An EMS Review of the 12 Days of Christmas

In 1909 Frederic William Austin published the standard melody for the holiday classic “The Twelve Days of Christmas.” You may sing this and many other holiday carols with great glee during December, but is your unit or agency fully prepared for the potential holiday trauma and illness that could come with the “12 days of Christmas”? Hitch up your ambulance sleigh, stuff your stocking full of oxygen masks, gauze, and meds, and get ready for a quick review of holiday responses!

On the first day of Christmas, my true love gave to me a partridge in a pear tree.

Pear and apple trees are not particularly toxic, nor are their ripe fruit. The seeds contain amygdalin, a glycoside that can release cyanide. You’d have to eat a lot of seeds to get cyanide poisoning by this route. However, let’s assume for a far-fetched moment that your holiday patient consumed a lot of pear seeds, leading to cyanide toxicity. Prehospital treatment would include supporting their airway, breathing, and circulation. ALS units can consider benzodiazepines for management of seizures if they occur.

On the second day of Christmas, my true love gave to me two turtle doves.

What if those turtle doves were infectious? It is rare that birds will pass avian flu onto humans, but it happens. If it does, mortality rates are high. Symptoms of the avian flu can include standard influenza symptoms (fever, chills, cough, sore throat, muscle aches, headaches), as well as severe pneumonia, acute respiratory distress, severe diarrhea, bloody nose and gums, encephalitis, seizures, coma, and death. From an EMS perspective, wear full PPE, support the ABCs, and provide comfort such as warming and positioning, similar to moderate COVID patients. Definitive care involves antiviral drugs.

On the third day of Christmas, my true love gave to me three French hens.

French hens lay 150–200 eggs a year. If eggs are not fully cooked when ingested, they pose the risk of salmonella, a bacterial infection. Symptoms of salmonella infection include diarrhea, vomiting, fever, abdominal cramps, and associated dehydration. While salmonella infections typically don’t require hospitalization, if a patient has a high fever, altered mental status, or is unable to rehydrate themselves to the point of becoming severely dehydrated, they may call EMS. Treatment would include ABC support and, if ALS, IV fluid rehydration.

On the fourth day of Christmas, my true love gave to me four calling birds.

Some of these calling birds don’t understand when they should call 9-1-1 for EMS and when they should not. One might even argue they are “frequent flyers” (see what I did there?). A referral to social services or law enforcement might be helpful in a situation where you have frequent unneeded calls for service.

On the fifth day of Christmas, my true love gave to me five golden rings.

In the event of trauma or a burn to a phalange, it might be necessary to cut a ring from a finger. While lubricating the finger with some kind of soap or oil might work, you do not want to risk infection if there is an open wound. A ring cutter works well to remove rings. Some are now even battery-operated, and if they’re used properly, jewelers may be able to repair the cut rings.

On the sixth day of Christmas, my true love gave to me six geese a-laying.

When you think of geese, as much as you’d like to think of them flying in beautiful formation, you probably think of goose poop, the awful byproduct of having flocks nearby. Goose poop contains E. coli, a bacteria that can cause severe infection and even death. For treatment see the salmonella treatment above.

On the seventh day of Christmas, my true love gave to me seven swans a-swimming.

If you have someone who goes swimming and goes under in below-freezing temperatures and requires resuscitation, remember the old adage, “They aren’t dead until they’re warm and dead.” While you most likely will not be able to rewarm them enough in the prehospital setting, measures to prevent further heat loss while performing effective high-quality CPR are paramount. These include removal of wet clothing, application of blankets, and use of warmed IV fluids. Constant monitoring of the EKG is essential, and in cases of cold-water drowning, transport to a hospital for appropriate rewarming is critical while high-quality CPR is performed.

On the eighth day of Christmas, my true love gave to me eight maids a-milking.

Milkmaid’s elbow or nursemaid’s elbow is a common injury for toddlers up to age 5 or 6. It happens when a ligament slips out of place and gets caught between two bones of the elbow joint. It is painful and can be caused by jerking or lifting a child by the arm or having them fall in an awkward way. They will present in pain and unable or unwilling to move their arm. While prehospital treatment is the same as a fracture, at the hospital a physician will most likely be able to quickly diagnose and fix the problem.

On the ninth day of Christmas, my true love gave to me nine ladies dancing.

What if one of those dancing ladies turned an ankle, resulting in a sprain or fracture? Immobilize the limb using a pillow or blanket splint and apply ice. Assess distal circulatory and neurological function before and after splinting.

On the 10th day of Christmas, my true love gave to me 10 lords a-leaping.

Just like those ladies dancing, those leaping lords could suffer falls that cause severe wounds. For uncontrolled severe bleeding in an extremity, a tourniquet placed high and tight would be appropriate. If the wound is in a junctional area such as a neck, shoulder, or the groin, wound packing with hemostatic gauze is indicated, followed by rapid transport to a trauma center.

On the 11th day of Christmas, my true love gave to me 11 pipers piping.

While I assume good intent with most pipers, what if one of those pipers were inhaling instead of exhaling? What if their pipe were filled with a large dose of opiates? Signs and symptoms of an opiate overdose include unusual sleepiness or lethargy; breathing problems that include slow, shallow, or absent breathing; and pinpoint pupils. Evidence of drug use such as pipes, track marks, or needles should increase your index of suspicion. The treatment of choice would be respiratory support and CPR if they are not breathing and pulseless, followed by administration of naloxone.

On the 12th day of Christmas, my true love gave to me 12 drummers drumming.

What if these drummers drummed so loudly that they caused temporary or even permanent hearing loss? As an EMS provider you may not be exposed to drums, but you are exposed to a great deal of noise at high decibels, including sirens, engines, power tools, pagers, and more. Whether you are near drummers drumming or sirens a-sounding, protect your hearing and minimize your exposure.

In addition to the illness and accidents possible from these 12 days of Christmas, here’s hoping you don’t have any fireplace burn injuries, elf trauma, or sleigh MVAs during your holiday season. Be safe, everyone!

Resources

Bachenheimer B. Hearing Loss in EMS. EMS World, 2018 Jul 20; www.hmpgloballearningnetwork.com/site/emsworld/article/220850/hearing-loss-ems.

Centers for Disease Control and Prevention. Salmonella and Eggs, www.cdc.gov/foodsafety/communication/salmonella-and-eggs.html.

EMS World. Bird Flu Basics: An EMS Guide for the Avian Flu, 2005 Dec; www.hmpgloballearningnetwork.com/site/emsworld/article/10364813/bird-flu-basics-ems-guide-avian-flu.

Gracia R, Shepherd G. Cyanide poisoning and its treatment. Pharmacotherapy, 2004 Oct; 24(10): 1,358–65.

Harries M. Near Drowning. BMJ, 2003: 327; https://www.bmj.com/content/327/7427/1336.full.

Pitone ML. Nursemaid’s Elbow. Nemours Kids Health, https://kidshealth.org/en/parents/nursemaid.html.

Stop the Bleed, www.stopthebleed.org.

Barry Bachenheimer, EdD, NREMT/FF, has been active in EMS and fire for 35 years. He is a frequent contributor to EMS World.