Monthly Archives: November 2012

Can Anyone Tell Me How I Got Here?

Tales of the Cunningham technique and one EP’s eventual journey to success through reverse engineering

The successful practice of medicine hinges on two things. A detailed grasp of medical knowledge, and being able to translate that knowledge into a positive patient interaction. For the emergency physician sometimes it’s a crash intubation, sometimes it’s talking to an elderly patient who lives alone about nursing home placement after their 4th visit to the ED in a week.

Whatever the road to a positive outcome for our patients, all physicians experience the nausea of staring into the dark chasm between knowledge and practice. Like neural dendrites gingerly reaching out to make a connection, the journey starts as a tenuous thread in the dark and can eventually become a well-lit pathway with clear signposts if given the right encouragement.

Giovanni Battista Piranesi

Giovanni Battista Piranesi: 1720–1778. An Italian artist famous for his etchings of fictitious and atmospheric “prisons”. He was a strong influence on the work of M.C Escher and his “impossible constructions”.

For me today the path comes in the form of learning the Cunningham technique for shoulder reductions. It’s no secret I’ve always liked doing joint reductions. Ask any of my colleagues and they’ll tell you I’m the first to jump in and help putting a displaced body part back where it belongs. I take satisfaction in doing them quickly, efficiently, and with minimal pain. I also like my patients to be happy with the whole experience; so it’s been a natural evolution for me to become enamored of a technique that requires less time, sedation or analgesia, and that makes my patients happy.

I started using the Cunningham technique about a year ago and I’ve refrained from writing about it until I had enough reduction attempts under my belt to make a post worthwhile. I think I’ve done about two dozen shoulders or more this way now, and I’m four out of five in the last two months (five out of five if you count some scapular manipulation added to one of them).

Like anything new I had plenty of failure in the beginning, and when I did achieve success I had no idea why, and couldn’t have reproduced it even if you put a gun to my head. Now I’ve reached a tipping point, and the Cunningham technique makes doing shoulder reductions feel almost like magic. Often I can see the signs of success begin to appear even before the humeral head slips gracefully into place. No secondary trauma, time-outs, sedation, traction/counter-traction, twisting, pulling or other nonsense.

How did this tipping point happen? Of course that’s the challenge of learning and subsequently teaching medicine.  It has never been a straight line from medical knowledge to clinical practice. Success requires absorbing a skill-set distributed across a multitude of strategies. Within these strategies are embedded a deep understanding of context, relationships, and timing; a detailed knowledge of our tools, and the logistics required to employ them. That “magic” experience of success is the emotional summation that all the pieces coming together to achieve a something good for one of your patients.  It’s one of the reasons I love my job.

However that “magic” experience of success is also why the signposts to it are so often invisible and thus difficult to teach. The signposts were there, but before you were in the dark. Now, you look back and wonder why you didn’t see them before.  It’s so obvious. But it’s the mind’s illusion that suddenly the light just went on.  In fact, a closer examination reveals an unconscious accumulation of multiple tools arranged across an array of skill-sets that allow you to consistently reproduce good outcomes.

How do you illuminate some of those signposts for yourself and others walking the path?  I don’t know exactly, It’s one of the reasons the EMBER project was started – a reverse engineering process in education.  Here are some of the signposts I’ve marked along my path with this particular technique that have helped me improve my success rate. They remind me that being a physician is about knowledge and skill, but also about context and relationships, pattern identification and intuition, resource management and logistics.

  1. Get the patient on board. Like most procedures on awake patients it requires co-operation, so explaining what you need them to do before you start and talking them through it is key. I like to think of it as a coach/player relationship. They are doing the work, you’re simply encouraging, leading and imparting knowledge. I also find that many patients find this active participation very satisfying and empowering. They get to share in the success.
  2. A little tincture of analgesia is never a bad thing, but once you get comfortable doing this you need very little or none at all.  The key is sizing up your patient.  Since there is no significant force or traction applied, if your patient is comfortable before the procedure, they will likely be comfortable during it. If they are uncomfortable before you start you’re going to have trouble, so give them something.  If they’re anxious treat the anxiety, if they’re in pain, treat the pain. Removing these barriers to success prior to an attempt at reduction just makes sense.
  3. Work on visualizing the anatomical and mechanical obstructions to reducing the shoulder. Surgeons have the advantage of being able to review this anatomy frequently in the operating theater, but we don’t have that luxury, so we must work with palpation, surface anatomy, and a visual image in our minds of the anatomic relationships. Use your eyes, your hands, and your mind to “see” the position of the humeral head and the barriers to slipping it back in place.
  4. The ideal position for the glenoid fossa is achieved by moving the scapula posteriorly and rotating it inferiorly.  This is achieved by having the patient sit up straight, adducting the rhomboids and having the patient drop their shoulders towards the ground. This is why having the patient sit in a chair is helpful and also reminding them repeatedly to sit up straight. It’s also why a touch of scapular manipulation by a partner can help in resistant reductions.
  5. The ideal position for the head of the humerus is to place the humerus in adduction with gentle internal rotation to present a greater articular surface to the glenoid fossa superiorly and laterally. This is why having the patient in front of you with your body to the outside of their affected arm is helpful to allow gentle physical reminders to keep their elbow in towards their body. Often I will stand or sit close to patient’s elbow to unconsciously force them to keep their elbow in and their arm internally rotated.
  6. Once the bones are in position it’s all about relaxing the muscles of the shoulder to overcome the dynamic forces that are pulling on the humeral head and trapping it, usually in a sub-glenoid or sub-coracoid location. This is why flexing the elbow and having them rest their hand on your shoulder is effective.
  7. Massaging the biceps, upper trapezius, and deltoid are equal parts physical and emotional. It is comforting, and it relaxes the mind and the muscles of the patient allowing the dislocated humeral head to “unlock” itself from its current uncomfortable position.
  8. Resist the urge to pull.  Remember muscle spindles?  Those sensory receptors within the belly of the muscle will actively resist excessive traction and make the spasming worse.  Once you are in the cycle of pulling and feeling resistance you are in a battle that can only be won at the cost of more force and likely sedation. There is also a psychology to this. If you radiate a relaxed and calm persona your patient can feel this and also begin to relax.  If you have sweat pouring from your face while you grimace and pull how can you expect anyone near you to be relaxed. Slow and gentle is the key.

Occasionally I have to revert to another method of reduction, or supplement this technique with scapular manipulation, but this is definitely the option I pick before anything else now. Once you feel the beauty of a non-traumatic reduction requiring no force you will never want to go back.  In my career I’ve gone from Conan the barbarian with heavy sedation, and traction-counter traction to Jedi mind trick:  “This is not the Propofol you’re looking for…”

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Postcards from the ED

The EMBER: Here is a nice blogpost from someone who went through the experience.  Sometimes a well told patient story is better than any textbook.

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