Tag Archives: orthopedics

Novel Hip Reduction Technique: The Captain Morgan

I wrote about posterior hip dislocation and how to reduce it using the “standard” technique quite some time ago (see link below). Emergency physicians and orthopedic surgeons at UCSF-Fresno have published their experience with a reduction technique called the Captain Morgan.

Named after the pose of the trademark pirate for Captain Morgan rum, this technique simplifies the task of pulling the hip back into position. One of the disadvantages of the standard technique is that it takes a fair amount of strength (and patient sedation) to reduce the hip. If the physician is small or the patient is big, the technique may fail.

In the Captain Morgan technique, the patient is left in their usual supine position and the pelvis is fixed to the table using a strap (call your OR to find one). The dislocated hip and the knee are both flexed to 90 degrees. The physician places their foot on the table with their knee behind the patient’s knee. Gentle downward force is placed on the patient’s ankle to keep the knee in flexion, and the physician then pushes down with their own foot, raising their calf. Gentle rotation of the patient’s hip while applying this upward traction behind the patient’s knee usually results in reduction.

Some orthopedic surgeons use a similar technique, but apply downward force on the patient’s ankle, using the leverage across their own knee to develop the reduction force needed. The Captain Morgan technique use the upward lift from their own leg to develop the reduction force. This may be gentler on the patient’s knee.

The authors report a series of 13 reductions, and all but one were successful. The failure occurred due to an intra-articular fragment, and that hip had to be reduced in the operating room.

I’m interested in hearing comments from anyone who has used this technique (or the leverage one). And does anyone have any other techniques that have worked for them?

Reference: The Captain Morgan technique for the reduction of the dislocated hip. Ann Emerg Med 58(6):536-540, 2011.

Posterior Hip Dislocation

Although posterior hip dislocation is an uncommon injury, the consequences of delayed recognition or treatment can be dire. The majority are caused by head-on car crashes, and 90% of these are posterior dislocations. The femoral head is forced across the back wall of the acetabulum, either by the knee striking the dash, or by forces moving up the leg when the knee is locked. This occurs most commonly on the right side when the driver is standing on the brake pedal, desperately trying to stop.

On exam, the patient presents with the hip flexed, internally rotated and somewhat adducted. Range of motion is limited, and increasing resistance is felt when you try to move it out of position. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.

These injuries need to be reduced as soon as possible to decrease the chance of avascular necrosis of the femoral head. Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. The ED cart needs to be able to handle both the patient’s weight and your own. I also recommend a spotter on each side of the cart.

Standing on the cart near the patient’s feet, begin to apply traction to the femur and slowly flex the hip to about 90 degrees. Then gently adduct the thigh to help jump the femoral head over the acetabular rim. You will feel a satisfying clunk as the head drops into place. Straighten the leg and keep it adducted. If you are unsuccessful after two tries, there is probably a bony fragment keeping the head out of the socket. See an instructional video on this tomorrow.

Regardless of success, consult your orthopedic surgeon for further instructions. And be sure to thoroughly evaluate the rest of the patient. It takes a lot of energy to cause this injury, and it is flowing through the rest of the patient, breaking other things as well.

The 30-Minute Rules: Documentation

In my last post, I reviewed timing for the 30-minute rules. When does the 30-minute timer actually start? When does it stop? Now that you understand those concepts, we can move on to actually documenting those times.

As I noted yesterday, the timer starts when the consultant is called or paged. It should be easy to record this, right? Nope. The problem is that a whole host of people can do this:

  • ED clerk
  • Trauma nurse
  • Attending surgeon
  • Resident
  • Medical student (nooooo)
  • And probably more

This makes it more difficult to find a common place to record the call time. The two possibilities are paper or electronic. The paper trauma flow sheet is usually only available to the trauma nurse. The others will either use a random piece of paper that gets lost, or doesn’t record it at all.

The other option is the electronic medical record (EMR). Everyone involved with the resuscitation probably has access to it. What’s the best option? This depends on your hospital. For paper, develop a process such that one person who has access to the trauma flow sheet (usually the nurse) is responsible for entering the call time. Otherwise, develop a specific template in your EMR so that whoever enters it does it the same way. And make sure that everyone who could possibly write the call time note knows how to properly create it.

Now, what about documenting consultant arrival? This is the most difficult part of the process. Once again, there are two alternatives: human factors or technology. Many programs try to rely on technology. Unfortunately, it is frequently flawed. The EMR timestamp when the consult is entered always  occurs after the patient was seen. Badge swipes can be forgotten. The most reliable method relies on personal responsibility. Your consultant must take a moment to check the time when he or she enters the room to examine the patient. They can then record that time when they write their note. And if they really want to be cool, they can also note the time they were called in the note.

Best practice: Have the trauma attending personally make the call to the specialist. And in that conversation, have them mention that “this is a 30–minute criterion consult.” This ensures that both your surgeon and consultant know that their presence is expected promptly. And maintain an expectation that the consultant will properly document their arrival time.

I hope you enjoyed this series. If you have any comments or questions, or want to share tips from your program, please leave a comment below or shout it out on Twitter.

The 30-Minute Rules: Response Times

In my last post, I reviewed the first component of the 30-minute rules, the actual criteria themselves. It’s not called a 30-minute response rule for no reason. There is an absolutely required time to respond that has been set at 30 minutes.  Today, I’ll look at an equally important component: the response time itself. Why do we have it, and when does the event start and stop?

So why does a rule like this exist? Is it to punish the providers who are being monitored, torturing them to get to the hospital as quickly as possible? No! As with so many of our performance improvement (PI) filters, they are designed to test many, many things. Some examples for this one are:

  • Recognition of a life or limb threatening condition by the in-hospital providers
  • Communications systems (ED clerk, pagers, phones, etc.)
  • The call schedule system
  • Clinician responsiveness and commitment (orthopedics, neurosurgery)
  • Nursing documentation
  • And more!

What is the actual time interval that must be measured? First, it does not start when the clinical condition in the criterion is recognized. If a patient has a large subdural hematoma with shift on CT scan, a radiologist must bring it to the attention of the advanced practice provider, emergency physician, or surgeon, who must then take the next step. The timer actually starts when the clinician causes the specialist to be notified. This may occur when the clerk pages or calls them, or when the clinicians do it directly.

One point of confusion: the clock does not start when the clinician responds to the page or call. What if they don’t call back for 45 minutes? Do they then have another 30 minutes to get to the hospital? No!! It starts when the first notification goes out.

So when does the clock stop? This one is easy. It occurs when the specialist who has been called gets to the patient’s bedside and begins the assessment.

One final thing about the clock? Does the clinician have to respond within the 30-minute time frame on every patient? Ideally, this would be great but it’s not realistic. There is no guidance in the Orange Book about a threshold. But if past experience is any indication, it is most likely a timely response somewhere around 80% of the time. But strive for perfection!

Tomorrow, I’ll list some ways to address the most challenging part of the 30-minute rules: actually recording the response times. And I’ll provide a best practice to help meet it.