Work Injury

Scene

Attack One responds to a report of a person injured at work. The call comes from the paper plant in the jurisdiction, where the crew has responded a number of times for minor injuries. This call comes in the middle of the night, traditionally a busy time for the plant. The crew is greeted by a security guard and guided to an interior corridor. At the other end of the corridor is one worker who is vomiting, and another sitting with his head between his knees. Your first thoughts are about toxic exposures, but the guard says, ¡§Those aren¡¦t the patient.¡¨

Through the noise of the machinery, you hear screaming, and down a side corridor you find the patient. He is a young male with his left arm trapped between two large paper rollers. He is in extreme pain, and there is a significant amount of his blood sprayed on the surrounding rolls of bright yellow paper. Several workers are trying to comfort him but are having difficulties not getting ill themselves. A supervisor is at the controls of the rollers, but due to the patient¡¦s pain, he is not operating the machine.

A rapid history reveals that paper apparently became stuck in the rollers, which are about 36 inches wide and compress with a force of several tons. As the worker attempted to remove the jammed paper, his glove caught in the rollers, and his left hand and forearm were pulled in up to the elbow. He was able to use the emergency shutoff to stop the machine. His coworkers and supervisor could not free his arm, so they reversed the rolling mechanism and attempted to push the arm back out. As they did so, the patient complained of extreme pain, so they stopped with the forearm still trapped above the wrist. As the injury occurred, blood sprayed from his injured arm, but as the Attack One crew?arrives, there is no active bleeding.

Impressions

The crew immediately requests a full extrication response. The patient is evaluated, and no other injuries are found. This is a healthy young man, but with his left arm still in the machine, he¡¦s in extreme pain. There are no further hazards present to the patient or crew. The supervisor states that the plant has done preplanning with the local fire department, but this machine cannot be opened using extrication equipment. The only method of removing the arm is by reversing the rollers. The patient, familiar with the machine, concurs and asks that the process be initiated as quickly as possible.

The crew agrees and begins treating the patient¡¦s pain. They quickly start a large-bore IV in the right arm and administer morphine. The supervisor tells them the rollers will take just a few seconds to roll the arm out. The arm at this point is not bleeding, but the Attack One crew prepares to control it if it starts by placing a blood pressure cuff¡Xwhich can be inflated if needed¡Xon the upper arm. A long armboard is prepared with a large dressing and towels for the lower arm and hand. The patient is prepared, the supervisor activates the machine, and the arm is extracted. The patient¡¦s glove is still caught in the machine, and it appears a little skin from the end of the middle and ring fingers has been amputated and remains in the glove.

The arm is now released, and the pain significantly reduced for the patient. No active bleeding is occurring. This injury is described as a roller amputation, with the skin being separated from the underlying muscle, tendon and bony structures. For this patient, the skin has been pulled off the end of the extremity and is hanging about 15 centimeters below the ends of his fingers. There is a crushing injury up the arm to just below the elbow. The skin appears dark and cool, and has little or no capillary refill. The patient places his arm on the board, dressings are applied loosely to the entire arm and skin surface, and a small amount of saline is used to dampen the dressings.

The Attack One members consult with the incoming heavy-rescue crew, who will be responsible for completing the removal of the worker¡¦s glove and tissue from the rollers. Once extricated, the glove and tissue will be brought to the hospital, in case any of the tissue is salvageable. Other incoming crews will evaluate and manage the coworkers who were sickened by the sight and sound of their colleague¡¦s injury.

Rapid transportation is provided to the local trauma center, which has an active hand-surgery service. While continuing pain control with morphine, the Attack One crew assesses the extremity during transport. They place a pulse oximeter on the ends of the skin from the fingers. The oximeter cannot find a pulse signal from any of the digits. The skin remains cool, and minimal capillary refill occurs over the more proximal portions of the skin.

Hospital

On arrival in the ED, the patient is assessed by an emergency physician and a hand surgeon. The injury is to his non-dominant left arm. Bony structures are not injured. Muscles are completely intact, but have been significantly crushed. Tendons are completely intact but exposed. Blood vessels are also exposed, but are not leaking. This is the most common finding in a roller amputation, as the elasticity of the veins and arteries allows them to stretch as the skin is moved off its usual site. When the injury is complete, the veins and arteries recoil and typically spasm so that no further active bleeding occurs. Nerves are usually left intact, and pain is significant, mainly from the crush injury to the muscles and bone.

The heavy-rescue crew later brings in the tissue found in the glove. The patient is taken to the operating room. A mid-forearm amputation is performed, because the crush injury to the lower forearm, wrist and hand makes them unsalvageable. Skin grafting is used to cover the remaining part of the forearm. A long rehabilitation period and prosthesis eventually allow the patient to return to work.

Discussion

The industrial setting can produce a variety of complex injuries. Extrication of workers from complex worksites requires significant interaction with those most familiar with the machinery. In this case, a preplan allowed the crews to understand what machinery could be spread, cut or moved using fire department extrication tools.

Roller amputations are devastating injuries. Most are not actively bleeding. They are often so ¡§dry¡¨ that significant parts of the anatomy can be identified. The crushing forces damage deep compartments of the extremity, and amputations often must be done because blood flow to the muscle cannot be restored. It is valuable to salvage as much of the skin as possible, because the skin and its supporting structures are more durable and can recover from a crush injury more readily than deeper tissues.

Pain control during extrication may allow for a more humane procedure. Many providers carry narcotic medications, and some carry sedative pharmaceuticals. This is the best time to use these medications. If medical control must be established per protocol, early contact will allow the hospital to provide timely direction and application of the needed medications. For extrications involving small areas of the body, like fingers or toes, local anesthesia using Xylocaine or bupivacaine can provide even more targeted pain control. These medications may not be stocked in the standard EMS drug box, but are available in every ED. If timeliness allows, it may be useful to have a physician respond to the scene to provide directed pain control using local or regional numbing agents, then completing the extrication. ƒÞ