Your SlideShare is downloading. ×
Things That Make You Go Hmm    Part 1ppt
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Things That Make You Go Hmm Part 1ppt

1,517

Published on

Abnormal Medical and Trauma …

Abnormal Medical and Trauma
Shore EMS Conference 2010

Published in: Education, Health & Medicine
1 Comment
6 Likes
Statistics
Notes
  • Useful slides on assessment.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
1,517
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
1
Likes
6
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Things That Make You Go Hmm… Unusual EMS Sean M. Elwell, EMT, RN Injury Prevention Coordinator Trauma Program Alfred I.duPont Hospital for Children Wilmington, DE
  • 2. About Me…
    • Injury Prevention Coordinator
    • Registered Nurse-NJ, DE
    • EMT-B, NJ and NR
    • EMT Instructor
    • Fire Instructor
    • EMS/Rescue Captain-7 Years
    • BLS/PALS Instructor
  • 3.  
  • 4. Alfred I. duPont Hospital for Children
    • 182 Bed pediatric hospital
    • 23 Bed Emergency Room
    • 24 Bed PICU
    • 12 Bed NICU
    • Specialize in:
    • Orthopedics
    • Child abuse
    • Cardiac
    • Pediatric cancer
    • Neurosurgery
    • Organ transplants
  • 5. Delaware Trauma Level Designation LEVEL I  A regional resource trauma center able to care for all trauma patients LEVEL II  Regional trauma center able to provide care to all patients. May need to transfer out depending on resources available LEVEL III  Provides for initial care of all trauma patients arranging for transfer for those requiring resources of a Level I or II Trauma Center LEVEL IV  A participating hospital that is an acute care facility which transfers trauma patients with moderate or severe injuries to Trauma Center after initial resuscitation. Not Designated  
  • 6. Trauma Alert Criteria: Stable
    • Injuries
      • Diminished mental status
      • (GCS 9-13)
      • Open or depressed skull fracture
      • Significant, blunt maxillofacial trauma
      • Pelvic fracture (stable)
      • Partial or full thickness burns <20% BSA or inhalation injury
      • Deep penetrating injuries to proximal extremities
      • Two or more long bone fractures without neurovascular compromise
    • Mechanisms
      • Falls over 12 feet
      • Death or severe injury of same-car occupant
      • Pedestrian hit by vehicle and thrown, dragged or run over
      • Pedestrian struck at 20 mph or greater
      • Ejection from motorize vehicle
      • Submersion injuries
    • Other
      • Emergency Physician’s Discretion
      • Stable trauma transfers < 24 hours post injury that initially met code/alert criteria
      • Request of Trauma Alert by pre-hospital providers according to EMS protocols
    • Consider Trauma Alert
      • Motor Vehicle Crash
        • Unrestrained passenger with rollover
        • High speed auto crash
      • If patient condition deteriorates: Upgrade to Trauma Code
  • 7. Trauma Code Criteria: Unstable
    • Airway
      • Intubation/assisted ventilations *
      • Significant maxillofacial injury with potential airway obstruction
    • Breathing
      • Respiratory arrest *
      • Respiratory distress (ineffective respiratory effort, stridor or grunting)*
    • Circulation: PALS Criteria for Shock
      • 0-28 days
        • Systolic BP < 60
      • 1 month-10 years of age
        • Systolic BP <:
        • BP 70 + 2X age years
      • 10 years and older
        • Systolic BP < 90
      • Clinical Signs of Shock*
        • Pale; cold; clammy; tachycardia with weak pulses; capillary refill > 3 sec assuming a warm environment
      • Transfer from another hospital receiving blood, fluids or medications to maintain vital signs*
    • Neurological
      • GCS < 8*
      • Suspected spinal cord injury associated with neurological deficits
      • Suspected head injury (GCS <12) with major torso or extremity injury
    • Specific Traumatic Injury
      • Penetrating injury to head, neck, torso, groin (GSW, impaling injuries)*
      • Open chest wound
      • High voltage electrical and lightening injuries
      • Burns > 20% TBSA (2 nd /3 rd degree)
      • Amputation proximal to ankle/wrist
      • Flail chest
