The Mess In the Garage

An accident with a saw poses opportunities for great customer service

     It's late on a Saturday evening, and as the Attack One crew is clearing another call, they are dispatched to a residential location for a report of a man with a hand injury. Most of the crew's trauma management equipment has been utilized during a recent string of calls, so they hope this is not a major incident. But as they pull into the driveway, they find a man lying in a large pool of blood in a garage at the front of the house.

     Blood seems to be everywhere. "Did we get dispatched on a hand injury or a head injury?" one crew member quietly asks as they step out of the vehicle.

     The man lies in the middle of the floor, his wife sitting next to him. He is as pale as the white paper towels wrapped around his left hand and forearm. Blood is on the towels, the floor, the ceiling, the walls and the door from the garage to the house.

     The natural opening question: "What happened, and is there someone else injured here?"

     "Just my husband," answers the wife, who is also pretty pale and has blood all over her. "He has some bad cuts."

     "Let us help," says the lead medic as each crew member dons gloves. One then heads to the truck to get the last big trauma dressing on hand.

     The woman stands and moves aside so the crew can work, and they remove the paper towels. They are prepared to use smaller dressings to put pressure on any active bleeding, and the paramedic near the patient's shoulder is ready to use his hands as a temporary tourniquet on the upper arm if the bleeding really cuts loose. The man is still lying quietly, and his wife volunteers that he was cut by the saw in the middle of the garage. He was working on a Mother's Day gift for his mom: a pretty wooden cabinet, missing a portion of the front cover, which sits on the other side of a radial saw with blood all over it.

     There are a number of wounds to the left forearm and hand, each of them bleeding, but nothing missing. All digits are in place, pink and warm. There are no obvious wounds close to the radial or ulnar arteries, and no need for that tourniquet.

     "Time for some good news," the medic tells the patient. "You have some pretty good cuts, but everything is in place, and you avoided your arteries. Can you move all your fingers?"

     The fingers move, and as the man begins to regain his composure, he is soon able to respond to questions. He has sensation and movement and good capillary refill at the end of each finger. He has good pulse oximetry readings on each. The trauma dressing and a little pressure bring active bleeding to a halt.

     "I was finishing up that cabinet for my mom—just a couple of pieces to go," the man relates. "The saw slipped, and I couldn't get my glove out of it. The trigger wouldn't shut off, the wood was stuck, and I just danced around the garage until the plug came out. I don't much like the sight of blood, especially mine, so next thing I know, I'm going to the ground."

     That explains the mess. The man hadn't missed a surface in the garage with his blood, and he apparently even made it to the door before he slid down.

     "We need to give you a little fluid and take you to the hospital to repair those cuts, but you should be fine," the paramedic reassures the man. He notices, though, that the man has tears in his eyes, and offers to call medical control for some pain medicine.

     "It's not that bad; I'll be fine," the man insists. "But my mom and family are coming tomorrow for Mother's Day, and I didn't get her gift done. That cabinet was something she really wanted, and the whole family contributed for it and are coming for the party and presentation at noon. I've messed the whole thing up. I need to talk to my wife to get her to start calling people and canceling the party. And we need to get my mom and dad over here so they can watch the boys, who are asleep."

     This poses some new issues. The boys are 8 and 10 years of age. Their mom will have to accompany her husband to the hospital, leaving an unfinished gift and a huge bloody mess.

     Working to get the IV started, the medic asks, "Are your parents OK to come over and watch the kids and house?"

     "They're both pretty feeble and have bad arthritis," the man says. "And my mom can't see her gift—it will ruin the surprise when we give it to her. Can you help me get it covered up? This is the only entrance to the house my parents can get in."

     The Attack One crew members exchange a few words. There is no way this will work out unless they take care of the family. The patient's arm and hand wounds can be repaired at the hospital, but the garage is covered with blood, and the parents aren't going to be able to clean it up. The wife is also covered. The boys are asleep, and it will require some time for their grandparents to arrive. The cabinet's not done, and the party's at risk.

     Just then, a neighbor appears, wondering what the red lights are all about. She is a friend of the wife, and offers to stay at the house until the parents get there. But she is immediately almost sick from seeing the blood, and asks to go inside right away. Her presence, however, allows the crew to solidify a customer service plan:

• The patient can get his IV line started and a fluid bolus.
• His wife can go inside to get cleaned up and change into clean clothes. She can orient the neighbor to the house, and drive to the hospital behind the ambulance.
• The neighbor can take care of the boys until the grandparents arrive.
• The Attack One crew offers to "take care" of the cabinet and garage. Away from the patient, they tell the wife to not cancel the party. One member gets on the radio: "Attack One to Dispatch, can you send an engine to this address, nonemergency, and ask them to bring an extra box of gloves? We have a customer service issue to address."

     One crew member stays behind as the ambulance leaves for the hospital, the wife trailing in her car. He consults with the arriving engine crew. There is no way they can leave the bloody mess in the garage for the patient's parents to find as they arrive and the boys to see in the morning. The patient and his wife will be at the hospital for hours, and won't have the time or energy to clean when they get home.

     The rescuers agree on a plan to clean the bloodstained garage and finish the cabinet. The Attack One crew member staying behind does woodworking on the side, and knows how to safely manage saws and finish wood. Everyone really wants to get the garage cleaned up and the cabinet hidden before the patient's parents arrive, so they quickly use the cleaning equipment from the engine, paper towels from the house and some bleach to clean all the spots. Finishing the cabinet takes very little time for the Attack One woodworker and another, similarly talented engine crew member. They hide the finished cabinet under a tarp. They then radio a report to the Attack One crew at the hospital, who reassure patient and his wife that his parents had arrived to take care of the boys, the cabinet was hidden and the party plans should not be interrupted.

Patient Transportation & Management
     Transportation to the local hospital is uneventful. The extremity wounds continue oozing during transport, but pulse oximetry reveals good perfusion at the end of each finger. The patient's blood pressure and overall perfusion improve with a liter of intravenous fluids and bleeding control.

     The patient has extensive lacerations, but bony, muscle and neurovascular structures are not injured. It takes about three hours to close the wounds, and the patient is splinted and released home. As the tired couple reaches their home, they open the garage door to find a completely cleaned area, the cabinet completed and hidden in the corner, sleeping boys and grandparents, and a handwritten note from the crews wishing them a happy Mother's Day and a speedy recovery.

Case Discussion
     What are rescuers' responsibilities in emergencies like these? It's a worthy discussion to have. First priorities are always safe operations and outstanding patient care. Rescuers are also often asked to take care of the public by participating in prevention activities and service programs. And, as demonstrated by this incident, each patient interaction also poses opportunities to excel in customer service beyond emergency medical care.

     Some departments have embarked on programs of improving customer service. One area of service can be in cleaning up messes, especially those involving bodily fluids. This element of our job is rather mundane to providers, but very dramatic to the public. Cleaning up blood, urine, emesis, stool or even body parts is an essential role for someone on the EMS team, unless a family member, friend or facility staff wishes to do it. Major blood loss is a dramatic event, but often has a good outcome for the patient. Our customer service opportunity with family or bystanders is to make sure we leave the scene as clean as possible, so they understand how much we care about them as well.

     This case demonstrates that opportunities exist to serve a patient need beyond the medical emergency, on a day (or night) that has already gone badly. Simple, safe, quick interventions can make a huge difference.

Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH. He is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.