Rural EM trauma questions

[Dr. Ditka]

I work most of my shifts in the big city but a few of my shifts every month are out in the boonies with no specialists other than OB/gyn and gen surgery. I had 3 cases the other night I wanted to get opinions on:
1. 68yo F with ground level fall with tibial plateau fracture. Only slightly displaced but she was a frail lady with a lot of pain and blood work ended up showing medical issues as well. I transferred her due to pain and fall risk along with medical issues. What if she would have been healthy with pain controlled. Transfer anyway or knee immobilizer and ortho referral?
2. 34yo M with moderately displaced tibial plateau fracture after a BMX accident. Moderate effusion but pain not that severe. Transfer or knee immobilizer and ortho referral? I transferred but receiving doc was questioning why I needed to transfer. I said concern for developing compartment syndrome, had no follow up possible and they reluctantly accepted.
3. 50yo F fell off horse and had lateral chest wall and upper chest pain. CT showed non displaced left 11th rib and non displaced right 1st rib fractures. CTA neck for vascular injuries? The level 1 trauma center I trained at does this but I've read a couple of articles that say it is not always needed and especially with normal mediastinum and no pulse deficits.

Thx,
Dr. Ditka

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[docB]

Good questions. I too work in a rural area in addition to my main gig in the city so I feel your pain.

I am always leery of putting tibial plateau fractures in knee immobilizers because they will be weight bearing. I worry about making a minimally displaced fracture worse. If you have an elderly person who can't manage with crutches they will require inpatient management and that should be enough for a legit transfer. The younger guy I have put in a long leg splint if they can use crutches.

The other question we run into all the time is what constitutes giving them follow up. Is it ok to discharge them saying "You need to open the phone book and find and orthopedist." or do you have to have someone who you can talk to and who agrees to see them? That's a tough question with no consistent answer.

As for the torso injury I'd go ahead and get the scan. That will give you more opportunity to observe them and more objective data to justify whichever of your two options you ultimately go with, transfer or discharge.

 

[dotcb]

1. Agree
2. Either way - prolly DC as long as able to follow up the next day somewhere.
3. We do trauma chest CT's w/ contrast. Depends where the 1st rib Fx is. If it is posterior and not near the subclavian, then I may not have done the CTA. In fact, I prolly wouldn't have done any CT in the first place and given clinical diagnosis of rib fractures based on 2 view chest and pleural US. If both those are neg and there's severe pain, I tell them they have at least one rib fracture, which is managed w/ pain medicine.