The City of Pittsburgh Bureau of EMS is a unique system, serving the area with 13 ALS transport units and two medically directed heavy rescue trucks staffed entirely by paramedics. In addition, emergency medicine residents from the University of Pittsburgh Medical Center (UPMC), in conjunction with the Center for Emergency Medicine, respond to EMS emergencies when requested by field units. The physician response unit (MD 550/551) may also be dispatched on high-priority calls as indicated by the 9-1-1 CAD system.
This physician response program is mutually beneficial because it provides the physician a broader scope of emergency medicine as it relates to EMS and promotes better interaction between physicians and EMS providers. The program was one of the first of its kind in the country. (1)
City of Pittsburgh EMS Medic 8 was dispatched to a 21-year-old female with a possible dislocated left shoulder. On arrival, my partner and I located the patient on the floor of the residence next to her bed, kneeling with her forehead resting on the floor. Both arms were bearing her upper body weight, while placing enough pressure on the dislocated shoulder to make the pain tolerable. She was positioned oddly and was unable to tolerate movement without a significant increase in pain.
The patient stated this was the second dislocation of this extremity, but that she had no medical history otherwise. On exam of the injury, the left shoulder appeared to have a deformity caused by an anterior dislocation. The extremity had good pulse, motor and sensation distally. The patient’s vitals were a pulse of 100, strong and regular; respiratory rate of 22 and slightly labored; room air saturation of 98% and blood pressure of 144 by palpation, as auscultation initially wasn’t feasible. IV access was unsuccessful after numerous attempts on the right arm due to poor vascular access.
The resident physician response unit was requested for additional pain control options and possible sedation to reduce the dislocation at the scene. This intervention was considered to reduce the risk of further injury including nerve, tissue or vascular damage. Reducing an acute dislocation is less complicated because time is a factor in the severity of swelling. The crew consulted with the physician via radio for pain management orders. Morphine sulfate was administered in the left gluteal muscle with no relief. Once the EMS physician arrived on scene, pain control was attempted using patient-self-administered nitrous oxide. Due to the patient’s awkward position, the only vascular access visible was her dorsal left foot vein, and an IV was successfully obtained by the paramedic lying on the floor on his left side. The EMS provider gave orders to administer an additional 5 mg of morphine sulfate via IV, resulting in minimal relief of pain.
After discussion, ketamine was administered for anesthesia to reduce the dislocation because the patient was still unable to be moved. The patient was placed on oxygen, and was given 3 mL (150 mg) ketamine via IV. Afterward, she was able to be moved to a sitting position. An additional 3 mL dose of ketamine and 5 mg of morphine sulfate were administered via IV for pain control. After the medications took effect, the physician was also able to reduce the dislocation with good pulses present in the distal extremity.
Shortly after the patient awoke from sedation, she had a brief hallucinatory period, which is one of the side effects of ketamine. She soon returned to baseline mental status and realized her shoulder was no longer dislocated and she was now free from pain. During ongoing assessment, the patient was determined to have good motor ability and sensation in her upper left extremities. She was transferred to a stretcher and transported to the hospital for further evaluation. X-rays were taken to confirm proper placement. We placed a commercial sling on the extremity with no change in the patient’s status. Her vital signs remained stable, and she was discharged following care in the emergency department.
This case is an example of a rare treatment intervention performed by EMS. Having the EMS provider respond to the scene was critical to safely and effectively reduce a dislocated joint injury in the field. Ketamine isn’t included on the drug formulary of Pittsburgh EMS, but it’s carried by the EMS physicians. It is a non-barbiturate anesthetic and effective for a short duration if a patient is in a dissociative state. It doesn’t cause a significant risk of respiratory depression, unlike other narcotics and benzodiazepines.
The ketamine dosage used on this patient was 2 mg/kg. The side effects include hallucinations, fear, temporary vision disturbances and brief amnesia while under anesthesia. Although it’s not always appropriate, in this situation, the benefit outweighed the side effects because the drug is a short-acting medication for the purpose it was used for in this case. (2)