Put In Her Place

   It's a beautiful summer day, and the athletes are out in large numbers. The crew of Attack One has been out for several sports injuries throughout the day, including one young softball player who slid into a base and dislocated his ankle. At the ED, the crew watched an emergency physician quickly reduce the ankle back into position, and the patient's pain rapidly resolve.

   This provided an opportunity for the physician to discuss a variety of bone and joint injuries and provide some education for the crew on placing joints back into position. As they reviewed the joints of the lower extremities, the physician explained that ankles and wrists are difficult to reduce, and frequently require putting the patient to sleep. Dislocations of the knees and elbows are very dangerous, and frequently injure the arteries that run through those large joints. Dislocations of the hips are of two types: the high-risk, high-impact injuries from vehicle accidents or falls (these usually require the operating room) and, more frequently, hip dislocations in patients who are older, have artificial hips in place, and typically have had such dislocations before. These are usually very easy to reduce in the emergency department.

   The easier joints to reduce are those of the shoulders, kneecaps, fingers and toes. These are frequently reduced by patients on their own.

   After a good lesson in these injuries, the rest of the day is full of broken bones…until the 4 o'clock call. At that point Attack One responds to an injury at a soccer complex where a big tournament is taking place. They are not directed to the fields, however, but instead stopped out in the parking lot. They find a young woman lying at the back of a minivan, obviously in a great deal of pain. She is dressed in a soccer outfit, her right leg is flexed, and she is beating the ground with her hands in agony.

   Her coach tells the story: The team had played all weekend and won the tournament. They were loading their equipment into the van to head to the airport to fly home. The 15-year-old patient placed her bag in the rear of the van, and when she twisted her body to back away, her patella dislocated. It had happened twice before, and each time the pain was excruciating. No direct trauma had occurred to the knee, either at the time of the injury or over the rest of the weekend.

   The other players are trying to comfort the young lady, telling her they all made it through the entire weekend of play without an injury. "How can we explain you got hurt loading your bag into the car on the way to the airport?" one asks, trying to raise her spirits.

   The crew members find the patient's vital signs to be stable, and there is no obvious injury to the knee or anything else. But her right patella is out of place, and located on the lateral surface of the groove in the femur where it should be. Her knee is flexed at 90 degrees, and she is in extreme pain. Her distal pulses, capillary refill, movement and sensation are all intact. The pulse oximeter placed on her great toe gives a reading of 99%.

   The coach pleads with the crew to make her more comfortable and try to expedite her care. The team's plane is leaving in 90 minutes, and the coach will have to make arrangements to stay with the girl at the hospital and send the rest of the team home with someone else. Some of the parents are already trying to check on flights for the two of them the next morning.

   The Attack One paramedic places a quick call to the same emegency department where the physician had been teaching the crew earlier in the day. She finds the physician still on duty, and asks him to take a call regarding the care of this patient.