Needle In a Racetrack

     It seemed the rain would never stop, but the sun finally came out, and the springtime Friday evening was an invitation to outdoor activities. The Attack One crew had eaten an early dinner, anticipating a busy evening. Almost on cue, the tones drop for a person injured at a popular local minicar racetrack, where amateurs try their driving skills against the clock.

     An excited staff member directs the arriving crew to the outside fence, where a car has driven off the track. A crowd has surrounded the injured young female driver, who is still in the car and partially wrapped in the chain-link fence surrounding the track. The miniature car lays on its side, leaking a small amount of fuel. The woman is still in her helmet, which resembles a football helmet without the facepiece. The muddy ground is soaking up the fuel, but makes working around the woman more difficult. One of the bystanders has placed a piece of towel on the young woman's face, which has bled.

     She can speak, and complains of right arm pain—there's an obvious forearm fracture—and pain around the right side of her face near her eye. She recalls that she lost control of the car, slid on mud and slammed into the fence. She never lost consciousness. Her seat belt system is still in place, and her chest, abdomen and lower body are uninjured. The helmet protected all of her head but her face. She has no neck pain.

     The Attack One crew and track staff agree it will be easiest to quickly cut through the lightweight fence, slide the patient out, upright the car and contain the small fuel spill. They will need to keep the patient calm, in her helmet and belted until the chain link can be cut and pulled away. It is easy to splint her injured forearm, and distal pulses and capillary refill, intact before, remain so after the splint is applied. The towel on her face is replaced with a large dressing pad. She has lacerations around her right eye and some dried blood, but there is no active bleeding.

     The fence is cut with simple tools and pulled away from the patient and vehicle. The restraint system is opened, and the patient is allowed to climb out. Several bystanders assist in moving the car to an upright position, and staff push it back toward the track. A fuel-absorbent material is placed on the spill. The patient is placed on a stretcher with her head upright and arm splinted. Under their cervical spine clearance protocol, there is no indication for the crew to perform spinal immobilization. The stretcher and patient are wheeled to the ambulance and loaded. It's a muddy mess, but the patient is comfortable with her arm splinted and in a sling, and it's now possible to clean up her face.

     The dressing pad is removed, and the crew prepares some saline-soaked 4 x 4 pads to clean the area. There is an extensive cut across the eyebrow, another below the eye on the right side, and another on that side of her nose. There is mud splashed into the area, and the mixture of mud and blood has caked firmly in some places around her face. As they clean the mess, the crew can examine her eye. And as the wet dressings remove more of the mixture, a problem becomes suddenly obvious: The entire upper eyelid is missing!

     The concern on the crew's faces is quickly apparent to the patient, and for the first time she realizes she can't blink or close her eye. Carefully and gently, the paramedic cleans the area around the eye and compresses the bleeding from the lacerations. The eye itself appears uninjured, and the patient says she can see fine out of it. Wondering what's wrong, she asks the paramedic why she can't get her eyelid to close. Gently and politely he reports that the upper eyelid is missing, and asks the patient if she knows where it might be.

     "It all happened too fast," she says. "I saw the fence coming at me and put my arm out. My face went into the fence and mud, and I was on my side. I knew my wrist hurt, but didn't think anything else was wrong."

     Calming the patient is now a priority. The paramedic asks her to do some quick responses to confirm that the eye itself is OK. He carefully checks the surface of the eye, and asks her to move it in all directions and read from a piece of paper he pulls from his pocket. He examines the lacerations, finding no remaining mud. With the bleeding completely controlled, he can see the eyelid has been avulsed with a clean cut, leaving the eye uninjured.

     He tells the patient, "Your eye is completely uninjured. You have a simple cut on your nose and around the eyebrow. The fence must have cut off a piece of the upper eyelid, but we're going to find it, and the surgeons are going to put it back on. The important thing is your eye itself, which has not been injured in any way I can see. Let me get to work with my partners."

     He moistens a soft eyepatch and asks her to use her uninjured left arm to put it on her eye, use it to keep her eye moist, and close off her vision as an eyelid would.

Developing a Plan
     The Attack One crew assembles at the back of the ambulance to develop a plan. One member has already done a survey of the scene and could not find the eyelid. Even worse, the area where the patient crashed is very muddy, and had been trampled as the patient was extricated, the car removed and the bystanders moved around. Finding the eyelid was going to require a meticulous search on hands and knees. It likely would be within an area of about 20 by 20 feet, and the crew member has already cordoned that area off. The paramedic working with the patient suggests she should not stay until the search is completed. Her care can be better continued at the hospital, where they will close her wounds, treat her arm fracture and wait for the eyelid to be found for reattachment.

     The crew is aware that only one physician in the metropolitan area performs eyelid surgery, and the patient is removed to that hospital. A second crew will have to come in, find the eyelid and take it to the hospital. Materials are pulled off the ambulance to clean and package the eyelid when it is found.