    • Other
      • Initiation of Trauma Code by pre-hospital providers according to EMS protocols
      • Emergency Physician’s Discretion*
    • *Mandatory Criteria as defined by American College of Surgeons
  • 8. New Jersey EMS… Captain Chief President All EMS and Rescue Operations All Fire Suppression Operations All Executive Operations EMS Chain of Command: Captain, Lieutenant, Chief, Deputy Chief
  • 9. A Review
  • 10. Back to Basics-Primary Survey
    • Rapid assessment to find and treat all immediate life-threatening conditions
    • “ Find and fix”
    • “ Treat as you go”
    • Decide if the patient needs immediate transport or additional on-scene assessment and treatment
  • 11. Primary Survey Steps
    • The primary survey has several parts:
      • General impression
      • A irway/level of responsiveness/cervical spine protection
      • B reathing (ventilation)
      • C irculation with bleeding control (perfusion)
      • D isability (mini-neurological exam)
      • E xpose (for examination)
      • Identification of priority patients
  • 12. Back to Basics-Secondary Survey
    • Purpose
      • Discover medical conditions and/or injuries that were not identified in the primary survey
    • Physical exam
    • Obtain vital signs
    • Reassess changes in the patient’s condition
    • Determine
      • Chief complaint
      • History of present illness
      • Significant past medical history
  • 13. Secondary Survey
    • Should be performed in the following situations:
    • Trauma patients with a significant mechanism of injury
    • Trauma patients with an unknown or unclear mechanism of injury
    • Trauma patients with an injury to more than one area of the body
    • All unresponsive patients
    • All patients with an altered mental status
    • Some responsive medical patients, as indicated by history and focused physical examination findings
  • 14. Case Studies
  • 15. By The Way…
    • ALS is NOT Available for These Alarms
  • 16. Case 1…
  • 17. Dispatch
    • Hagersville Road
    • MVC
    • Initial Dispatch
      • Rescue
      • Squad
      • Engine
    • Officer on Radio
      • Report tree fell on vehicle
      • No other information available
      • Requested 2 nd rescue dispatched
  • 18. What are your initial reactions?
    • Scene Size Up Starts at Dispatch
  • 19. Scene Size-Up
    • En route to the scene consider:
      • What additional help might be needed on the scene?
        • Law enforcement personnel?
        • Fire department?
        • Utility company?
        • Advanced Life Support personnel?
      • How will you gain access to the patient?
      • What questions will you ask the patient or family?
  • 20. Upon Arrival
  • 21. Now What?
    • Wires Down
    • Is there a patient?
    • How can we gain access?
  • 22. Plan of Action
    • Downed wires are cable lines
    • We are able to get to the car
    • Only access is through back window
    • Window punch used to gain access
    • First communication with patient there is no response
  • 23. Extrication Dilemmas
    • Tree Branches-Supporting Tree
    • Tree Covers Entire Car
    • Vehicle Still Running
    • Patient is Unresponsive
    • Fire Potential
  • 24. C-Spine
    • Sent EMT into Vehicle to Assess and Hold C-Spine
  • 25. Proper Collar Sizing
    • Measure the width of the patient’s neck by placing your fingers between the patient’s lower jaw and shoulder
  • 26. Things to Remember
    • Too tight
      • Can reduce blood flow in the neck
    • Too loose
      • Can cause an airway obstruction
      • Will not adequately stabilize head/neck
    • Too short or too tall
      • Will not provide adequate stabilization
  • 27. Primary Assessment
    • Airway
      • Patient Speaking
    • Breathing
      • RR 16, Unassisted.
      • O2 Provided
      • 15 lpm via NB
    • Circulation
      • Carotid Pulse 60
      • Unable to Obtain BP
      • Unable to Check PMS
  • 28. Extrication Complete
  • 29. Secondary Assessment
    • Focused adjuncts:
      • Full set of vital signs
      • Family
    • Give Comfort:
      • Positioning, padding
      • Meds?
    • History:
    • Inspection:
      • Time to log roll!
