Emergency Medicine Specialist

Author Adam Branoff taking a late drop at G Land

The Inertia

It’s finally here. You’ve saved for this trip and looked forward to it for months. You’ll be 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 it off. You swing into position and pull in deep. You’re racing through each section, about to get spit out, and then you get caught in the foam ball and slammed. 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. Eventually, you surface and scramble across the reef only to realize that shoulder doesn’t look right. It’s dislocated. And to top it all off, you’re in the middle of nowhere.

Unfortunately, when these injuries occur in remote locations, managing them can be painful, frustrating, and challenging. And if you spend enough time in extreme conditions and locations, you’re likely to run into this problem at some point. Fortunately, there are several effective techniques that may be employed by non medical personnel to enable successful treatment with limited resources in remote locations.

How to approach possible shoulder dislocations
Step 1: Look at the shoulder

First, look at the shoulder. Before proceeding with trying to put 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. 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:
-Leash, Rope, Belt
-Water bottle or medium size rock
-Pickup truck bed or flat surface to lay on
-First Aid kit

Step 3: Fix the Shoulder
Stimson Method
By far, the easiest technique is called the Stimson Method. Try this first: it is technically easy and has little chance of causing harm.

-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.
-Next, attach 5-10 lbs of weight to the dangling wrist. A 1 or 2 liter bottle of water would work.

-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.

Cunningham Technique
The alternative method is the Cunningham technique. It also works by relaxing the spasming shoulder muscles allowing shoulder to slide back in place.

-Relax the patient. Reassure this should not cause more pain. Once the shoulder goes into place, the pain should be gone.
-Next, position the patient in a chair, sitting straight up (this is key): pushing chest out and pulling the shoulder blades together.
-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.

-Gently, but steadily, pull the elbow down. Ease up with new spasms or pain.
-Have the patient focus on staying straight upright: pulling shoulder blades together.
-With your other hand, massage the shoulder muscles. Remember, you are trying to help the muscles relax.
-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.


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