     The Attack One crew leader requests a response for patient care service from two engines and the light truck. The engines are asked to bring extra gloves and towels. The Attack One members stake out the area for search, and as crews arrive the members are briefed on what happened, asked to prepare for a hands-and-knees search in the muddy area, and instructed on what to look for. The piece of tissue will be shaped like a football, measuring at most 1 x 2 centimeters, and is likely to be completely enclosed in mud. Hopefully it will be in one piece, but it might be folded over or wrapped on itself. It will be easiest to look for the straight line that was the bottom of the eyelid, which will be thicker and, when cleaned, have eyelashes.

     The needle-in-a-haystack search begins. The light truck was called because sunset is imminent and the area is unlit. Its crew rigs direct overhead lighting, as well as indirect lighting for each of the search groups. Four search groups are assigned sections, each moving from the periphery of the search area toward the middle. The crews work shoulder to shoulder, doing an inch-by-inch search with gloves in the mud. It is critical to do a meticulous search the first time through, as crews crawling over it would almost certainly pack the eyelid even farther into the mud, making a second search even more difficult and time consuming. Two basins of water are filled, and any found object that could be the lid will be given to the paramedics, who will clean it to see if it's the eyelid. When it's found, one of the engines will remove the eyelid to the hospital.

     The process proves even more time consuming than originally planned. Puddles and grass pose problems. The crews use towels to soak up the water, carefully dabbing at the mud. Some of the crews use scissors to trim back the grass to make the search easier.

     Command is in place, and the PIO function is managed by the battalion chief serving as Command. The media has arrived and are aware of the operation being performed. After an hour of searching, the message comes from the ED that the patient is stable, and the operating room and surgeon are just waiting for the eyelid. Command has also assembled a relief crew and rehab area for the members doing this painstaking work.

     Almost two hours into the operation, the intact eyelid is found buried in the mud. It had in fact wrapped itself up, and was hard to identify. The paramedics do a gentle and thorough cleaning, place the tissue on a moist eyepatch and cool it as the engine crew loads up to transport it.

Hospital Course
     On notification of recovery of the tissue, the patient went to the OR. The engine crew took the tissue directly upstairs. A two-hour operation followed, and the patient was then sent to a hyperbaric chamber for the first of many treatments to help the tissue recover.

     A week later, the patient came to the station for a thank-you visit, sporting a slightly swollen but working eyelid. She made an outstanding recovery with a completely functional eyelid.

Case Discussion
     Amputations are dramatic, infrequent and high-profile events. Providers may be called upon to provide immediate emergency care and then do a search for missing tissues, as in this case.

     Many such salvage situations can occur, and all emergency providers should be aware of the need to recover body parts and tissues. It is critically important that EMS providers be aware of body parts that are, because of their specialized functions and composition, not possible to replace. When we review anatomy, there are some immediately identifiable structures that are amenable to salvage and would be difficult or impossible to replace with a prosthesis. The most important are large pieces of scalp, teeth, eyelids (probably the most intricate structure that is hard to replace on the body), pinnae, lips, digits (particularly thumbs), nipples, noses and genitalia.

     Obviously, major pieces of extremities may be replanted, particularly in healthy patients with sharp mechanisms of amputation. For any of these tissues, replant success depends on the mechanism of injury, the length of time unattached, and associated injuries. The best recovery comes when there is a sharp mechanism of injury, a short time of detachment, no damage to the reattachment site/part, and no underlying medical problems (particularly hazardous for the patient are diabetes, hypertension, immune deficiency and infections). Tissue salvage is possible for some period of time, maybe up to 6–8 hours in the best circumstances.

     Every fire and EMS organization needs a clear policy regarding recovery of amputated body parts. Prehospital emergency care is facilitated by recovering all amputated parts and tissues, and letting ED staff and specialists determine what to do with them. The industrial setting can produce a variety of complex amputation injuries. The management process steps are:

• Save the patient's life, if it is threatened;
• Control any hemorrhage;
• Control pain;
• Save any tissue found;
• Remove the patient with appropriate rapidity to a hospital prepared to manage a possible replant case, even if removal of the tissue must take place later;
• Treat tissue gently, clean it, and keep it moist (not soaked) and cooled;
• Don't make statements to the patient that provide either too much or too little hope;
• Be aware of long-term implications for the patient of this work to salvage something critical to their body.

     Learning Point: Amputations are dramatic events. EMS organizations sometimes are called upon to perform extraordinary searches for critical body parts that are amputated. Providers should be aware of parts that are possible to replant, and have a clear policy regarding recovery of amputated parts. Prehospital emergency care is facilitated by recovering all amputated parts and tissues, and letting emergency department staff and specialists determine what to do with them.

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, and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.