The Quiet Ones Dying

   It's a beautiful afternoon when Attack One responds to a report of a "house that exploded." The crew pulls into a recently completed neighborhood of two-story family homes. Crew members have performed several walkaround tours of the nice homes in the neighborhood, and are aware that they all have one unusual feature: propane heating systems.

   There are at least four victims, along with some bystanders, and several of the victims are screaming. One is lying on the ground near the home, very quiet. The second paramedic on the crew immediately moves toward that victim, but it's not until he reaches him that he notices the patient's right leg is missing. The victim is severely burned, with signs of trauma to his chest and abdomen, and his leg has been amputated below the knee.

   The crew leader reports a multiple-casualty incident due to the explosion, and requests additional EMS resources and law enforcement control of a wide perimeter. His last exploding-house incident was caused by an illegal drug lab in the basement, and he wants to protect against any risks to his crew. They quickly determine there are just the four victims, no one else is in the home, and the incident was likely the result of a gas explosion, because the worst-injured victim is a worker who was at the house trying to fix a gas leak.

   The EMT has moved quickly to the victims who were screaming on the crew's arrival. His quick triage work and report to the crew leader allow appropriate calls for additional ambulances. One victim has an injured hand, another an injured leg. A third victim complains of difficulty breathing. All are moved quickly away from the house, where fire crews work to extinguish the fire.

   The EMT organizes the care of the three lesser-injured victims while the two paramedics rapidly initiate treatment of the man with the amputation. The second paramedic works quickly through the care. He applies a tourniquet to the leg and stops the bleeding. Knowing intravenous access will be difficult to secure, he administers a dose of morphine through a mucosal atomization device in the nose. He inserts an endotracheal tube and begins assisting ventilations with oxygen. The man has burn injuries to both arms and is in frank shock, so the paramedics insert an intraosseous device and begin fluid resuscitation with warm saline. They cover the patient's burns and prioritize him for transport to the regional burn center.

   The crew then organizes care of the remaining three victims, whose injuries are less severe. They establish a rehabilitation area for the ongoing firefighting operation, and arrange for counseling resources for neighbors shaken by the appearance of the badly injured man.

Hospital Course

   On arrival at the burn center, the burned and injured patient is unstable. It is difficult to ventilate him, and the lead surgeon decides to perform a surgical procedure called an escharotomy to release the compression of the burned skin on his chest. Once this is accomplished, the patient will be much more easily ventilated. He is taken to the operating room, where he has multiple procedures done, including a cleanup of his right leg. He has a series of followup operations, then burn care and rehabilitation.

Case Discussion

   The crew discussed the case when they arrived back at the station late in the day. The lead paramedic found the care provided by the second paramedic to be exceptionally well-organized, and the EMT was amazed at how that paramedic, upon arriving at the scene, had decided immediately to go care for the critical victim, bypassing the other victims who were much more verbal.

   The second paramedic had a simple and humble explanation: He had just returned from a stint with a military medical unit on the front lines in the Middle East. He noted that this patient had injuries remarkably similar to those of victims of improvised explosive devices. He was trained in treating IED victims, so was comfortable with the priorities of emergency care, even though the victim had a combination of serious trauma and burn injuries. He also was taught that "it's the quiet ones who are dying," so he knew to move through those with less-serious injuries to the victim with problems that wouldn't allow him to scream. With these critical burn/trauma/explosion patients, priorities may include:

• Tourniquets for uncontrolled extremity hemorrhage;
• Airway;
• Breathing;
• Pain medication by intranasal route;
• Intraosseous access for fluid resuscitation.

Conclusion

   There are incidents in which patients can be both severely injured and burned. EMTs with military backgrounds may be experienced with these patients. In the civilian setting, there is a potential for incidents involving hydrocarbon explosions, vehicle accidents, illegal drug-producing labs and violent incidents with IEDs to produce similar patterns of injuries. Prehospital providers will make critical decisions about victim care priorities in very compressed time frames, and must be comfortable with rapid airway management, use of devices to stop hemorrhage and management of severe burns.

   Explosives can produce shear injuries, shrapnel wounds and crush avulsions of the extremities, with bleeding that is difficult to control. There has been a renewed use of tourniquets in recent years, and a variety of commercial products have come on the market for both military and civilian applications. Protocols must be written to guide their use, and these must be developed in concert with local trauma centers, so ED physicians and surgeons are prepared to receive patients with those devices in place.

   Surgeons returning from war assignments may be familiar with tourniquets and wounds that are typical of war. They are also comfortable with measures for pain control, intraosseous infusion devices and new airway devices. This may be an ideal time for updating trauma protocols and equipment, along with providing a continuing education session on complex trauma patient management.

Initial Assessment

Victim #1: A 23-year-old male in acute distress. His right leg has been amputated, and he has suffered major burns to his torso and head, as well as other traumatic injuries.

• Airway: Temporarily intact but obviously burned.
• Breathing: In respiratory distress.
• Circulation: Compromised perfusion with poor capillary refill. Significant bleeding from amputated right leg. Arms are burned. Other abrasions and lacerations. Pulse oximetry can at times get readings from digits on both hands.
• Disability: Patient can move all intact extremities but has pain in each. He is lapsing in and out of consciousness.
• Exposure of Other Major Problems: Burns and trauma create access problems for fluid resuscitation.

AMPLE Assessment

• Allergies: None.
• Medications: None.
• Past Medical History: No significant prior medical problems.
• Last Intake: Unknown.
• Event: Gas explosion with multiple victims. The most severely injured has a traumatic amputation, major trauma and full-thickness burns.

Victim #2: Injury limited to right upper extremity. The hand has been burned, and the patient complains of severe pain. The patient is placed on a cardiac monitor, oxygen is provided, and a left-arm IV line is initiated. There is no immediate indication of airway or lung injury. Pulse oximetry is monitored continuously.

Victim #3: The patient has sustained several lower leg injuries. There is no active bleeding and no obvious dislocation, fracture or burn.

Victim #4: The patient has suffered smoke inhalation and responds well to a nebulizer treatment. The lungs are now completely clear. This victim is sobbing uncontrollably after witnessing the injuries to the other victims.

Learning Point

Explosive incidents can produce multiple casualties, severe injuries, and scene safety and security issues. After establishing a safe approach to victims, rescuers will need to conduct rapid assessment, management of ABCs and rapid transport. In certain victims, tourniquets have proven lifesaving.

   James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area and director of clinical operations at EMP Management in Canton, OH. He is also a member of EMS World Magazine's editorial advisory board. Contact him at jaugustine@emp.com.