  • 30. Transport Decisions
    • Drive or Fly
    • Weather Considerations-High Winds
    • Patient is Stable
    • Transported to Trauma Center for Evaluation
  • 31. Patient Outcome
  • 32. Compression Injury
    • Can result from a fall from a significant height onto the head or legs
      • Force of injury can drive weight of head into neck or pelvis into torso
  • 33. Paraplegia
    • Loss of movement and sensation in the body from the waist down
    • Results from spinal cord injury at the level of the thoracic or lumbar vertebrae
  • 34. Case 2…
  • 35. Dispatch
    • Silverlake Road
    • Injured Person
    • Ambulance Makes Response
      • Reported bicycle injury
  • 36. What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
  • 37. Upon Arrival
    • Upon BLS arrival find an 11 year old male
    • Was going over a jump
    • Flipped off his bike
    • Upon landing handlebars impaled patients leg
    • Femur area
    • What are your concerns?
  • 38. Femoral Artery
  • 39. Bike Accident X
  • 40. Bike Accident
  • 41. Primary Assessment
    • AVPU-Neg LOC
    • Airway
      • Patent
    • Breathing
      • RR 16
    • Circulation
      • HR 70
      • BP 116/78
    • Denies PAIN!!
  • 42. Secondary Assessment
    • Focused adjuncts:
      • Full set of vital signs
      • Family
    • Give Comfort:
      • Positioning, padding
      • Meds?
    • History:
    • Inspection:
      • Time to log roll!
  • 43. BLS Actions
    • Requested Rescue
    • Requested ALS
    • Drive or Fly?
  • 44. Rescue Arrival
    • Cut handlebars off. Patient packaged with handlebars still attached.
    • Boarded and collared per mechanism
    • Couldn’t lay flat
  • 45.  
  • 46. Next…
    • ALS Arrived
    • LZ Established
    • Patient Transported to Trauma Center
  • 47. Patient Outcome
    • Arrived as a Trauma Alert
    • Surgery to Remove Handlebar
    • Stayed in Hospital Overnight
    • Returned Home Next Day
    • No other deficits
    • LUCKY!
  • 48. What if?
    • Femoral artery was severed?
    • Bleeding was uncontrolled?
    • Patient was unresponsive?
    • Other potential injuries?
  • 49. Femoral artery was severed?
    • Severe Bleeding
    • Death in Maximum Three Minutes
  • 50. Bleeding was uncontrolled?
  • 51. Patient was unresponsive?
    • Manage
      • Airway
      • Breathing
      • Circulation
    • Think Mechanism!
  • 52. Other potential injuries?
    • Head Injury
    • Abdominal Injury
    • Any Extremity Injury
  • 53. Case 3…
  • 54. Dispatch
    • Main Street
    • Injured Person
    • Initial Report: Patient was Playing Basketball and Suffered Facial Trauma
  • 55. What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
  • 56. Upon Arrival
    • 12 Year Old Playing Basketball
    • Lower the Basket so he could Dunk
    • On descent got teeth caught in the net
    • Immediate bleeding
  • 57. Primary Assessment
    • Uncontrolled bleeding
    • Airway-Patient crying
    • Breathing-No SOB, does not appear to be any teeth missing, no coughing choking, or gagging
    • Circulation-Heart Rate 80
  • 58. Does this patient meet alert or code criteria?
  • 59. Secondary Assessment
    • Vitals
      • HR 80, RR 16, BP 128/84
    • Rapid Trauma Assessment Completed
    • No other injuries noted
  • 60. Interventions
    • Airway Compromise?
    • Control Bleeding?
    • Suctioning?
    • Splinting Injury?
  • 61. Oxygen Delivery
    • NB or NC?
    • NPA or OPA?
    • Contraindications
  • 62. Oral Airway
    • Curved device made of rigid plastic
    • Inserted into patient’s mouth
    • Keeps tongue away from back of throat
    • May only be used in unresponsive patients without a gag reflex
  • 63. Nasal Airway
    • Soft, rubbery tube placed in the nose
    • Can be used in unresponsive patients
    • Can be used in semi-responsive patients who have a gag reflex due to
      • Intoxication
      • Drug overdose
  • 64. Transport Decisions
    • ALS?
    • Fly or Drive?
    • Cervical Spine Immobilization?
    • Treat for Shock?
