterolac as well. I'd consider 30mg IV for pain. If the injury is isolated I'm inclined to assist them to standing and help them walk down the stairs. Stair chair or scoop are both going to place pressure on the shoulder. Pop in a lock, push keterolac, maybe combo with Morphine or fentanyl as carried, then splint/sling and walk out of the house to the stretcher.


it's an isolated upper extremity injury.  

I'm glad someone else thinks that having her walking down using her uninjured lower extremities is better than carrying her down the stairs.


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## akflightmedic (Jul 17, 2016)

I have no problem walking a patient. However, we have an elderly patient who fell, lives alone and states she stumbled upon which she was not able to get up for well over an hour. While her stumble may have been just that...a stumble, we do have to wonder if there were any underlying new conditions at work here. Am I reaching? Absolutely, however which is the more sound practice? Put an already injured, elderly patient at further risk for another stumble walking her down the stairs or simply securing her arm and then put her in a stair chair which should be managed by trained technicians on proper lift techniques and securing adequate crew resources?

If you want to go all American on this one, you could also ask which one puts the service at more liability risk as well...but for now, the patient is being discussed and what would be best. We do not know the layout of the house and whether or not it was cluttered with stuff or cats. Could be spotless for all we know. My point is, in this case there are plenty of reasons to carry in a chair rather than make her walk. It simply is not that cut and dry.


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## TransportJockey (Jul 17, 2016)

I spaced that he said the pt is ambulatory


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## SpecialK (Jul 18, 2016)

We have the following non-opiate pain relief:
Paracetamol
Ibuprofen
Entonox
Methoxyflurane
Ketamine

Opiate or opioid medicines:
Tramadol
Fentanyl
Morphine 

Most patients who reckon they are "allergic" to morphine have just had a bad experience on it, and it is not true allergy.


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## QRScomplex (Jul 18, 2016)

akflightmedic said:


> You are asking about a better way to lift/carry/position a patient who is heavy (190 pounds), has a flight of stairs involved, already injured and elderly....and part of the plan was to wave off ALS due to patient denying any pain control (at that time)? Was any consideration given that more manpower or a different perspective would be a benefit? Just sayin...you had tools at your disposal and decided to not use them.



We had a full engine company on scene so manpower wasn't an issue. This was more an exercise to see how others would approach this situation and I have to say there have been a lot of helpful insights. 

For some reason I thought that all patients had to be packaged up for transport, so in this case a stair chair, scoop stretcher, etc. A number have commented on the other ABC (ambulatory before carry) and after checking the NH protocols I couldn't find anything related to that. In this particular case would there be any concerns to injury further by the patient moving herself with assistance down the stairs and out to the ambulance? I'm just thinking of the risk/reward if she fell or something (accidental) during the walk between floor and ambulance. 

Thanks all for the feedback! 


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## QRScomplex (Jul 18, 2016)

SpecialK said:


> We have the following non-opiate pain relief:
> Paracetamol
> Ibuprofen
> Entonox
> ...



I checked the NH protocols and most of the non-opiate drugs aren't listed in our paramedic protocols with the exception of Ibuprofen and Ketamine (looks like it's only in the RSI protocol vs pain management). I know this is only at the BLS level but is there a contraindication to give ketamine to a patient which would then act as a sedative? Or is the dosing such that you can just take the "pains edge off" without altering their mentation?


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## Jim37F (Jul 18, 2016)

If the patient can stand and walk, and walk down the stairs themselves, no need to risk hurting yourself doing unnecessary work. We'll have someone walk down behind the patient, and someone walking down in front facing the patient (with a firefighter behind them, going down the stairs first, just to make sure they don't trip over backwards).

NOW, if you stand the patient up, and they get dizzy or woozy or otherwise don't feel good, and/or they're stutter stepping or wobbly on their feet, or anything else that makes you go "I don't feel comfortable having this person walk down under their own power" then yeah, get the stair chair. For an upper extremity injury I don't see any reason they can't go in the stair chair vs. being carried on a flat/scoop.


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## OCemt86 (Jul 22, 2016)

Pillow or two under armpit, pillow on the outside, secure it with the sheet. Even if she was walking wounded, you wouldn't want her to walk down stairs just in case. Whether the use or stair chair or scoop was more appropriate is on you, you kno the scene better than us.


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## Tigger (Jul 23, 2016)

OCemt86 said:


> Pillow or two under armpit, pillow on the outside, secure it with the sheet. Even if she was walking wounded, you wouldn't want her to walk down stairs just in case. Whether the use or stair chair or scoop was more appropriate is on you, you kno the scene better than us.


