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April 21, 2016
10 tips for great prehospital splints
A long time ago, when I was a baby EMT, I ran a nursing home call with a more experienced medic. A sweet little old lady had fallen and broken her femur, and my partner sent me back to the rig for our traction splint.
When I pulled it out of its case, it was not the familiar Hare traction splint I had been trained to use. Instead, I found a folding contraption consisting of two steel shafts, with an ischial pad on one end and a plastic crossbar fitted with an S-hook on the other. The plastic crossbar was supposed to slide up and down the shafts, engaging on little notches cut into their inner borders, thereby allowing you to attach the S-hook to an ankle hitch and pull traction with it.
The only problem was, the ankle hitch was missing and neither of us could figure out how to get the crossbar to release.
So we wound up improvising an ankle hitch from a cravat, tied it to the S-hook and used a Bic pen as a Spanish windlass to pull traction. It worked just fine, but later, as I was grousing about shoddy equipment and worrying about what the ED staff would think of our Rube Goldberg traction splint, my partner grunted and gave me some of the most useful advice I’ve ever gotten: "If it looks stupid, but it works… then it ain’t stupid."
Given our fondness for gadgets and doodads in EMS, we often tend to make the same mistake. So with that, I give you ten ways to effectively splint that have nothing to do with the device you’re using:
10. If it looks stupid, but works … then it isn’t stupid.
My partner’s advice all those years ago still applies today. Think of splinting as the EMS version of arts and crafts class at summer camp; a way for us to express our creativity.
Anything can be a splint — a rolled up magazine, an IV bag, a bottle of Gatorade, even the patient’s other, uninjured extremity. It doesn’t have to be pretty, it just has to work.
9. Pillows are your friend.
They not only make excellent padding, they’re effective splints all by themselves. Got a patient with a distal fracture, like a hand, foot, wrist or ankle? Simply roll the injured extremity up in a pillow with the patient's fingertips or toes sticking out and tape it tightly.
Not only will the pillow retain its softness for comfort, by rolling it tightly you’ll enhance its rigidity. Don’t believe me? Take that soft, fluffy pillow you used in a pillow fight, roll it lengthwise and tape it and see how it feels to get hit with it then.
8. Cold packs make dandy padding.
A little cryotherapy is helpful in relieving pain, and a malleable cold pack also serves to pad any voids between the injured extremity and the splint. Wrap a cold pack over the fracture site when you apply a splint.
7. If you’re splinting something, you have a stable patient. You can afford to take your time.
If you have decided to splint a fractured extremity on a scene, you have tacitly admitted that the patient is in no danger of immediately dying. Why then, would you rush your way through the process? If you’ve decided that packaging is more important than transport, then you can afford to take an extra five minutes to package well. Or ten minutes, if that’s what it takes.
6. One of the purposes of splinting is to reduce pain. But splinting itself can be painful.
If you have the means to do so, provide analgesics. Sometimes that may involve controlling the patient’s pain before you apply the splint. You might be surprised — but you shouldn’t be — how much easier it is to apply a splint when your patient isn’t screaming in pain whenever you touch them.
5. Three-point long bone checks are barbaric.
If you were taught to do them in EMT class, stop doing them immediately. If a patient has a painful, swollen, deformed extremity, do you need to determine the presence of crepitus or instability to justify splinting it? If not, then why deliberately manipulate an extremity you suspect is fractured? Gentle palpation will suffice, or if you really want to be thorough, try auscultatory percussion.
4. Want a way to monitor distal perfusion? Use your pulse oximeter.
Place your pulse oximeter probe on a digit in the injured extremity. If you’re still getting good oxygen saturation and a steady plethysmography waveform, your patient still has adequate perfusion in the injured extremity.
3. Think outside the box.
Wish desperately you had a pelvic binder, or a full-leg splint, but your employer is too cheap to buy them? You probably already have a suitable alternative on your truck. An upside-down Kendrick Extrication Device works as a dandy splint for hip fractures, and it can also double as a full-leg splint.
The original owner’s manual for the KED is full of alternative uses for the device, and given the current science on spinal immobilization, those alternative uses are probably better choices than its intended application.
2. Make the splint fit the fracture, not the other way around.
Add extra padding if you must. Add an extra SAM or cardboard splint above or below if necessary. Use all the supplies you need, because a splint that does not immobilize effectively is no splint at all.
1. Remember the general rules of splinting.
Immobilize bone ends above and below the fracture, immobilize the joint above and below the fracture, check PMS — perfusion, motor function and sensation — before and after application, and protect the immobilized extremity.
My father used to tell me, "It’s a poor craftsman that blames his tools," and on that call, I was more focused on my tools than my technique. If you follow those guidelines, it doesn’t matter if you use a vacuum splint, a SAM splint, cardboard, KED, Hare or Sager, you won’t go wrong. Ignore those rules and the fanciest toys can’t compensate for your lack of skill.
Got any other tips and tricks for splinting? Share 'em in the comments!