Out at Home

     As the Attack One crew runs onto the field, it's so quiet, they can hear every whisper in the crowd. The young baseball player lies motionless on home plate. A coach crouches next to him, but most everyone else is trying to look away. The reason becomes obvious as the lead paramedic crosses first base: The player's right ankle is grossly broken, and blood is staining his sock and shoe.

     The player is pale and groggy. The coach tells the crew the player slid into home, colliding with the catcher, and his ankle snapped. He was in so much pain he was screaming, then looked at his bloody ankle and passed out. The coach is also getting a little pale as he tries to care for the young man without looking at the ankle.

     The patient is 15 years old and has a slow, regular pulse. His only injury is the ankle, which has a very unusual angulation, and actually has a piece of fibula sticking through the sock. There is a moderate amount of blood on the sock and the surrounding ground. As the crew moves to immobilize the boy's ankle and remove his athletic cleats, he wakes up and complains of severe pain. The crew recognizes that the severe deformity of the ankle is causing a great deal of distress for bystanders, so they strategically cover the ankle with a sheet as they work. Any movement of the ankle causes exquisite pain, so the crew moves rapidly to remove the shoe, cut off the sock, and rest the ankle and foot in a splint. With the grossly deformed ankle, the boy has a weak pulse in his foot and poor capillary refill in his toes.

     The player lies directly on home plate. Players from both teams are providing support from their dugouts, so one of the EMTs asks if either team can provide some ice to help reduce the pain of the injury. A person in the crowd offers to go to the concession stand to get a bag of ice. The crew decides it will be best to make a quick removal to the medic unit, because staying in front of the other players and spectators won't be good for anyone.

     The coach accompanies the player as they wheel him to the ambulance. The young man's parents are not present at the game, and attempts to contact them have been unsuccessful. After the crew places the patient in the vehicle, he complains of more severe pain, and the paramedic notices his foot is even paler than it was on the field. The splint is maintaining the ankle in the position it was found, but the circulation to the foot has been compromised. A pulse oximeter placed on the great toe of the right foot cannot find a pulse.

     The coach asks, "You can't treat him, can you? I don't have a permission form from his parents for medical care, and I probably should."

     "Yes, sir, we can," the paramedic tells him. "We will provide care to anyone, including a minor, who requests it. We evaluate the patient, and if we find an emergency condition, we treat the emergency. We cannot withhold needed treatment for a young person who needs it, like this young man does."

     Without a pulse, they will have to reposition the ankle to get it more in alignment. The crew contacts medical control as they start an intravenous line, then loosen the splint. They report the injury to the emergency physician, as well as the need for pain medication and putting the ankle into a better position. The physician asks if the boy's parents are present, and is told they aren't. But given the report from the paramedic and the young man's pain, he gives an order for administration of morphine and attempting to get the ankle back grossly into position, so as to restore blood flow to the foot.

     The crew starts an IV line, and administers morphine 2 mg at a time until the patient's pain is under better control. The medic tells the young man and his coach that he's going to have to pull very gently on the ankle to get it back to its normal position and restore blood flow. At that point the paramedic gently applies traction on the ankle and returns it to a more normal position. The bone sticking through the skin is not going to go back into place, but getting the joint back to a better place restores the pulse in the foot, reduces pain, and decreases the bleeding from the end of the bone. The splint is reapplied, the leg is elevated and the bag of ice from the person in the crowd is placed on the splint. The patient is much more comfortable as they start the 20-minute trip to the hospital.

     Before they leave an assistant coach, who had been waiting outside the ambulance, is asked to talk to the player and the coach inside. They agree that the other players and the crowd will be notified that the player's broken ankle has been put back into better position, and he has been treated with pain medication and is in good condition going to the hospital. They also agree that the assistant coach and some other players' parents will continue to attempt to contact the injured boy's parents. Whether they show up at the game or are contacted by phone, they will be directed to the hospital where he is being transported.

Initial Assessment

     A 15-year-old male with an open fracture of the right ankle due to a baseball accident. He then had a syncopal episode after seeing the injury.

     Airway: Intact.

     Breathing: No distress.

     Circulation: Patient was originally pale, but on return of normal heart rate, had normal capillary refill and pink skin.

     Disability: Fractured ankle, but no distal neurologic deficits. Exposure of Other Major Problems: Open fracture and dislocation of the right ankle. No other injuries present.

Vital Signs

AMPLE Assessment

     Allergies: None.

     Medications: None.

     Past Medical History: No medical problems.

     Last Intake: No food intake since breakfast around 0800.

     Event: Open fracture and dislocation of the ankle, with bone penetrating through the sock and mild active bleeding. Patient passed out after seeing the injury.

Hospital Management

     The ED staff is prepared for the patient's arrival. During the 20-minute transport, the assistant coach finally reaches the parents, who call the emergency department to say they're on their way. The ankle is still deformed, but the patient has a good pulse in his foot, and pink skin with good capillary refill in his toes. The elevation, ice and morphine have made him much more comfortable.

     X-rays show fractures of both the tibia and fibula, and a dislocation of the joint. The boy will require surgery. The parents arrive and, after talking with their son and his coach, place a call to the EMS service to express their appreciation for the prompt care the Attack One crew provided.

     After surgery and extensive rehabilitation, the patient returns to baseball. When he visits the EMS crew during his recovery, he is proud to tell them: "Before I was 'out' at home, the umpire had called me safe!"

Customer Service Opportunity

     Athletic injuries in front of crowds put EMS personnel in the position of providing care in a very public arena. Events that happen in major crowd venues require special management. Crowd concerns about the patient should be acknowledged, and when possible, spectators and bystanders should be reassured that the athlete will be OK.

Case Discussion

     Athletic injuries in front of crowds put EMS personnel in the position of providing care in a very public arena. EMTs should be comfortable in performing their usual medical role, but should be flexible enough to know when interventions should take place. Taking the athlete out of the public eye before doing any procedures and minimizing the athlete's discomfort are important elements for the patient, their teammates and bystanders.

     The management of teenage patients can present issues related to legal aspects of consent for care. These situations are managed by understanding the consent rules outlined by agency medical direction and legal counsel, and generally by providing the best evaluation and emergency medical treatment available to the patient. Teenagers are often involved in activities that take them away from their parents, and may need evaluation, treatment and transportation before parents can be contacted. The teenager requesting care should be evaluated and treated promptly, and transported to the appropriate emergency department. EMS crews should be helpful in providing information to parents that will allow them to meet their child at the best location and understand their child is receiving excellent care. If the patient has an illness or injury that is not life-threatening, it should be made clear to the parents that the child is stable and receiving care, so they do not feel the need to drive inappropriately fast to the hospital, or assume their child is suffering until they arrive.

Learning Point

     Teenage athletes can be injured in a variety of ways, and EMS care should include adequate evaluation and managing any emergency medical condition found. This is a good discussion item for EMS providers and their legal counsel and medical direction. Dramatic injuries occurring in front of crowds, often including parents and friends, require EMTs to modify procedures to consider what's best for all involved.

     James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.