By Dr. Ken Lavelle, MD, NREMT-P
When confronted with a firefighter injury, we could very easily just choose to transport the firefighter to the hospital. But in some locations in the country, the hospital may be quite far from the scene, and EMS resources may be limited. Not every injury requires a trip to the hospital. If the firefighter suffered a minor injury at home, they would likely not call an ambulance for evaluation. But since they are on the fireground, they are often referred to the EMS that is present for evaluation.
Unfortunately, evaluation and disposition of minor injuries is something that the average EMS provider is not trained in. We offer transport and basic first aid, but often leave disposition to the physician in the emergency department — and that makes sense to reduce liability in light of limited training. But maybe there are some injuries we see that could either wait for treatment or not require going to the hospital at all. Let's explore some.
Lacerations are not uncommon at a fire scene. There are plenty of sharp edges and sometimes shortcuts are taken and proper PPE is not worn. The first priority for the EMS provider assessing a laceration is to make sure nothing more serious is going on. Ensure that the obvious injury did not occur from an extreme mechanism of injury such as a fall from height. Next, determine if the bleeding is life threatening. Is an artery involved? Arterial bleeding typically is spurting briskly. If it is, apply immediate direct pressure, and if it is an extremity, elevate it. If there is any difficulty in getting the bleeding to stop, apply a tourniquet. These injuries require immediate transport.
If the bleeding is stopped and there is no serious mechanism of injury, then we have some time. Stitches can be placed with a delay of up to six hours after the injury without any significant harm. The need for stitches is indicated if a wound is "gaping" — the edges are spread apart. We typically place stitches for one or more of three reasons — to control bleeding, to minimize infection and for a better cosmetic appearance. A wound that is very shallow and that has the edges back together may not need stitches. If there is any doubt, recommend transport — but the patient may refuse. The firefighter — or EMS — may also wish to delay transport until there are more resources or the situation has been stabilized. As long as there are no life threatening conditions present, this is reasonable.
In any case, wounds should be copiously irrigated. Tap water is fine, but if you have sterile water, it can be used. Irrigation is the most important action that can be done to reduce the risk of infection. Quantity and pressure are the keys. If you are an ALS agency, a normal saline bag or sterile water bottle can be used with several holes placed in the bag or bottle with an 18-gauge needle. Then squeeze the bag so jets of water come out into the wound. Move around and cover all areas of the wound at multiple angles. Use at least several hundred CCs.
Next, dry the wound and place a bandage. If there is oozing from an extremity, a pressure bandage can be applied to help control bleeding. If the wound is significant — more than just a superficial, small cut — and transport is being delayed, then this firefighter should probably be restricted in his or her duties for the duration of this fire. Active firefighting could worsen the injury, and the injury may hinder the ability of the firefighter to perform regular duties.
Even in firefighter boots, an ankle sprain is possible. The more mobile a joint is the higher the risk of injury. The ankle can move around quite a bit so it is more susceptible to injury than many other joints. Often the mechanism is a twisting of the ankle, usually inward rotation of the foot, or "inversion." In this case the lateral (outer) aspect of the foot is toward the ground during the injury. Eversion — where the medial or inner portion of the foot is toward the ground — is possible as well, but less common.
Ankle injuries are so prevalent that emergency physicians explored the possibility of coming up with a rule to figure out which injuries needed radiographs and which did not. The set of rules formed are called the Ottawa Ankle Rules. These are not designed to be used by EMTs and paramedics — though in my opinion they could be — but it does give the EMS provider some insight into which patients should really be encouraged to go get radiographs and which may be permitted to refuse with less persuasion.
In the ankle there are two bones that stick out a bit. These are the medial and lateral malleoli. They are the distal portions of the tibia and fibula, respectively. In brief, the rule states that radiographs should be done on any patient that has pain in the area of the malleoli and has bony tenderness — pain on palpation — at either malleoli. Also, if the patient is not able to bear weight on the injured extremity, radiographs are indicated. The purpose of radiographs is to rule out a fracture. There can still be significant swelling in a sprain, which is a non-bony injury to the soft tissues of the ankle.
A patient with severe pain or suspicion of fracture should have a splint of some sort applied. The foot can be elevated to reduce swelling, and the patient can be transported to the hospital non-emergently when convenient. A patient who does not want to go to the hospital and does not meet the above criteria can have ice applied and an ace bandage wrap. They should not participate in active firefighting, as the injury — even if minor — can hinder their ability to do their duties. In addition, the ankle is now less stable, and they are at risk for more serious injury.
These are just a couple of the more common minor emergencies that EMS may experience not only on the fireground, but anywhere. As always, follow local protocol, but discuss various options with your medical director to ensure that the fireground is covered with adequate EMS resources without possibly worsening the injury of the firefighter.