Fence Splitter

The early morning hours find the Attack One crew cleaning and resupplying their vehicle and completing reports for patients they treated during the day. It feels like they’ve treated every type of illness and injury that can happen to a person. Then comes a simple communication from dispatch: “Person injured, police on scene.”

The crew finds the young male patient in handcuffs in the backseat of a police cruiser. The police officer in the front simply says, “The guy hurt something.” The patient, although a little disrespectful of the paramedic, reports that “Something is bad down there.” Since his hands are cuffed behind his back and the cruiser is small and dark, it is difficult to figure out what he’s referring to.

“Can we walk you to the ambulance and see what’s injured?” the paramedic asks.

“It hurts to walk,” the patient replies, “but it hurts worse to sit here.”

The officer just says OK to the idea of examining the patient in the ambulance.

The patient slides gently out of the cruiser, and the Attack One crew notes he’s dressed only in a t-shirt and a pair of red boxer shorts. He walks with his legs wide apart for the few steps to the ambulance, then sits straddling the stretcher. “It hurts bad down there,” is all he will say.

“Before we examine you, can you tell us what happened and where the rest of your clothes are?”

The patient will not reply. The police officer finally reports that the patient was driving a car trying to evade them, then got it stuck in mud on the country road. He ran from officers into a field and tried to climb over a barbed-wire fence. He got caught on the fence and started screaming in pain. He was lifted off the wire by a pair of police officers, and was handcuffed and walked to the cruiser. He complained of pain, so they activated EMS.

The patient won’t discuss what caused the event, saying only that he hurts. He denies any other injuries.

The lead EMT turns the lights on bright, asks the patient to lie back on the stretcher, uses a sheet to maintain some modesty and cuts the patient’s shorts off using trauma scissors along the outside seams. There is some clotted blood attaching the shorts to the patient’s perineum, and as the EMT slowly tries to peel the shorts away, the patient howls in pain. With a promise to move very slowly, the EMT tries to finish the job. He finds more blood and clots, and finally realizes he cannot find the injury, separate the patient’s shorts from his perineum and keep the patient from screaming. He decides he will use some saline to clean the area, and hopefully make it easier to remove the shorts and find where the blood is coming from.

As they lift the patient to place some towels underneath him and start to pour some saline on the area, the patient shrieks again. “You guys are killing me! Stop, that hurts like crazy!” the patient wails. “That cold water makes it worse! Stop!”

His statements become increasingly descriptive, so the paramedic proposes a different plan: “Let’s have you stand up, and we’ll just let the shorts fall down.” The new plan works: As the patient stands up, the crew gently tugs on the back of his shorts, and they fall to the floor of the ambulance. The shorts have a large, jagged tear in the middle of the crotch and are filled with blood. The patient lies down on the stretcher, and it is now possible to examine him.

The paramedic finds the patient has a large laceration extending along his scrotum for about 10 centimeters. And although the paramedic has never seen them directly before, he notes that what appears to be both of the young man’s testicles are lying in the wound. There is no active bleeding, the man’s penis is not injured, and there are only a few other scratches in the area.

“OK, sir, we can now see you have a cut to your scrotum,” he tells the man. “The bleeding is controlled, but we can see why you were uncomfortable with the cold water. Your testicles are in the cut. Right now it does not appear they are injured, but I cannot tell for sure. Those are very sensitive to cold, so we will not use anything cold in the area.”

The patient starts crying and wondering if he has done any long-term damage. “We can’t tell you anything about that,” the medic says, “but they will examine you fully at the hospital and be able to give you a better answer.”

The crew now moistens a couple of dressing pads with warm saline. They put them up against the man’s inner thigh to let him confirm that they are warm enough, then carefully place them over the scrotum and testicles. They place some clean absorbent pads below the man and ask him to relax the area with his legs apart as they transport him to the hospital. They place a quick call to the emergency department to advise them they are en route with a man in custody and give a basic description of the injury.

The transport is very quiet. A young man who was very mean and mouthy is now remarkably silent and tearful. He asks once if some more warm water can be placed on the dressings, and the paramedic carefully does so.

On arrival in the emergency department, the staff members carefully remove the dressings. The wound is now clean, and during the transport the testicles retracted back inside the skin. The emergency physician and nurse take quite a bit of time warming some fluids, irrigating the wound and separating the skin so the testicles can be examined directly. There is no further bleeding, the clots can be irrigated away, and the physician reports to the patient that the testicles have fortunately been spared of any obvious injury.

There is even more good news over the next few hours: ED testing finds no injury to the man’s urinary tract, and he is taken to the operating room, where the trauma surgeon carefully closes the wound, finding no other damage to the genitals.

The patient makes a full recovery, although he has a large scar in an uncomfortable place. His trip to the courtroom also results in some discomfort.

Case Discussion

There are certain injuries that make emergency providers cringe, and the genital injury in this case certainly fits that description. With both males and females, there are several types of injuries to the pelvic area that require careful management.

This case describes an open injury from a cutting object. These injuries require providers to clean out any dirt, stop hemorrhage and preserve tissue using moist dressings. Direct cold exposure to the testicles should be avoided.

Blunt injuries can occur to the pelvis with painful and sometimes devastating consequences. Bones and soft tissue can be damaged from “straddle” injuries. These commonly happen on bicycles or other athletic equipment. Painful pelvis fractures can occur in these events, especially at higher speeds or with longer falls. Blunt injury can occur to the soft tissues and genitals, with the worst being a rupture of the testicles or penis of a male and the labia of a female. All these are extremely painful and cause a tremendous amount of swelling. They are treated by immobilizing the area and carefully applying cold compresses to areas other than the testicles. An injury unique to the male is a twisting injury to the penis, which can rupture the internal compartments. Yes, it really is called a fracture of the penis.

High-impact injuries to the pelvic area commonly occur from motorcycle accidents. These can fracture the pelvis, severely contuse soft tissues, and cause enough soft-tissue pressure that it tears tissues anywhere from the lower abdominal area to the buttocks. These are terrible injuries and commonly associated with life-threatening internal or external hemorrhage. Patients with these injuries should have the tissues cleaned quickly and returned to an anatomic position, then a pelvic immobilization device applied. Then treat shock and the other life threats.

The other common injury for EMS providers is genitals trapped in another object, like a zipper. This was depicted dramatically in the 1998 movie There’s Something About Mary, and real victims of this event are often as humiliated as the character in the movie, for a long, long time. This injury also happens in females, but much less frequently. This is an injury where the EMT really can perform simple treatment and be called a hero.

The treatment is with a lot of slippery stuff: Skin caught in a zipper will release itself if given enough lubrication. The EMT can facilitate this by using trauma scissors to cut away the pants, which hold the zipper in maximum tension. If there is hair trapped in the zipper, trim it away also. Then apply a generous amount of mineral oil, lubricating jelly or ideally lidocaine jelly to the zipper and skin. Keep it moist throughout transport by applying more jelly. Often the skin will free itself by the time the patient arrives at the ED.

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