Location: SEMS HQ
Time: 11:10 Wednesday
Conditions: Overcast and wet
Equipment: fully stocked
Dispatch
You’re relaxing at the base, touching up the shine on your boots. Steve is snoozing on the couch across from you, and the crew of the P4 is outside giving their truck a bath. Then the overhead speakers tone out, and the radio crackles… (click for audio)
[Ambulance 61, respond priority 1 to 267 Beacon St; 2-6-7 Beacon, between Philips and Hamlet St, for a 51-year-old male, conscious and breathing, with a hand laceration. Response with Engine 1. A61?]
- Click to expand
Response
“I’m guessing pillow fight injury,” you quip. Steve is already halfway out the door; the dude has a miraculous ability to wake instantly at the sound of the tone.
Out you go, hitting the street just after the engine a block away. It’s only a minute or two until you’re pulling down Beacon to find a nice two-story home, the engine parked out front. Cars line both sides, so Steve just parks behind the engine, which is already blocking the lane.
He grabs the stair chair, you bring the first-in bag, and you tromp up the steps. The front door is open.
Scene
Inside, you find the fire department loitering around a fairly nice kitchen. A middle-aged gentleman is lying on the floor, eyes open, head resting upon a folded blanket, and a rag is wrapped around his right hand. A woman (wife?) and a younger man (son? brother?) are in the room as well.
“Hi folks. What’s happening?” you ask as you set down your bag.
“Cut his hand,” the lieutenant says.
Initial Assessment
You kneel beside the man and make eye contact. “Hey! I’m Sam.”
“Dave,” he answers easily, meeting your gaze.
“What happened?”
“I cut my thumb on a saw.”
“A saw? Like a hand saw?”
“Table saw.”
While you chat, you find his uninjured left hand and palpate a radial pulse. It’s somewhat weak, regular, and his skin is warm and dry. He’s breathing easily and there’s no other frank injury.
“Mind if I take a look?” you ask.
“Sure.” With a gentle touch, you unwrap the rag. His right thumb has about a 1.5cm laceration running diagonally across the pad. It’s a millimeter or two in depth, with wound edges pulling apart, but it’s mostly dry and bleeding seems controlled. There’s no gross contamination.
The rest of his fingers are on the cold side. Capillary refill is perhaps a little slow. He wriggles his digits for you, and when you pinch, he has normal sensation in the others, but the thumb seems a little numb.
“All right, let me just wrap that up for you.” You place a folded gauze 4×4 over the laceration and start wrapping a 2″ roller bandage around to secure it. Once it’s thick enough to satisfy anybody’s gauze fetish, you cut off the remainder with your shears and pat the end into place. It holds fine with no tape.
While you bandage, you ask, “How did you end up on the floor?”
“I was downstairs, working on a table I’m making… I build furniture… and I laid my hand down on the blade. I put that rag on it and felt dizzy, so I sat down, then when I felt a little better I walked here… but then I got really light-headed again and I fell here.”
“Fell? Did you pass out?”
“No… I don’t… no, I just went down, and I figured I’d stay here until you showed up.”
“Did you hit your head?”
“No.”
“Okay. Anything hurting you now besides the thumb? Head, neck, anywhere?”
“Just the hand.” You palpate the posterior of his head and neck, finding nothing remarkable.
“What kind of medical history do you have?”
“Uh, nothing much… high blood pressure. High cholesterol. I had Lasik done a couple years ago.”
“Taking any medications?”
“Simvastatin and Lisinopril.”
Steve comes up behind you and hands you a card. “I got ’em.” It says:
David Cohara
7/7/62
Lisinopril
Simastatin
Aspirin 81mg
ALL: Penicillin
“Thank you sir.”
You look down at David. “All right, what do you think? Shall we visit the hospital?”
He chuckles at you. “Probably should, huh?”
“Yeah, I think they’re gonna need to do something about that. Is there somewhere you usually go?”
“Not really.”
His wife chimes in: “How about Memorial? My sister works there.”
You look at David, and he nods. “Okay, sounds good to me,” you agree.
“I’ll follow you guys with my car,” says the wife.
“Any numbness or tingling in your hands or feet?” you ask David.
“Nah.”
“Squeeze my fingers?” you offer him some fingers, which he squeezes with his uninjured digits. There’s equal strength on both sides.
“Push down against my hands?” you let him plantarflex against your hands, then — “Pull up?” dorsiflex. Strength is equal bilaterally.
