Ottawa Rules – OK!

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My chest feels like I’ve contract some kind of insidious respiratory disease. I blame it on Kevin, or to be more precise on his friend, the one that rents the flat where Kevin was staying. We’ve all been there; a studio type flat; kitchen filthy with piles of week old washing-up all over the counters and muck everywhere. The main room had a shabby mattress in the corner, grey in colour and probably spawning mushrooms. There were the leftovers from the last few nights’ takeaways littered across the coffee table, the sofa and the floor. Every ashtray was full to overflowing and there were copious fag ends and ash ground into what remained of the carpet. It was, as we say, a place where you wipe your feet on the way out. Of course there was the obligatory large screen TV and wires littered over the floor attached to the PlayStation, XBox or whatever else they had to play the hundreds of DVD and games piled around the walls.

I found it almost impossible to talk to Kevin. It wasn’t just the five flights of stairs I’d just climbed but the air was thick with stale cigarette and wacky-backy smoke mixed in with a rancid miasma of chip fat and oily takeaways. It made me gag and my chest still feels full of noxious substances.

Kevin was complaining that he’d hurt his ankle, having tripped up a step the previous evening after a drunken night out. Now he reckoned he couldn’t move it or walk on it and that it “hurts like hell.”

“How did you manage to climb all the stairs?”
“We carried him up.” grunted one of the two rather large gorillas skulking around the room.
“Do you feel like carrying him back down again?” I quipped. A suitable grin in place.
The sarcasm was lost on these two; both a sandwich or two short of a full picnic. By the look of them I decided not to trust my luck with any other fancy ideas.

I got Kevin to pop both legs up on the sofa so I could have a better look; not easy as the only light was a dim old bulb in the centre of the ceiling. All the windows where blocked up with ancient sheets and blankets stapled/nailed/blu-tacked up at the windows. I struggled to avoid vomiting and examined his legs: Look, Move, Feel. No swelling / deformity / bruising / redness or anything else of note. I asked him to move his foot – no chance. Every attempt was greeted with groans and cries. I gave his ankle a rather cursory prod. He practically hit the ceiling when I palpated his lateral malleolus. Was he just being a complete wuss or was this genuine?

On the ECP course you get taught about ‘Ottawa rules’ for knees and ankles. Without boring everyone with the history behind this, suffice to say that, for ankles at least, if any of the following are positive then the patient should be referred for an X-ray.

X-rays are only required if there is any pain in the malleolar or midfoot area, and any one of the following:

* Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus
* Bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus
* Bone tenderness at the base of the fifth metatarsal (for foot injuries).
* Bone tenderness at the navicular bone (for foot injuries).

* An inability to bear weight both immediately and in the emergency department for four steps.

Barely able to stomach the choking atmosphere I headed for the front door and ordered an ambulance. Kevin had come up ‘Ottawa positive’ as far as I was concerned and he could go in. I wasn’t prepared to go back inside for a more comprehensive examination, they could do that down at A&E. I still wasn’t totally convinced that Kevin had fractured his ankle so I apologised to the crew when they turned up as this could have turned out to be a complete waste of time. To keep them sweet I carried one end of the chair on the way down.

Later in the afternoon I had occasion to pitch up at A&E with another patient so, afterwards, I wandered around to minors to see what had become of Kevin.
“We sent him home.”
“So there was nothing wrong with his ankle then?”
“Oh yes, he’d broken his ankle all right but he was being a real cry-baby until his mother turned up to collect him.”

So I guess those guidelines do work then. Ottawa Rules – OK!


9 Responses to Ottawa Rules – OK!

  1. ecparamedic says:

    They work fine until you are assessing an ankle of South African or Polish origin, where any expression of discomfort is seen as an admission of being screamingly gay, something that seems to be frowned upon.


  2. Millietant says:

    Thanks for that very vivid description, my morning coffee doesnt taste right now!
    When i first started on the pts, i was put on a run which included regulars to a day hospital, so my colleague knew them all.
    We pulled up outside one house and while waiting at the front door, he leant forward and smeared a big dollop of vicks under my nose, saying it would help with the rancid smell inside the house.
    It worked a treat, although i couldnt see very well either as my eyes were streaming and i had to walk around with a Hitleresque shaped rash under my nose for the rest of the day. Kept hold of my breakfast though.

  3. Kingmagic says:

    One of my pet hates…..going into a house/flat where there are small children and the whole place is full of cig smoke! And you,ve been called due to an asthma attack! In a child!
    Another of my pet hates….seeing a patient who has been injured somewhere else and has been carried up several flights of stairs! –
    -“I heard her fall on the garden path with such a crack! She could,nt move, we had a hell of a job getting her to her attic bedroom!”

  4. I have rather a history of ankle problems, mainly down to my hypermobility – I can turn my foot into some really odd positions, pain-free, and apparently have the ‘loosest ankle-joints’ my physiotherapist has ever seen. Hmm. Anyhow, a lot of the ligaments in my ankle don’t work properly any more, especially since I’ve gone over on them more times than I care to mention.
    Once, all I did was stand up, my foot went ‘snap’ and I was in excruciating pain on the top of my foot. It swelled considerably, so despite the lack of a decent mechanism of injury to denote a fracture, I reluctantly went off to A&E.

    I would not have passed the Ottowa test, and yet I was sent for X rays, which showed a health set of bones in my foot and ankle.

    I couldn’t walk, and was in obvious pain, and my treatment was………
    Yes, you’ve guessed it – some tubigrip (its magic you know!??) and some ibuprofen.
    No crutches.
    I love A&E.

  5. kevinmillhill says:

    There was a time when I used to buy cheap (100 watt) light bulbs and keep them in the ambulance. They came in quite handy in such houses. Now, we’ve got much better torches.

  6. Tom Reynolds says:

    I love Ottawa (I know it although I couldn’t write it down, I just have one of those posters with pink blocks on it stuck in my mind), it’s great for leaving patients at home after telling them that the A&E department won’t even x-ray it.

    (Unless you see a sappy SHO who x-rays everything)

    And I love kevinmillhill’s idea…

  7. […] splint he had on. “I did break my leg”. Recognition slowly dawned, it was Kevin, who we last met back in mid December. That would explain why the address seemed familiar but the […]

  8. Lixoykkk says:

    very interesting
    big brunette pizza sausage big danielle pizza sausage

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