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!