“Turn your head left and right for me. Feels okay?” he freely rotates his head 45 degrees, noting no pain.
“Right on. Are you feeling okay to walk out there?”
“Uh, I think so.”
“Okay, let’s try getting up. Just do me a favor and press down on that thumb, okay? Pinch with your fingers there.” He makes an “A-OK” hand-sign, applying pressure to the cut. Then you and Steve help boost him to his feet. You’re right there to catch him if he goes down, but he seems okay; you shepherd him outside, and SFD grabs your bags for you.
At the truck, you help him climb inside, then sort him out on the stretcher. Once he’s strapped in, you give Steve a thumbs-up. “Memorial on a 3.”
As the truck pulls away, you take a moment to reassess the thumb. Blood is visibly seeping through the gauze. Sigh. You grab some more gauze and wrap it a bit more, trying not to create a gigantic franken-thumb that merely hides the problem.
“Push down hard on that, okay? Right where the cut is. I know it probably hurts. And just hold it up like that.” You position his hand elevated above his head, resting against the stretcher while he holds pressure. Looks like he’s casting a spell.
Using his other arm, you capture some vitals. He’s got a pressure of 128/68, pulse of around 84, breathing 16 a minute. Compelling stuff.
The thumb still looks okay, so you grab the radio and hail Memorial Hospital with this note (click for audio):
[Memorial, Scenarioville A61. We’re coming in with a 50-year-old male, laceration to the thumb from a table saw. Pretty good cut but no structural damage. Bleeding is mostly controlled, vitals stable, no other injury. Seven minutes out. Questions?]
“No thank you, we’ll be waiting 61!” replies a needlessly perky voice.
You chat with David about his carpentry for a bit, and as you’re pulling down the road to Memorial you take another look at the thumb. Once again, a red blotch is starting to creep through the gauze. Probably no big deal, but you ask him to grab the thumb with his other hand for some better pressure and squeeze the heck out of it.
As you roll in, they send you to a hall bed. David sits himself down, and a tech shows up helpfully to offer a procedure tray he can rest his arm upon for comfortable elevation.
A young ponytail-girded female RN you haven’t seen before strolls up. “Hi guys!”
Steve, who was rolling the stretcher away, stops to tip his hat. “Ma’am.”
You offer: “Salutations! We come bearing patients.”
“Oh good, we love those. Who’s this?”
Click for audio: “This is David Cohara, he’s 50. Was building a table and put his hand down on the table saw, opened up a 1 or 2 centimeter lac right across the pad of his right thumb. Decent amount of bleeding but nothing dramatic, maybe a millimeter or two deep, pretty good separation on the edges. He got lightheaded, walked upstairs, then kinda felt weak and went down, and just decided to chill on the ground until we got there. Didn’t hurt himself or anything in the fall. Vitals are good, no real history except hypertension and cholesterol, takes a baby aspirin, simvastatin, lisinopril. Some numbness in the thumb, fingers are a little cold, having some trouble getting it to stop oozing. Doing okay otherwise.”
“Okey doke,” she says. “Hi David, I’m Cynthia. Keep some pressure on that, the doctor will come take a look in just a second.”
You say your good-byes and wander out, where you’re collared by the registration lady with a computer-on-wheels. By the time you escape to the bay, Steve has the stretcher sorted out and he’s smoking in the parking lot.
“Ma’am? What are you, a cowboy?”
“Did you say ‘sontimeter’?” he retorts. “Anyway. She’s cute.”
“And you’re married, you dirty old man.”
“I was a gentleman.”
You suppose. “Just stay away. Tricia has my cell number and she scares me.”
“She scares me too,” he admits. “Makes a hell of a pot roast, though. I guess I’ll keep her.”
“What’s it been now, twenty years?”
“Twenty two. It’s good pot roast.”
Discussion
Diagnosis: simple laceration
BLS doesn’t get much more straightforward than small lacerations that don’t penetrate or cross significant structures, such as veins, arteries, tendons, or delicate areas like as the eyes. Injuries to important functional areas like hands shouldn’t be taken lightly, but a cut like this will most likely get closed in the ED and sent home. Consider the presence of any anticoagulation, and remember your basic first aid — direct pressure, and perhaps some judicious elevation or pressure points. (The latter two have been deemphasized from trauma care due to poor evidence for their effectiveness, but for minor injuries like this they’re a perfectly sensible approach.)
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