Hands Down

The day is cold, and an early-season snowstorm has had the white stuff accumulating for about 16 hours. The streets are largely quiet, since most of the schools and some businesses have closed. There were few emergencies during the day, but a large number of medical transports.

The afternoon saw the snow intensify. The Attack One crew ate a late lunch, anticipating a busy evening. The station alert is activated, and they are to respond for a “person injured.” Additional information indicates the patient is a man with an injury from a snowblower.

The crew marks on the scene to find the patient sitting in a garage with a bloody towel around his hand and a tourniquet around his right forearm. A neighbor placed the tourniquet near his wrist, using a piece of a kitchen towel. A large old snowblower is nearby.

The patient is in significant pain but able to speak. He says he’d just repaired the snowblower and was using it to clear snow that had blown into his garage and onto the narrow strip of sidewalk between his garage and his neighbor’s. He strayed into some grass and other debris and had some material get caught inside. He used his gloved hand to try to remove the material, and his hand was drawn into the rotating mechanism.

“It all happened quickly,” he says, “and my hand just got pulled in. It really hurts, mostly where the tourniquet is. I need that hand for my job.”

The Attack One EMT is good at calming patients, so he takes a position talking with the man while the paramedic removes the towel from the hand and examines the wounds. The EMT asks the patient about his medical history and his job to distract him for a few minutes.

The fingers are badly injured. The worst harm is to the ring and the fifth fingers, with lesser injuries to the others. The paramedic pulls an intravenous splinting board from the first-in bag and layers some gauze on it, then places the fingers carefully on the flat surface. All of the wounds are easy to visualize, and in his judgment the tourniquet will not be needed to control bleeding. He cuts it off the forearm, and the patient reports immediate reduction in pain. There is barely any oozing of blood from the wounds, so the tourniquet will not be needed for further care. He shields the patient’s view of the hand using a towel. “Tell me when you can feel me touch your fingers,” he instructs.

One by one he checks the fingers, starting with the barely injured thumb. The man has no problem feeling the ends of his thumb and index and middle fingers. All three of those have lacerations and injuries to the ends of the fingernails. There are bits of glove and grass in the wounds. The patient reports no sensation at the end of the ring and fifth fingers. Both have deep lacerations and skin torn away, and the middle phalanx (bone) in the fifth finger is broken and angled at 90 degrees to the bottom of the finger. The nails are in place, but the fingers are badly damaged, and there is grass and glove material mixed in the wounds.

It is the patient’s right hand, and the paramedic assumes the patient is right-handed. If the patient is already worried about his job, this could be a devastating injury. “What kind of work do you do?” he asks.

“I’m a design engineer, and I craft building models,” the man replies. But he uses his left hand to gesture about how he shapes Styrofoam and fabrics.

“Are you left-handed?” the paramedic asks.

“I am,” the man answers.

“That is fortunate,” the paramedic responds. “This right hand is going to take a little time to get healed, but we have a great set of hand surgeons in the city, and they will take good care of you. We are going to give them the best chance by cleaning all the debris out of the wounds, straightening out the fingers, putting them in clean dressings, giving you some pain medicine, and taking you to the hospital with the best hand-injury services.”

The paramedic quietly thinks to himself that it’s fortunate this patient’s left hand is dominant. Most of the time the dominant hand is the one injured in snowblowers, lawn mowers and garbage disposals.

He takes some sterile saline and flushes the dirt and glove pieces out of the wounds, using gauze to assist in pulling out the pieces. Bleeding is controlled in all of the digits. There are some pieces of the ring finger caught in the torn glove, so the paramedic cleans those, places them on a clean piece of moist gauze and puts them into a bag to take to the hospital.

He cleans the hand and fingers and straightens out the remnants of the ring and fifth fingers. Since the nails are intact, he uses the pulse oximeter to see if there is any pulsatile flow in the nail beds. The fifth finger does not register any. The ring finger does, with an oximeter reading of 99%. He touches the button to check carbon monoxide, and surprisingly the CO-oximeter gives him a reading of 22%. He’s glad the ring finger has pulsatile flow and understands the fifth finger probably doesn’t because of the severe injury, but he wonders what the high CO reading is about.

The CO-oximeter reads 20% on the right index finger, 23% on the left ring finger and 22% on the left middle finger.

“Do you have a headache?” the paramedic asks. “Or are you feeling bad in any other way?”