  • 65. What is Shock?
    • Shock is failure of the cardiovascular system to keep adequate blood circulating to the vital organs of the body, namely the heart, lungs and brain
  • 66. Shock
    • Caused by failure of the body’s:
      • Pump (heart)
      • Fluid (blood)
      • Container (blood vessels)
    • Life-threatening condition
    • Types of Shock
      • Cardiogenic Shock
      • Hemorrhagic Shock
      • Hypovolemic Shock
    • Stages of Shock
      • Early (compensated)
      • Late (decompensated)
      • Irreversible (terminal)
  • 67. Signs of Shock
    • Confused behavior
    • Very fast or very slow pulse rate
    • Very fast or very slow breathing
    • Trembling and weakness in the arms or legs
    • Cool and moist skin
    • Pale or bluish skin, lips and fingernails
    • Enlarged pupils
  • 68. Treatment for Shock
    • Putting a victim in a lying-down position improves circulation
    • If the victim is not suspected of having head or neck injuries, or leg fractures, elevate the legs
    • If you suspect head or neck injuries, keep the victim lying flat. If the victim vomits, turn on their side
    • If victim is experiencing trouble breathing, place them in a semi-reclining position
    • Maintain the victim's body temperature, but do not overheat
    • Give oxygen
    • Prevent heat loss
    • Watch closely to make sure airway remains clear
    • Control all obvious external bleeding
    • Perform physical examination
    • Take vital signs, gather medical history
    • Rapid transport
    • Splint any bone or joint injuries en route
    • Comfort, calm, and reassure patient
    • Ongoing assessment every 5 minutes
  • 69.  
  • 70. Patient Outcome
    • Bleeding Controlled
    • Transported to Trauma Center
    • Diagnosed with Open Maxillary Fracture
    • Admitted for Surgery
  • 71. Open Maxillary Fracture
    • Maxilla
      • Upper Jaw
      • Fractures are rare
      • Associated with other injuries
      • Nose or central face fractures
    • Vertical fracture through palatine process
      • Between tooth 6 and 7 on the right
      • Between tooth 10 and 11 on the left
  • 72. Treatment
    • Realign and set the fragmented bone
    • More complex fractures to the maxilla and surrounding bone may need to be treated with a procedure called &quot;open reduction.“
    • This means surgically exposing the bone and re-positioning the fractured pieces with the use of small screws and plates that are attached directly to the bone.
    • These screws are left to hold the bone together while it heals over the following several weeks.
  • 73. In The End…
    • Admitted for Observation
    • On soft food/liquid diet
    • Will return to pre-trauma state
  • 74. Case 4…
  • 75. Dispatch
    • Pedestrian struck by ice cream truck
    • Initial Dispatch:
      • Squad
      • Rescue
      • ALS Unit
  • 76. What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
  • 77. Arrival
  • 78. Findings
    • 10 Year Old
    • Behind Ice Cream Truck
    • Laying on Ground
    • Initial Reactions?
  • 79. Level of Consciousness?
    • AVPU
      • Alert
      • Verbal
      • Painful
      • Unresponsive
      • Responsive to Painful Stimuli
  • 80. Primary Assessment
    • Airway
      • Patent, No bleeding noted
    • Breathing
      • RR 16
    • Circulation
      • HR 60
      • BP 90/60
  • 81. Secondary Assessment Secondary Assessment
    • Focused adjuncts:
      • Full set of vital signs
      • Family
    • Give Comfort:
      • Positioning, padding
      • Meds?
    • History:
    • Inspection:
      • Time to log roll!
  • 82. Injuries
    • Deep Skin Laceration Over the Lateral Malleolus
    • Open Lateral Malleolar Fracture
    • Road Rash
  • 83. Interventions
    • Open Fracture Management
      • Bleeding Control (Don’t Remove Dressings)
      • Irrigation if Necessary (Not if Bleeding)
      • Splinting
        • Check PMS Before and After
        • Secure Above and Below Fracture
      • Air Splint or Vacuum Splint?-Not Suggested
      • Best is Sam Splint
      • Position of Comfort
      • Secure Fracture
      • Continual Reassessment
  • 84. Open Fracture
  • 85. Put Bone Back In?
