Case Review: Eye-catcher

It’s a cool fall afternoon, and the Attack One crew is surprised to be dispatched to a location on a large lake for an unknown injury. This area can be very busy on warm summer weekends and holidays, but not traditionally at this time of year. The only additional information the dispatcher gives the crew is to “meet the patient at the boat dock.”

They are on scene quickly, but there is no one at the dock. Some distance out on the lake, they see a boat moving toward them, and soon they notice the driver is signaling to them. The boat is moving at a relatively slow speed. They see only two occupants on board, one man driving and another sitting in a front seat with his head down. As they approach, only the pilot, a middle-aged man, speaks.

“We have a serious injury here! My friend has a fishhook in his eye!”

The story is accurate: Protruding from the front of the other man’s left eye is a fishing line, which is cut off about 6 inches away from the eye. The injured man doesn’t want to speak, preferring to keep his head in a stable position with his eyes closed; he has vomited once, and feels like he may again. The driver explains that the two of them were friends out fishing on the lake. The injured man cast his line with bait on the end, it got caught on something in the lake, and the man pulled back forcefully to try to dislodge the hook. When he did, he felt something snap, and then something hit him in the eye. Since it had his fishing line attached to it, he assumed a piece of the fishhook was at the end of the line and in his eye.

His friend cut the line so the pole could be detached, then used a cellular phone to call for help. As they began to power toward the dock, the patient developed a severe headache, and then became very nauseated lying on the floor of the boat. He found his discomfort was significantly reduced if he sat up and faced forward in the boat, and the driver moved the boat slowly. Now the patient begs the Attack One crew to let him sit upright, keep his eyes closed, and face forward in the ambulance.

The crew leader, a paramedic, asks the man to open his eye so he can see the full extent of the injury. He suspects light will make the patient uncomfortable, so he shields the patient from the sunlight, has him open his eyelids and checks the injury. He sees a single small puncture wound in the clear surface of the eye (cornea), with the fishing line coming out of it. There is no obvious blood. The patient can’t move his eye up or down, and can only see light in that eye. He cannot count fingers held in front of him with the other eye closed.

The paramedic checks the right eye and the patient’s nose and eyelids, and finds no other injuries. The paramedic then tells the patient everything he found, and tells the man the most important things they can do are to keep his eye still, have him sit upright and take him safely to the hospital. The patient complains of a general headache and severe nausea, and is worried about vomiting again. Knowing that vomiting causes a dramatic increase in pressure in the eyes, and that pressure will worsen any injury or bleeding present in the eye, the paramedic wants to make every effort to prevent that from happening.

“Let’s do everything we can to prevent that,” he tells the man. “You tell us, sir, what makes you feel less nauseated. We will keep your head up and use a cold washcloth on your head. If you want to sit facing forward in the ambulance, we will position the cot so you can. We can start an IV line and give you medication. If you need something for your headache, we can give you some medicine for that also. As we treat and transport you to the hospital, just keep us informed of what makes you feel better.”

“Can I keep my eyes closed?” the patient requests.

“Yes,” the medic says. “You can either keep them closed yourself, or we can tape patches lightly over both eyes to keep them both comfortable and at rest. We will do whichever makes you feel more comfortable.”

The patient opts to keep his eyes closed. He is seated on the stretcher in a forward-facing position, and the crew starts an IV line and administers morphine for pain and ondansetron for nausea. They initiate transport, with the driver working to achieve a smooth but expedient ride.

En route, they contact medical control and confirm each of the steps used to keep the patient’s head upright and eyes at rest and reduce nausea. They will contact the trauma center and have them decide about communicating with eye specialists. The patient continues to be very uncomfortable on the trip, and the crew gives him another dose of the antinausea medication.

Hospital Course

The man arrives in the emergency department stable. Crew members share the history and examination with the emergency nurses and physician, and carefully move the patient to the ED stretcher. The emergency physician has consulted the eye specialist on call, and both do an initial evaluation of the injured man. The injury to the front of the eye is obvious, but a quick set of x-rays determines the injury is actually much more extensive. A piece of metal from the fishhook, measuring almost 2 inches in length, has penetrated all the way through the eye and is sitting in the middle of the skull. The tip of the metal is stuck just in front of the brain stem, and the blood from that injury is causing the headache and extreme vomiting.

The injury will require the work of a team of eye specialists, with assistance from a radiologist, a neurosurgeon and an ear, nose and throat specialist. The team is assembled in the emergency department before the Attack One crew is ready to go back in service. They make an unusual request of the Attack One crew leader, asking if the crew can find a resource person to get a specimen of water from the area where the injury occurred. They will use that information to give the patient the right antibiotics to combat any infection. The Attack One crew contacts a representative of the Department of Natural Resources, and using information from the victim’s friend, they obtain a lake specimen later that day.

The patient goes to surgery and, in a complex procedure, has the fishing line and remnant of the fishhook removed from his eye and skull. Several eye specialists work on his eye, repairing the front portion where the line was in place. Another specialist works on the back portion of the eye, the retina, where light is actually processed and converted into signals the brain can process into what we call vision.

After a complicated recovery and an infection of the area around the brain (meningitis), the victim recovers his health and some vision in his injured eye. With corrective lenses, he maintains normal vision.

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