Words by Adam Branoff, MD, who's been surfing from around the same time he started walking - and seen most of the nightmares associated with charging heavy waves.
It’s finally here. You’ve saved for this trip and looked forward to it for months. Surfing perfect waves in a remote location, with only a few friends. After trading barrels all day, and being on the verge of complete exhaustion, you look for one last wave to finish an epic day.
As the set approaches, you swing into position, drive hard, and pull in deep. You’re racing through each section about to get spit out, when you get caught in the foam ball and thrown over the falls. You tumble like a rag doll, and suddenly you’re struck with severe, terrible shoulder pain. You try to swim to the surface but your shoulder hurts too much to move.
You’re able to surface and scramble across the reef, only to discover your shoulder doesn’t look right, and hurts too much to move. You’ve dislocated your shoulder, and you’re in the middle of nowhere.
Unfortunately, when these injuries occur in remote locations, management can be painful, frustrating, and challenging. If you spend enough time in extreme conditions and locations, you’re likely to eventually encounter this. Maybe as a guide, as a friend, or even yourself.
Fortunately, there are several effective techniques that may be employed by non medical personnel to enable successful treatment with limited resources in remote locations. Let's look at how to approach possible shoulder dislocations.
Step 1: Look at the shoulder
First, look at the shoulder. Before proceeding with trying to put it back in place, it is imperative to make sure the shoulder is actually dislocated.
This may sound obvious, but many injuries may mimic shoulder dislocations. For example, upper arm or shoulder fractures may be confused with dislocations.
The overwhelming majority of shoulder dislocations will have a classic “step” appearance of the dislocated side (see below). If you see this, the shoulder is dislocated.
Step 2: Consider your resources
Do you have a clinic with medicines and supplies? If the answer is no, several techniques have been developed that can be employed with minimal resources or medical training. Common items that can be used in this situation include a leash, rope, belt, a water bottle or medium size rock, pickup truck bed or flat surface to lay on and a first aid kit
Step 3: Fix the Shoulder
By far, the easiest technique is called the Stimson method. Try this first. It is technically easy and has little chance of causing harm.
1. Position the patient face down on a sturdy table, truck bed, or anything level and high enough for the injured arm to hang down without touching the ground.
2. Next, attach 5-10lbs of weight to the dangling wrist. A one or twi litre bottle of water would also work.
3. Wait. Gently massage the muscles of the shoulder and arm to help stop muscle spasm and allow the muscles to relax. Eventually the muscles will fatigue, then relax, and the shoulder will pop back in. This can sometimes take hours.
The alternative method is the Cunningham technique. It also works by relaxing the spasming shoulder muscles allowing shoulder to slide back in place.
1. Relax the patient. Reassure this should not cause more pain. Once the shoulder goes into place, the pain should be gone.
2. Next, position the patient in a chair, sitting straight up (this is key): pushing chest out and pulling the shoulder blades together.
3. Get the arm into position: elbow next to the body and bent at 90 degrees. You kneel in front of the patient and act like you’re going to shake hands, but instead grip the elbow. The patient rests their hand on your forearm.
4. Gently, but steadily, pull the elbow down. Ease up with new spasms or pain.
5. Have the patient focus on staying straight upright: pulling shoulder blades together.
6. With your other hand, massage the shoulder muscles. Remember, you are trying to help the muscles relax.
7. Lastly, massage the bicep with your thumb.
At this point the bone will slide into place without any clear indication (no sound or ‘clunk’ feeling). Look to see that the step appearance is gone, and that both shoulders look the same, then you know the shoulder has gone back into the joint.
If you can't get the shoulder to relocate and move normally, or if the pain remains severe, then you will have no choice but to get the patient into a sling you can fashion from what you have on hand and arrange transport to the nearest hospital as soon as you can.
Cover shot, your author about to get drained. Illustrations by Albert Shelton/Dave Schindler