    • Tissue Damage
    • Vessel Damage
    • Bone Damage
    • Introduce Bacteria
    • Introduce Foreign Bodies
  • 86. Pain Management
    • Ohio Study
    • 1,073 Patients Diagnosed with an Extremity Fracture
    • 182 (17%) Received Ice
    • 268 (25%) Had a Splint Placed
    • 18 (1.67%) Received Pharmacological Treatment
    • What does this show?
  • 87. RICE
    • Rest
    • ICE
    • Compression
    • Elevation
    • Therapeutic Touch?
    • Causes blood vessels to constrict (Will Initially Throb)
    • Decreases Swelling
    • Decreases Pressure
  • 88. Transport Decisions
    • Level of consciousness
    • Pain Management
    • Mechanism
      • Board and Collar?
    • Destination
  • 89. Arrival to ED
    • Report Given to ED
    • Patients Pain Has Decreased
    • Vital Signs Remain Stable
  • 90. Injuries
  • 91. Management
    • Taken to the OR
    • No evidence of tendon injury
    • Laceration of the saphenous vein
    • Possible injury to the sural nerve
    • The periosteum could not be closed over the distal fibula
    • Therefore, local coverage of the subcutaneous tissues and local muscle were mobilized and secured over the bone
    • The wound was left open for drainage, covered with a sterile compressive dressing, and a short-leg splint was applied to the foot
    • Returned to OR three days later for closure
  • 92. Outcome
    • Patient Admitted for 7 Days
    • Left Non-Weight Bearing (Crutches)
    • Follow Up 6 Weeks Later
    • Expected to have full mobility
  • 93. Case 5…
  • 94. Dispatch
    • Froggy Bottom Lane
    • Injured Person
    • Initial Report: Child with a Nose Bleed
  • 95. What are your initial reactions? What are your initial reactions? Scene Size Up Starts at Dispatch
  • 96. Upon Arrival
    • Child Does Have a Nosebleed
    • Probably Because He Was Running, Fell, and a Pencil Was Shoved Up His Right Nare
    • Treatment Priorities?
  • 97. Concerns
    • How far did the pencil go?
    • Damage that occurred?
    • Remove the pencil or keep it in?
  • 98. Primary Assessment
    • Airway
      • Patent
      • Visible Obstruction in Right Nare
    • Breathing
      • Increased WOB
      • RR 12
    • Circulation
      • Regular rate and rhythm
  • 99. Secondary Assessment Secondary Assessment Secondary Assessment
    • Focused adjuncts:
      • Full set of vital signs
      • Family
    • Give Comfort:
      • Positioning, padding
      • Meds?
    • History:
    • Inspection:
      • Time to log roll!
  • 100. Neurological Assessment
    • Consists of:
    • Normal Neuro Exam
    • Normal Sensation
    • Age appropriate mental status
  • 101. Pencil Stabilization
    • How would you stabilize any object?
    • How about a pencil?
  • 102. Transport Decisions
    • Trauma Center?
    • High Priority?
  • 103. Arrival at Emergency Department
    • Report Given to ED Staff
    • They Get Initial Films to Determine Placement and Damage
  • 104. Pencil Through Nose
  • 105. Now the Real Pictures
  • 106. Findings
    • CT Reveals Pencil is Penetrating Ethmoid Sinus into the Cranial Vault with Evidence of Pneumocephaly
  • 107. Ethmoid Sinus
    • Matchbox-sized areas
    • Filled with 7 to 10 interconnected bubbles
    • Made of very thin-walled bone.
    • These bubbles are lined with mucous membrane
    • Each bubble has its own opening to drain into the nasal cavity
  • 108. Pneumocephaly
    • Pneumocephalus
      • the presence of intra cranial air
      • implies there is a communication between the extra- and intra-cranial compartments.
  • 109. Management
    • Taken to the OR by Neurosurgery
    • Pencil Was Removed
    • Dura was Inspected
      • Had Not Been Penetrated
      • Had Been Stained
    • No CSF Leaks Found
    • Admitted to PICU for Observation of ICP
  • 110. Outcome
    • Patient Remained Stable in PICU
    • Patient DC’d Two Days Later
    • Follow Up Visit One Week Later
      • Normal Cognitively
    • No Need for Additional Follow-Up
  • 111. Case 6…
  • 112. Dispatch
    • State Park, for an Injured Person
    • Winter-Snowing
    • Initial Dispatch: Utility and Squad
  • 113. Where Are We Going?