The patient answers that he’s dizzy and has a little headache but thought it was just due to the cold weather.

“How long were you using that gas-powered snowblower?”

“I just got a few minutes in before this happened. But it wouldn’t start and run right, so I was working on it here in the garage for a while. Why are you asking?”

The paramedic had noticed the smell of exhaust in the garage but really hadn’t paid any attention due to his focus on the patient. He asks the fire engine captain to bring in a gas monitor, and sure enough, the carbon monoxide level in the garage is about 250 parts per million.

“Sir, nothing serious, but we are all going to move out of the garage and let it air out. Your carbon monoxide level is high enough in your blood that it alerted our monitor. We will need to put you on some oxygen to clear your system, and blow some air through the garage and keep everyone out for a while. Don’t have anyone use that blower until it is repaired. It must be pouring a lot of carbon monoxide into the air.”

The patient reflects a moment. “Maybe that’s why I used poor judgment and stuck my hand into the machine.”

The hand is clean, bleeding controlled, and the fingers are all splinted with gauze neatly on the IV board. They give the patient a plastic bag with some snow in it to use for pain control and cooling, and elevate his hand with a sling. They apply an oxygen mask.

The patient receives an injection of pain medicine en route, and the trip to a hospital with a hand-surgery service is uneventful.

Hospital Course

Staff treat the patient in the emergency department and take him to the operating room for extensive repairs of the hand. He makes an outstanding recovery with a functional hand and most of the tissue intact. It will take him many months to regain sensation in the fifth finger.

Case Discussion

Serious hand injuries may affect patients’ ability to care for themselves and do a job for the rest of their lives. EMS providers cannot change a primary injury but may reduce secondary injuries and long-term impact on the patient if they provide outstanding care and minimize the risk of infection, tissue loss and poor blood flow. Injuries that involve mangled tissue, contamination, severe displacement of normal anatomy and loss of blood supply are the ones that can benefit most from early care. Hands and feet have remarkable abilities to recover from wounds, especially in younger patients.

For injuries causing severe damage to hands and feet, the management process will include these steps:

• Deal immediately with any life-threatening injury, if present.

• Manage any uncontrolled bleeding. This can occur in patients who are on blood-thinners, and those with injuries that cut a blood vessel at an angle.

• Control pain, including ice, elevation and pain medication.

• Remove any dirt and debris from the wound, and any pieces of material like gloves, shoes, socks or other fabrics.

• Save any tissue found. Treat it gently, clean it, kept it moist (not soaked) and cooled.

• Place the injured extremity on a splint, with the bones in alignment with the way the extremity usually is. If it is twisted, untwist gently to reduce ongoing strain on the blood vessels and nerves.

• Once it’s in a straightened position, use capillary refill and if possible a pulse oximeter to help confirm the ends of the fingers or toes are being perfused.

• Remove the patient to a hospital prepared to manage severe extremity wounds.

• Don’t make statements to the patient that provide either too much or too little hope.

In a prior column we reviewed the body parts that, because of their specialized functions and composition, are extremely difficult to replace.¹ It is good to make this list part of training on injuries. These parts include:

• Fingers and toes (particularly the thumb and great toe);

• Large pieces of scalp;

• Teeth;

• Eyelids (probably the most intricate structure that is hard to replace on the body);

• Pinna;

• Lip;

• Nipple;

• Nose;

• Genitalia.

Each of these pieces of the body, if amputated or nearly amputated, is treated the same way in prehospital care: Treat the tissue gently, clean it, moisten but don’t soak it, and cool it. The only exception is teeth, which if possible are rinsed and placed back in the empty socket or somewhere safely in the mouth.

Replant success with amputated parts depends on the mechanism of injury, length of time not attached and associated injuries. The best recovery of any tissue is when there is a sharp mechanism of injury, short time of detachment, no damage (especially crush injury) to the body part it needs reattached to, younger age and no underlying medical problems.

Reference

_{1. Augustine J. Needle in a Racetrack. EMS World, www.emsworld.com/article/10320971.}

James J. Augustine, MD, is an emergency physician and the director of clinical operations at EMP in Canton, OH. He serves on the clinical faculty in the Department of Emergency Medicine at Wright State University and as an EMS medical director for fire-based systems in Atlanta, GA; Naples, FL; and Dayton, OH. Contact him at jaugustine@emp.com.