In case of what?


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## DesertMedic66 (Jul 23, 2016)

OCemt86 said:


> Pillow or two under armpit, pillow on the outside, secure it with the sheet. Even if she was walking wounded, you wouldn't want her to walk down stairs just in case. Whether the use or stair chair or scoop was more appropriate is on you, you kno the scene better than us.


So you never let patients walk?


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## WolfmanHarris (Jul 23, 2016)

Keep in mind too; it's a transfer home. What's the plan for self-care and getting around the house. If she's not safe to walk up stairs, she's probably not safe to discharge home.


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## akflightmedic (Jul 23, 2016)

WolfmanHarris said:


> Keep in mind too; it's a transfer home. What's the plan for self-care and getting around the house. If she's not safe to walk up stairs, she's probably not safe to discharge home.



HUH? Where did you get this was a transfer home?


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## Qulevrius (Jul 23, 2016)

And even if (magically) it was a discharge home, do you feel confident enough to call out the doc who signed the PCS ?


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## Tigger (Jul 23, 2016)

Qulevrius said:


> And even if (magically) it was a discharge home, do you feel confident enough to call out the doc who signed the PCS ?


Is it calling out or just making sure the PCS was signed for the right patient? It would be unusual to discharge an actual shoulder dislocation.


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## Qulevrius (Jul 23, 2016)

It is our job to make sure the discharge papers are present and in order, but it is the doc's job to make sure that he/she has a good reason to discharge the patient. So whilst I personally feel comfortable with x2-checking and making inquiries, there's less than a zero chance I would openly *question* the doctor's decision.


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## WolfmanHarris (Jul 23, 2016)

akflightmedic said:


> HUH? Where did you get this was a transfer home?



Sorry disregard, post night shift fog, confused it with another thread entirely. (The no-stair chair thread from awhile back)


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## Tigger (Jul 23, 2016)

Qulevrius said:


> It is our job to make sure the discharge papers are present and in order, but it is the doc's job to make sure that he/she has a good reason to discharge the patient. So whilst I personally feel comfortable with x2-checking and making inquiries, there's less than a zero chance I would openly *question* the doctor's decision.


I suppose it's all about context. At our local hospital we will happily talk to the doc if we think a discharge home is not appropriate without more care than has been around. They want to know that sort of thing, some times they don't get the whole story and if our crews are out at that patient's residence a lot we can provide additional insight.

Tact matters.


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## Qulevrius (Jul 23, 2016)

Tigger said:


> I suppose it's all about context. At our local hospital we will happily talk to the doc if we think a discharge home is not appropriate without more care than has been around. They want to know that sort of thing, some times they don't get the whole story and if our crews are out at that patient's residence a lot we can provide additional insight.
> 
> Tact matters.



I understand where you're coming from. We do not interact with doctors too often. It's mostly due to procedural constraints, since our primary hospital contract works through company rep who handles the paperwork before we even show up on scene. And if it's a 911/ER dropoff, we still do the usual triage nurse/MICN thing and if the doc suddenly shows up, we simply restate the report.


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## WolfmanHarris (Jul 24, 2016)

Qulevrius said:


> It is our job to make sure the discharge papers are present and in order, but it is the doc's job to make sure that he/she has a good reason to discharge the patient. So whilst I personally feel comfortable with x2-checking and making inquiries, there's less than a zero chance I would openly *question* the doctor's decision.



Not here. My role is to advocate for my patient. Hospital staff often do not have a complete picture of the living conditions or social determinants of health. I have brought transfers home and then turned around to hospital as the living situation was so precarious as to be dangerous. We then engage with the Geriatric Emergency Team at the hospital, social services and home care to ensure that the patient has the right resources in place. This is a rare occurrence as social work is typical a key player in discharge planning here. 

I do love my socialized single payer health care system of which Paramedic Services are becoming an integral part.


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## Handsome Robb (Jul 27, 2016)

Ketamine.

But if she doesn't like the effects of opiates she probably won't life the pain management effects of ketamine either. 

With that said she probably won't care while she's on the ketamine anyways so it's a moot point. 

As far as getting her off the floor without hurting her shoulder. Use a sheet or a mega mover that's folded long-ways a couple times. Slide it behind her down near her waist then around to the front, cross it and then pull. Pops them right up and doesn't put pressure on the shoulders. 


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## RiverWatcher (Jul 28, 2016)

We would use a Binder Lift (rbinder@binderlift.com) or a mega-mover.


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## akflightmedic (Jul 28, 2016)

RiverWatcher said:


> ....or a mega-mover.



We have those here...we call them firefighters.


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