    • New Partner
    • Never Heard of Location
    • Caller Didn’t Know Exactly Where He Was
  • 114. What are your initial reactions? Scene Size Up Starts at Dispatch
  • 115. Upon Arrival
    • Met by Park Ranger
    • States your apparatus wont be able to make it to the patient
    • Only one person can fit on park ATV
    • You jump on the park ATV and are taken to the patient
    • After traveling for about 2 miles you reach the patient
  • 116. Patient Contact
    • You find a 6 year old who was sledding
    • Using a car hood as a sled, and being pulled by an ATV.
    • The “sled” went into a tree causing the injury
    • Initial thoughts?
  • 117. Primary Assessment
    • Level of Consciousness
      • Positive LOC
    • Airway
      • Jaw Thrust?
    • Breathing
      • Increased WOB
    • Circulation
      • Environmental Concerns?
  • 118.
    • Focused adjuncts:
      • Full set of vital signs
      • Family
    • Give Comfort:
      • Positioning, padding
      • Meds?
    • History:
    • Inspection:
      • Time to log roll!
    Secondary Assessment
  • 119. Injuries Noted
    • 5 CM Laceration on Scalp
    • No Other Injuries Noted
    • Vomited X2
    • No Headache
    • No Visual Disturbances or Changes
  • 120. Management
    • Cervical Spine Precautions Taken
    • Bleeding Controlled by Bandaging Laceration
    • Vital Signs Obtained
    • GCS=15
  • 121. Transport Decisions
    • How do we get the patient to the ambulance?
    • Weather considerations
    • Treat for Shock?
    • Keep Patient Warm
  • 122. What About the Driver
    • As your taking care of your patient, you notice the driver of the ATV has fallen and begins to have a seizure
    • No signs of trauma
    • Manage the seizure which lasts for 1 minute
    • Patient is pale and diaphoretic
    • Vitals are: BP 110/72, HR 112, RR 26
    • The patient regains consciousness and state he has blacked out twice this week
  • 123. What do you think?
  • 124. Huffing
    • Toxic Chemicals are Inhaled from Spray Cans
    • Aerosols-Sprays that Contain Propellants and/or Solvents
    • Common Among Pre-Teens and Adolescents
      • Low Cost
      • Easy Access
      • Absence of Paraphernalia
    • Signs and Symptoms:
      • Apathy, Fatigue, Irritation or Aggression, Forgetfulness, Dizziness, Unsteady Gait, Nystagmus, Anxiety, Slowed Reflexes, Slurred Speech, Red Watery Eyes
  • 125. Huffing Management
    • Only Pre-Hospital Treatment
      • Supportive Care
      • Manage Signs and Symptoms
      • Maintain ABCs
      • Provide Supplemental Oxygen to help Decontaminate the Lungs
  • 126. Critical Thinking
    • Which Patient is Priority?
    • Who Do We Transport First?
    • How Do We Transport?
  • 127. Back to our 6 Year Old
    • Boarded and Collared
    • Taken By Park Ranger Back to Ambulance
    • Secondary Assessment Completed
    • Patient Transported to Local Hospital
  • 128. Arrival at ED
    • Patient in and out of Consciousness En Route
    • Report Given/Initial Assessment Completed
    • CT Scan Completed
  • 129. CT Scan
  • 130. Outcome
    • Parietal Skull Fracture
    • Subdural Bleed
    • Admitted to be Monitored
    • Diagnosed with Concussion
    • Tylenol to Assist with Headache
    • Follow up with Concussion Clinic in 1 Week
  • 131. When Can I Return to Play?
    • All symptoms must disappear
    • Once they disappear, light aerobic exercise can be started
    • If still no symptoms, can begin sport specific exercises
    • If still symptom free, can start NON CONTACT drills
    • If first 4 steps go well contact physician for approval to go back to full activity
  • 132. Summary

×