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A Field Guide to Splinting
This article appeared in the EMS World special supplement Combating the Hidden Dangers of Shock in Trauma, developed by Cambridge Consulting Group and sponsored by North American Rescue, LifeFlow by 410 Medical, and QinFlow. Download the supplement here.
Almost exactly 53 years ago, I was sitting at a card table, staring at my first good hand of the night, when I heard the thump thump thump of a Huey medevac chopper, and I knew the dustoff crew would soon be hard at work delivering God knows what to our ED.
Ten minutes later I was examining a young man who had tripped an IED wire on a jungle trail in the central highlands of Vietnam. The blast ripped off his left leg and shattered and burned his left forearm.
As a partially trained general surgeon now assigned to orthopedics, his care belonged to me. A makeshift tourniquet was doing a good job of stanching the flow from his left traumatic below-knee amputation. While a colleague attended to that injury, my examination revealed obvious open fractures of both bones of his left forearm.
A mixture of blood and dirt filled the overinflated air splint applied by some well-meaning field medic. The young man’s hand was pale and numb, with little active movement. Clearly the evac flight over the mountains had increased the pressure in the splint to a dangerous degree of tightness.
My first thought was to relieve the pressure on the forearm by removing the clear plastic air splint, which I did…along with almost all the skin on his forearm. That’s when the severe burns became obvious. Not a good way to begin a day for this poor casualty or me.
A Sharper Focus
Up until that point of my young career, I hadn’t spent 5 minutes thinking about anything related to the splinting of fractures. Isn’t it amazing how an unexpected bad result can sharpen your focus?
I recall my professor of surgery inquiring how one of my first operative cases went. When I said I thought it had gone well, he just shook his head and said, “Pity, then—you learned nothing.”
This young soldier’s splinting experience was a clear violation of one of the cardinal rules of medicine: First do no harm. That night as I lay in bed, I couldn’t rid myself of the image of that hellishly overinflated air splint filled with jungle grunge…cutting off the circulation…sticking to the burned skin…and not even immobilizing the fractured extremity very well.
As the monsoon season passed into blistering heat, my interest in splinting also heated up. I became very attentive as to which bony and soft-tissue injuries should or should not be splinted or immobilized by some other means (eg, traction), why, and how. What were the advantages and disadvantages of each method? Was there an optimum time frame to begin treatment? How should splinted extremities be monitored, and how often? What other prehospital fracture treatment should be provided? When and where?
By the time I approached the end of my service, I had accumulated a boatload of splinting knowledge.
General Anatomy of Bones
The basic anatomy of bones is quite simple. There are 3 main structures (see Figure 1).
The first is a fibrous, membranous outer covering called the periosteum. This outer layer, much thicker in children, contains numerous blood vessels and nerves. The pain fibers on these nerve endings are exquisitely sensitive to any irritation, such as that caused by the disruption, bleeding, and swelling that occurs at any fracture site. Therefore, not immobilizing or splinting a fracture allows the periosteum to stretch and move, causing the patient to suffer severe, unnecessary pain. In short, it’s inhumane to leave a fracture unsplinted, even for a short period of time.
The second layer is thick, hard cortical (compact) bone. This layer is thicker in large weight-bearing bones such as the femur and tibia. This layer can shatter in any number of pieces depending on the amount, velocity, and angle of force applied. This can produce razor-sharp shards of bone or spearlike pointed ends that can easily slice through adjacent arteries, nerves, and muscle (as well as an exploring surgeon’s finger). Bones may have broken during the original trauma; it is your obligation to prevent any additional damage now that the patient is in your care. You do this by properly splinting the fracture.
The third and final layer of bone is the marrow. The marrow is a honeycombed network of plates and bony struts called trabeculae. These are nature’s studs, joists, and columns that provide maximum engineering support for the outer roof and walls of cortical bone. But in addition to bracing and structurally reinforcing the cortex layer, the marrow portion of the bone has an even more important function.
In 1922 legendary physician Cecil Drinker cleverly described the marrow of a mammalian bone as a “noncollapsible vein, because it is the source of 95% all our blood cells, and even though surrounded by hard cortical bone still communicates with the central venous system through nutrient and emissary veins.”1
In short, bone is vascular, sometimes very much so. This is obviously a good thing for the patient who needs the white and red cells supplied by the bone to live, but not so much for the EMS providers who must learn to stop bleeding from hard vascular structures that cannot be clamped or controlled with pressure. Fortunately blood will clot at a fracture site if you keep it still and protect the clot—another good reason to splint.
Other clues to the level of potential patient danger are as basic as which specific bones are involved and how many. Some bones are larger, more vascular (ie, contain more marrow), and intimately related to vital soft-tissue structures such as arteries, veins, nerves, and organs. The pelvis is the best example of this.
Some long bones are large, vascular, and tremendously sturdy. It’s important to remember that pound for pound, bone is stronger than steel. One cubic inch of bone can withstand the weight of 5 standard pickup trucks. Hence, the amount of force required to break bones, and the attendant potential for adjacent soft-tissue damage and bleeding, can be huge.
The femur is the first such bone that comes to mind. When broken it should set off alarm bells in your head. Breaking a femur may require 900 lbs of force, depending on the velocity, angle of attack, age, sex, metabolic state, and activity level of the bone’s owner. If you run across a femoral shaft snapped in a 20-year-old athletic male, wouldn’t you be a little curious as to the mechanism of injury and what additional injuries may have occurred?
Clearly a high-velocity missile wound or motor vehicle crash at 70 miles an hour is more likely to cause severe injury than a rear-ending event in a McDonald’s drive-through. The height of a fall, the age and sex of the person involved, and the surface impacted are other obvious factors. Elderly osteoporotic females are more likely to sustain fractures when falling down a half a dozen stairs onto the sidewalk than your 12-year-old nephew.
Tug Test
The facts above are things we all have access to simply by looking, asking, and examining the patient. Nowadays medical professionals are without question amazing typists, but the time-honored concept of a quick but thorough history and physical exam is often more honored in the breach than the observance.
First, the history may be given to you by the patient, if alert, or by someone else on scene, but it will not be given unless you ask. Most of the time, when I’ve asked a patient what happened and where they were hurt, they told me. But what if they can’t or won’t tell you?
Although it’s recommended that you perform complete palpation of all injured victims, you’re probably thinking you don’t have time to palpate every inch of the casualty’s extremities. If that’s the case, keep in mind that careful observation will reveal obvious deformity, bruising, abrasions, and swelling. If not, and the patient is alert, a 15-second “tug” test, followed by targeted palpation, will usually demonstrate what you missed visually.
This test is performed by giving a simple firm 15-second tug on the distal end of each extremity. If there’s any injury of almost any sort proximal to your tugging point, the patient will let you know.
Reasons to Splint or Immobilize Fractures
Before delving into the first responder treatment of 2 of the most dangerous fractures, I would like to summarize the 4 main reasons to splint or immobilize a fracture.
1. To relieve anxiety—Purely from a psychological standpoint, the minute you immobilize a fracture by a splint or traction, you have begun treatment by reducing your patient’s anxiety—that is no small thing. From that moment on they understand something is being done.
2. To relieve pain and facilitate transport—The periosteum and marrow are a virtual spaghetti of sensory nerve endings. Therefore, any movement at the fracture site, which will certainly increase during transport, is comparable to having your teeth drilled without anesthesia. That pain alone can produce or enhance shock.
I have heard it said, “I don’t need to take the time to splint—my run to the hospital is only 5 minutes.” OK, let me drill your root canal for only 5 minutes and see how you like it! Plus, we all know how long most patients can sit in an ED before anyone lifts a finger, let alone applies a splint.
3. To reduce bleeding at the fracture site—Bone can be thought of as a hard-shelled blood vessel that cannot be clamped with a hemostat or compressed with your hand—so what can a first responder do to control fracture bleeding? The first and simplest thing is to support nature. You have no control over your patient’s natural clotting ability or what anticoagulant medications they may be on. Aside from administering an antifibrinolytic such as tranexamic acid, which many first responders can’t currently do, you can protect whatever clot does form at the fracture site by immobilizing/splinting the fracture. When a clot remains still, it’s much more likely to remain intact, strengthen, and grow.
4. To prevent further damage to any adjacent soft-tissue structures—We talked about the potential damage sharp bone ends/fragments can do to surrounding structures. Some damage may have already been done, but why would we want any more to occur? According to the “first do no harm” mandate, it’s our duty to prevent more damage. We can do this by immobilizing/splinting the fracture site.
More than 50 years ago, when I first started delving into the subject of fracture splinting, I discovered something rather surprising: Most first responders didn’t bother to splint. And if they did, it was just a perfunctory, nonthinking activity that allowed them to check the required box on the patient care report.
Physicians were much worse—they considered themselves too far up the health care food chain to engage in such a menial task. And the higher up the academic ladder they were, the less likely they felt they needed to have any practical splinting skills.
My thought was, If you can’t do it, how can you teach it? I finally understood the prevailing level of splinting illiteracy that unfortunately exists to this very day.
Dangerous Fracture No. 1: Pelvic Ring
The pelvis consists of 3 bones—2 innominate bones and the sacrum. The innominate bones are made up of the ilium, ischium, and pubis. Pelvic fractures are common—there are more than 100,000 fractures involving disruption of the pelvic ring every year2—and dangerous; they are a major cause of morbidity and mortality.
Data suggests as many as 25% of scene and transport fatalities involve pelvic ring disruptions. The presence of a pelvic ring fracture can double or triple mortality. When a pelvic fracture patient arrives in the ED already in shock, the mortality rate increases dramatically. This is of course much worse in complex fractures, open fractures, and the elderly.3
In fact, pelvic fractures were among the primary causes of death and disability from the 2016 terrorist attack at the Berlin Christmas Market, when a man drove a steel-laden tractor trailer through a crowd.4
Hemorrhage is the most common cause of early death in pelvic fractures.3 Some 80% of this bleeding is from the venous plexus in the retroperitoneal space.5 Arterial bleeding is less common but can be severe.5 Bleeding from fracture surfaces is substantial and can result in up to 2–3 units per break. Soft-tissue structures adjacent to fractures also bleed.6
How much blood can you lose in a pelvic fracture? All of it! When should a first responder treat a suspected pelvic fracture? The answer is to treat it when you suspect it, and suspect it when the mechanism of injury is consistent with a pelvic ring injury—for example, in a fall from a height, high-velocity blunt trauma (eg, a motor vehicle crash), or crush injury.
I use the words suspect it because diagnosing a pelvic fracture in the field is very difficult. Physical examination is inaccurate about 90% of the time. This can be especially true in the confused or unconscious patient.
Of course, it’s helpful if the patient is alert and complains of pain and tenderness in or around the pelvic ring, or if there is bruising over the pelvis or bleeding from the urethra or rectum. Perhaps an alert patient will complain of pelvic pain when you tug on one leg or the other.
Note I didn’t mention attempts at compressing or grinding the pelvis. Please don’t do that. You are unlikely to feel anything leading to a diagnosis, but you are likely to disturb clots that may have already formed at fracture sites.
Accept that it is OK not to know for certain if the pelvis is fractured or exactly what pelvic ring fracture classification may have occurred. Even if you had an x-ray machine in the field and a radiologist to interpret it, there might be a debate concerning the fracture pattern, stability, and recommended definitive treatment—none of which has anything to do with you.
How do you splint a pelvis? By using a circumferential pelvic compression device (CPCD), which in plain English can be anything from a sheet tied around the pelvis to commercially available pelvic belts or binders.
Sheets have the advantage of being inexpensive and can completely encircle the pelvis. They apply circumferential compressive force to the front, back, and sides of the pelvic ring. But the main disadvantage of a sheet as a fracture-stabilizing device is imprecision. A sheet’s effectiveness depends entirely on the strength and judgment of the applicant.
The force applied might be enough to stabilize and secure a pelvic ring fracture; it might also be not enough or too much. Applying too much force could cause an unstable pelvic ring fracture to collapse. In short, every time you apply a sheet, you are rolling the dice.
Commercial pelvic binders are in divided into 2 categories:
1. Virtual sheets—These are devices that, like sheets, are strictly user-dependent. They can be affixed tightly around the pelvis but provide no greater precise control of the total compressive force.
Included in this category are numerous Velcro-secured girdlelike binders that are applied at whatever tightness the healthcare provider estimates to be correct. Another, the T-POD (Trauma Pelvic Orthotic Device), is a single-use device designed with pulleys that provide an extreme mechanical advantage but no greater precision or force control. It comes in 1 size but can be trimmed or multiple devices joined together to customize fit for most people (see Figure 2A).
The VBM Pelvic Sling is a pneumatic device that uses inflatable laterally placed cuffs to apply pressure on the pelvic ring. In my view there are 2 problems here: First, like the sheet, the pressure applied is at the discretion of the user. Second, the pressure is applied on the lateral surfaces of the pelvic ring by 2 inflatable pneumatic pads (see Figures 2B–2D).
Since the pelvis is a ring, any vector force applied to any surface will affect it someplace else. We all know, for example, that you can’t break a pretzel in only one place. That’s why circumferential force extending completely around the pelvic ring is required to adequately secure pelvic ring fractures.
2. SAM Pelvic Sling—There is only 1 device in this category, which includes devices that are scientifically documented in peer-reviewed studies to provide the safe and correct range of force to stabilize and secure pelvic ring fractures.7–11 The SAM Pelvic Sling, available in 3 sizes and an adult military version, is placed circumferentially around the pelvis at the level of the greater trochanters, and its free-handle Velcro strap pulled. When the optimal circumferential compressive force has been reached, the SAM Autostop buckle stops the pull. The sling is then secured in place with the strap (see Figure 3).
Clinical evidence indicates pelvic stabilization devices can improve pelvic fracture outcomes.3
A few words about splinting the pelvis of a pregnant patient. As a vivid photo taken following the attack on a maternity/children’s hospital in Mariupol, Ukraine, so aptly demonstrates, we must also be prepared to splint pelvic fractures in pregnant women. In these circumstances a CPCD must be applied correctly around the greater trochanters so it lies at the level of the symphysis pubis, well below the fully pregnant uterus. By design the narrow anterior portion of the SAM Pelvic Sling facilitates this.
In addition, postpartum diastasis and instability of the symphysis pubis can be quite painful and disabling. The SAM Sling may also be considered as a device to relieve this pain.
Dangerous Fracture No. 2: Femoral Shaft
Some fractures are due to compression—as, for example, from skydiving. Others arise from twisting or torquing, as may occur from catching a ski tip. Femurs can also snap like tree branches as they wrap around motorcycle handlebars, and they can be blasted apart from penetrating trauma.
On the other hand, in individuals with metastatic cancer lesions or bone disease, the required force to fracture the femur can be negligible.
With all types of femoral fractures, the pain can be intense, especially where the fracture ends are displaced and overlapping. For these the powerful quadriceps and hamstring muscles contract virtually unopposed, resulting in intense spasm.
First responders often discover such patients writhing in agony and simply unable to move. And some casualties may be found quite dehydrated, having been stranded on the floor for hours. Because the femur is so vascular, shaft fractures can lead to a blood loss of up to 3 units into the thigh. Up to 40% of isolated femoral fractures may require transfusions.12
This blood loss is especially significant in the elderly, who have less cardiac reserve. For all these reasons be particularly alert when managing femoral shaft fractures—hypotensive shock may be present with no sign of external bleeding.
To follow the principles of fracture immobilization, we must splint the joints above and below the fracture—the hip and knee joints. A spica (body) cast works well in the hospital setting but will not work on scene at a motor vehicle crash. So, what to do?
From a structural engineering standpoint, this is a tricky problem. When a femur is fractured, the surrounding musculature lacks the internal bony scaffolding to resist contraction. Like a guitar with a broken neck or a crane with a broken boom, there’s insufficient structure to resist the contracting force. But in the case of a fractured femur, muscle contraction further exacerbates the structural failure. Pain and spasms form an agonizing feedback loop. The solution is to provide temporary external scaffolding, although this is easier said than done.
The first man to solve this conundrum was Welsh surgeon Hugh Owen Thomas, considered the father of orthopedics in Britain.13 Thomas made many contributions to British orthopedics. In the treatment of fractures and tuberculosis, he advocated rest, which should be “enforced, uninterrupted and prolonged.” To achieve this he created the Thomas splint to stabilize the fractured femur and prevent infection.15
In 1875 he published his first book, Diseases of the Hip, Knee, and Ankle Joints, wherein the world-famous hip and knee splints were described for the first time. Further contributions to medicine and surgery appeared throughout the rest of his life.14 His teaching, however, made little impression in the scientific community, mainly because he chose an obscure publisher, and his works were not well produced. In addition. he worked in isolation and could not be persuaded to disclose his teaching at scientific meetings.14
Sadly, he died at the young age of 57.14 His work was never fully appreciated in his own lifetime, but when his nephew, Sir Robert Jones, applied his splint during the First World War, it reduced mortality of compound fractures of the femur from more than 60% to 12%.16 This convinced the medical establishment that applying traction to a broken femur just might help in the emergency immobilization and transport of injured patients.
Since Thomas and his splint, the topic of emergency femoral traction has been a lesson in engineering evolution, as at least 6 distinct improvements have been made to the original design.17
The basic principle of the Thomas ring emergency traction splint is that 1 end of the splint is positioned against the hip and pushes against the pelvic ischium. A strap around the foot and ankle is connected to the other end of the splint and tightened, often with an improvised windlass mechanism.
The traction created from pulling on the foot and ankle counteracts the muscle spasm in the thigh. Eventually the contracting thigh muscles will fatigue, the spasm and pain subside, and the bones will pull out to their normal length.
The original Thomas ring splint is still used as definitive treatment in numerous medical facilities around the world, especially for patients too sick or with wounds too contaminated to allow for other forms of treatment. It still works. In the hospital setting traction is applied through hanging weights attached to pins usually drilled through the distal femur or proximal tibia.
Thomas splints consist of a simple steel rod bent to contain, traction, and cradle a leg. Straps are used to support and traction the fractured femur (see Figure 4).
A modified version called the Thomas half-ring eliminated the need to slide the ring up the entire injured leg. Dangled weights are not needed for such splints; this represents the first major advance in traction splinting.
Products introduced since the Thomas splint have represented incremental improvements, but Drs. Thomas and Jones deserve full credit for their leap in femur fracture management.
In the late 1960s Glenn Hare, a San Diego police officer, shared ambulance-driving duties with fellow members of his police department. That assignment inspired him to invent a leg splint designed to quickly immobilize long bone fractures of the lower extremities, while simultaneously placing the leg in traction.18
His original version was fashioned from bicycle parts, a toilet seat cover, a ratchet, and gears from a washing machine.18 His Hare traction splint, as he called it, became the signature product of DynaMed, an emergency medical care products company he founded in 1967.18
Hare modified the half-ring splint by incorporating a ratchet mechanism and additional means for length adjustment. The ischial pad was also improved. Most important, the Hare traction splint provided a more rapid and effective means to stretch a femur fracture. Before the Hare a variety of straps and other creative ankle hitch tensioning techniques were required.
The Hare splint is more compact than the Thomas, as it uses telescoping poles and clamps. Unfortunately, the adult version is not compact enough to suit pediatrics, so with the Hare came the first instances of separate pediatric and adult traction splint versions (see Figure 5).
Today many EMS services still have protocols that require both pediatric and adult traction splints because of this historical branch point. Many versions of the Hare splint are still available and in use today.
There are many splints on the market specifically designed to immobilize and apply traction to femur fractures. They are all designed to do the same thing: Apply traction and stabilize the femur, reduce hemorrhage, and reduce pain. Select the right one for your agency and train your personnel to use it as indicated.
For a detailed review of splints available to properly immobilize femur fractures, go to www.hmpgloballearningnetwork.com/site/emsworld/original-contribution/splints-femur-fractures.
Conclusion
The frequency of femur fractures is extremely variable depending on the setting. For example, the military periodically sends thousands of troops jumping from planes, sometimes all at once. Femur fractures are expected, and medics plan accordingly. Training is continuous, and the quest for the best medical practices and products is never-ending.
In other settings femur fractures are rare events. EMS personnel may spend their entire careers never applying traction to a single femur. In such settings traction splints may gather dust along with the skill sets of the provider. This, in my view, is one of the major sources of the “scoop and run” approach: It’s a convenient way to explain not doing what you don’t know—or forget—how to do.
The sheer number of available femoral traction splints and variability in fracture occurrences makes training an even greater challenge. Still, being prepared means regularly practicing on the devices you have available. As we all know, in a pinch we default to the level of our training.
With today’s simpler and less-expensive lateral monopole splints, on-scene traction will hopefully be the path chosen more frequently, applied in the field, and left in place all the way to the operating room.
Video: Anatomy of a Femur Fracture
To illustrate how much damage a fractured femur can do to surrounding tissue and blood vessels and the amount of hemorrhage that can result from a femur fracture, the Centre for Emergency Health Sciences in Spring Branch, Texas, created this video in their cadaver lab emphasizing the need to find and stabilize these potentially deadly injuries.
