Another voice in the growing crowd (and some of my ponts have been addressed
already)...
1. I tend to frown rather actively if I find a typical shoulder dislocation
who manages to get past an SHO and into X-ray without some morphine on board
(few exceptions - e.g. clinically-missed posterior dislocation and otherwise
complex cases). Ditto for many other #s/lesions. I'll moan a lot less at
someone doing without a pre-pull X-ray IN SOME CASES.
2. Find the combination of M&M very un-"daqngerous" as it always encourages
much observation and attention and less risk of missed deterioration. Danger
in A&E is usually the resulat of misconceived safety.
3. Once Morphine is given and then there's a gap (X-rays + setting things up
+ consenting patient), I find that, when it comes to Midaz time, you end up
using far less (as has been mentioned). The gap also seems (in my un-audited
experience) to prevent excess side-effects you would get if doses given
simultaneously).
4. Then one should SLOWLY titrate Midaz, say 2mg stat and 1mg Q1-2mins to
prevent over-shooting the mark. Then wait a couple of minutes before a
traction-only reduction (please don't get me started on why it's the best).
There is ALWAYS another doc with me - whichever SHO I am instructing. Then,
after immobilising, I LIKE to see the customer fall off for a tiny snooze,
as I find this virtually guarantees their retrograde amnesia. I stay nearby,
write notes, etc... Then wake them up, confirm amnesia and set them talking
to relies, etc. There WILL be a resus nurse watching them, but, as they are
talking, it's easier.
5. I have never used capnography, etc for this. A few years back I stopped
even checking whether we had Flumazenil in the department, never mind my old
policy of having an un-opened ampule ready. I have not had problems with
over-sedation from this or for other procedures.
Now... a question:
If an elder has a neck-of-humerus #, requiring some traction, we all know to
put them in a Collar&Cuff for traction, not a sling for support. But in this
case... why do some people still put painful joints, such as a recently
dislocated-relocated shoulder, in traction?
Have seen others' work negated by a Collar&Cuff tractioning a shoulder back
out - after all, inferior subluxation is often the means by which the head
escapes out of the glenoid in the first place.
I prefer a "body-sling" arrangement intitially, but with NHS budegt in mind
I usually just use a broad sling with a ring of material to flatten it onto
the torso (allowing respiration by being very loose, but preventing any
accidental use of the limb).
Answer me that one...
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