"Never mistake knowledge for intelligence; it is like mistaking a cup of milk for an entire cow."-Thomas Jefferson
Even though it's been months since Halloween, a few days ago my kids decided to put on their costumes again. One was a cat, another a princess. The youngest dressed as some sort of monster. He loved the fact that his costume hid his true identity. He likes the idea of fooling people into believing they're seeing something different than what's really there by wearing the mask. That got me thinking-do our patients wear masks? Are their injuries sometimes hidden from us? In this month's case, I discuss the danger of not seeing through the mask an injury can sometimes wear, threatening the lives of our patients.
Scenario
You're hoping for a quiet night. Neither you nor your partner have much experience on the job. You've both been paramedics for less than a year, and prior to your current assignment, you worked as an EMT in a low call-volume volunteer ambulance squad. Your partner has even less experience than you do. His volunteer unit was quieter still.
As your shift winds down, dispatch sends you to a collision with injuries at the intersection of North Conduit Ave. and Belt Parkway. Time out is 0627. The fire department is also responding because of a reported fire on scene. A vehicle has burst into flames after striking a street pole. When you reach the scene, the fire department hasn't yet arrived. A police officer informs you there are two victims in the car. You know they're gone, though-no mistaking that smell.
But you do have a patient waiting for treatment on the street. His chest and left arm are charred, and the skin is beginning to slough off. After your initial shock, you and your partner quickly compose yourselves and begin treatment.
As your partner places the victim on high-flow oxygen, you immobilize the C-spine and examine the patient's face. You find no airway burns, carbonation sputum or singed nasal hairs. Your backup arrives, and the EMTs take control of the C-spine. The man's only obvious injuries are the burns on his chest and arm.
The patient tells you he's in terrible pain. He says he was an unrestrained passenger in the vehicle and his chest and abdomen hurt. Your partner obtains the patient's vitals: blood pressure 90/70, pulse 128 and respiratory rate 24. You both agree he's a burn center candidate and begin transport to the nearest facility, St. Flanagan's, approximately 40 minutes away.
You realize you're passing at least four trauma centers while en route to the burn center, but you remind yourself burns like these can cause phenomenal fluid loss and associated hypovolemia. As you're thinking this, the patient's condition rapidly deteriorates before your eyes.
You place two large-bore IVs and begin aggressive fluid resuscitation. The patient's vitals continue to slide as you administer more saline. Your protocols allow you to continue this course of treatment until you've administered 3 L. If you want to go beyond that, you need physician intervention. You call the online physician to present the patient's condition and request permission to administer additional saline.
After hearing your report, the doctor orders you to the nearest trauma center. Even though your partner isn't happy with this turn of events, he drives to the nearest trauma center. Before you arrive, your patient arrests. The trauma team's subsequent efforts prove futile.
The next day, you're summoned to the medical director's office to explain your actions. The patient died due to internal bleeding caused by the vehicle collision. His liver was torn, and he bled out into his abdominal cavity.
In an attempt to explain your actions, you mention the burns. The director simply shakes his head and reminds you that fluid loss from burns doesn't begin for a couple of hours, and you needed to treat the primary mechanism of injury-not the most gruesome. He reminds you that two people died in the collision-a clear indication for immediate transport of the third victim to a trauma center. The physician also reminds you that when you see shock without a clear cause, you need to suspect internal injuries. He tells you to study this during your one-month remediation period.
Discussion
In our day-to-day practice, we sometimes see things that fool us into believing the most outwardly frightening injury we see is, in fact, the worst. As this case illustrates, however, not focusing on hidden injuries that don't evoke the visceral reaction of a serious burn or other horrible injury can often have terrible consequences for our patients.
Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.
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