This video shows:
- The anatomy of the upper thigh and femur, showing how close the vascular structure is to the femur;
- What a fracture and the associated trauma and hemorrhage caused by the sharp bone ends can do to the veins and femoral artery adjacent to the femur; and
- The amount of blood that can accumulate from the damaged vessel, contributing to the patient’s hemorrhagic shock.
Video: Anatomy of a Pelvic Fracture
To illustrate how much damage fractures to the pelvis can do to surrounding tissue and blood vessels and the amount of hemorrhage that can accumulate unseen to responders, the Centre for Emergency Health Sciences in Spring Branch, Texas, created a video in their cadaver lab emphasizing the need to find and stabilize these potentially deadly injuries.
The video shows:
- The anatomy of the pelvis and pelvic cavity;
- What a fracture of the pelvic ring looks like and what it does to damage surrounding muscles, tissue, and vessels;
- How much blood can be lost—and accumulate—in the pelvic cavity; and
- Application of a circumferential pelvic compression device (CPCD) like the SAM Pelvic Sling in stabilizing and securing a pelvic ring fracture, as well as reducing trauma and hemorrhaging at each fracture site.
References
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2. Buller LT, Best MJ, Quinnan SM. A nationwide analysis of pelvic ring fractures: Incidence and trends in treatment, length of stay, and mortality. Geriatr Orthop Surg Rehabil. 2016; 7(1): 9–17. doi: 10.1177/2151458515616250
3. Halawi MJ. Pelvic ring injuries: Emergency assessment and management. J Clin Orthop Trauma. 2015; 6(4): 252–8. doi: 10.1016/j.jcot.2015.08.002
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6. Gänsslen A, Hildebrand F, Pohlemann T. Management of hemodynamic unstable patients “in extremis” with pelvic ring fractures. Acta Chir Orthop Traumatol Cech. 2012; 79(3): 193–202. PMID: 22840950
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8. Cole PA. What’s new in orthopaedic trauma. J Bone Joint Surg Am. 2003; 85-A(11): 2260–9.
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10. Simpson T, Krieg JC, Heuer F, et al. Stabilization of pelvic ring disruptions with a circumferential sheet. J Trauma. 2002; 52(1): 158–61. doi: 10.1097/00005373-200201000-00027
11. Bottlang M, Krieg JC, Mohr M, et al. Emergent management of pelvic ring fractures with use of circumferential compression. J Bone Joint Surg Am. 2002; 84-A (Suppl 2): 43–7. doi: 10.2106/00004623-200200002-00005
12. Romeo NH. Femur injuries and fractures. Medscape. Accessed April 4, 2022. https://emedicine.medscape.com/article/90779-overview
13. Hagy M. ‘Keeping up with the Joneses’—The story of Sir Robert Jones and Sir Reginald Watson-Jones. Iowa Orthop J. 2004; 24: 133–7. PMCID: PMC1888408
14. Jones R. Thomas, Hugh Owen (1834-1891), orthopaedic surgeon. Dictionary of Welsh Biography. Accessed April 3, 2022. https://biography.wales/article/s-THOM-OWE-1834
15. Robinson PM, O’Meara MJ. The Thomas splint: Its origins and use in trauma. J Bone Joint Surg Br. 2009; 91(4): 540–4. doi: 10.1302/0301-620X.91B4.21962
16. Orr HW. The use of the Thomas splint. Am J Nursing. 1920; 20(11): 879–80.
17. Rescue Essentials. Femoral traction: Evolution, engineering, and systems. Accessed April 3, 2022. www.rescue-essentials.com/femoral-traction-evolution-engineering-and-systems/
18. San Diego Police Museum. Officer Glenn F. “Bud” Hare. Accessed April 3, 2022. www.sdpolicemuseum.com/Glenn-Hare.html
Sam Scheinberg, MD, is an orthopedic surgery specialist in Portland, Oregon, and has more than 60 years of experience in the medical field. He graduated from the University of Tennessee College of Medicine in 1965. He invented the SAM Splint during his tenure as an orthopedic resident at the University of Louisville in Kentucky. He and his wife, Cherrie, cofounded SAM Medical nearly 40 years ago to provide innovative practical solutions for the “feet on the street” in the prehospital world.
