Note: The purpose of this site if to provide free open access medical education (FOAMed) in the context of rural and remote health. Though all stories have been inspired by real cases, all identifying details such as names, ages, locations and background descriptions have been thoroughly changed to ensure the absolute privacy of the patients, families and communities we serve.
The monsoonal rains had been keeping most people indoors, the storm had been roaring and the seas were rough. The soon-to-be-patient was a 45 year old Australian crew member working on a Chinese container ship passing through the northern Torres Strait. He had been soaked by the storm while attempting to secure a dinghy to a pilot boat that was traveling with the main ship. On his approach to the boat a large wave washed over the dinghy and tipped it backwards and then upside down into the ocean while the motor was running. The man was dragged underneath the dinghy. He attempted to surface, but came up against resistance of the hull of the pilot ship. Disoriented, he dove again, trying to find a way to the surface and avoid the hazards of the propeller and other boat. Eventually he surfaced with air above him and whilst being tussled in the waves grabbed onto one of the tires hanging from the pilot boat. He held on tightly to the tire as the wave crashed over him. Sometimes the waves went over his head, he swallowed water and he gasped for air. The sole crew-mate with him was unable to pull him back on board.
A distress call went out for more support and help was dispatched from the container ship. He managed to stay gripped onto the tire for 40 minutes before he was pulled to safety! While in the water his left shoulder dislocated, then relocated and then dislocated again. In pain, he was pulled to safety.
With his shoulder still dislocated, he showered on the container ship, put on a fresh change of clothes and was transported in a dinghy by his workmate to one of the island clinics in the Torres Strait where I was enjoying a cup of delicious coffee and watching the rain. Fortuitously, he presented on a day where a doctor outreach clinic was running. He did not make the reason of his presentation immediately known and sat quietly in the waiting room. After a few minutes, he lost his patience and loudly screamed for somebody to put his shoulder back in.
On examination, his left shoulder was obviously displaced anteriorly and the limb was neurovascularly intact. He had no history of previous dislocations. With no x-ray facilities on the island and the patient in distress, the decision was made to attempt a reduction using the modified Cunningham technique. With no analgesia or sedation, the shoulder was gently relocated on first attempt with minimal resistance. Relocation of the shoulder resulted in immediate resolution of pain and full assessment was then performed.
Apart from a temperature of 35.1 degrees Celsius, examination was normal. The patient was warmed with blankets and a cup of hot tea and temperature rose to 36.0 degrees within an hour as recounted his harrowing tale. Transfer via helicopter was arranged to Thursday Island Hospital for x-ray and further review. His course was uncomplicated, x-rays did not identify any bony injury and the patient was very grateful to have survived the storm.
Prior to reduction of a dislocated shoulder plain films should be obtained where possible. In the Torres Strait and Northern Peninsula Area, nurses or health workers trained in x-ray are able to perform chest x-rays and long-bone films. The infrastructure for this is available in three of the 21 sites. Skilled radiographers based on Thursday Island are able to provide a more extensive x-ray services and ultrasound. Transfer to an island clinic for the purpose of imaging takes a minimum of three hours in good conditions pending availability of a helicopter. It is not uncommon for further delay due to logistics. Considering this, shoulder reduction was performed prior to obtaining imaging.
Below is a good summary of shoulder dislocation and reduction techniques:
This post reviews the glenohumeral (shoulder) dislocation in detail with a focus on multiple reduction techniques.
Though this patient did not quite meet the criteria for hypothermia (Temperature <35 degrees Celsius), passive warming was used. As hypothermia is a very rare presentation in the tropical climate of Torres Strait this case provided a good to review management of hypothermia: