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CASE REVIEW | By James J. Augustine, MD, FACEP THE DAY IS cold, and an early-season snowstorm has had the white stuff accumulating for about 16 hours. The streets are largely quiet, since most of the schools and some businesses have closed. There were few emergencies during the day, but a large number of medical transports. The afternoon saw the snow inten- sify. The Attack One crew ate a late lunch, anticipating a busy evening. The station alert is activated, and they are to respond for a "person injured." Additional information indicates the patient is a man with an injury from a snowblower. The crew marks on the scene to fnd the patient sitting in a garage with a bloody towel around his hand and a tourniquet around his right forearm. A neighbor placed the tourniquet near his wrist, using a piece of a kitchen towel. A large old snowblower is nearby. The patient is in signifcant pain but able to speak. He says he'd just repaired the snowblower and was using it to clear snow that had blown into his garage and onto the narrow strip of sidewalk between his garage and his neighbor's. He strayed into some grass and other debris and had some material get caught inside. He used his gloved hand to try to remove the material, and his hand was drawn into the rotating mechanism. "It all happened quickly," he says, "and my hand just got pulled in. It really hurts, mostly where the tourni- quet is. I need that hand for my job." The Attack One EMT is good at calming patients, so he takes a position talking with the man while the paramedic removes the towel from the hand and examines the wounds. The EMT asks the patient about his medical history and his job to distract him for a few minutes. The fngers are badly injured. The worst harm is to the ring and the ffth fngers, with lesser injuries to the others. The paramedic pulls an intravenous splinting board from the frst-in bag and layers some gauze on it, then places the fngers carefully on the fat surface. All of the wounds are easy to visualize, and in his judgment the tourniquet will not be needed to control bleeding. He cuts it off the forearm, and the patient reports immediate reduction in pain. There is barely any oozing of blood from the wounds, so the tourniquet will not be needed for further care. He shields the patient's view of the hand using a towel. "Tell me when you can feel me touch your fngers," he instructs. One by one he checks the fngers, starting with the barely injured thumb. The man has no problem feeling the ends of his thumb and index and middle fngers. All three of those have lacerations and injuries to the ends of the fngernails. There are bits of glove and grass in the wounds. The patient reports no sensation at the end of the ring and ffth fngers. Both have deep lacerations and skin torn away, and the middle phalanx (bone) in the ffth fnger is broken and angled at 90 degrees to the bottom of the fnger. The nails are in place, but the fngers are badly damaged, and there is grass and glove material mixed in the wounds. It is the patient's right hand, and the paramedic assumes the patient is right-handed. If the patient is already worried about his job, this could be a devastating injury. "What kind of work do you do?" he asks. "I'm a design engineer, and I craft building models," the man replies. But he uses his left hand to gesture about how he shapes Styrofoam and fabrics. "A re you lef t-handed?" the paramedic asks. "I am," the man answers. "That is fortunate," the paramedic responds. "This right hand is going to take a little time to get healed, but we have a great set of hand surgeons in the city, and they will take good care of you. We are going to give them the best chance by cleaning all the debris out of the wounds, straight- ening out the fngers, putting them in clean dressings, giving you some pain medicine, and taking you to the hospital with the best hand-injury services." The paramedic quietly thinks to himself that it's fortunate this patient's left hand is dominant. Most of the time the dominant hand is the one injured in snowblowers, lawn mowers and garbage disposals. A 28-year-old man in pain with a mangled hand. He also complains of dizziness. Airway: Patent. Breathing: No distress. Circulation: Poor capillary refll in several digits of the right hand. Disability: No compromise of neurologic function. Exposure of Other Major Problems: Nondominant right hand injury from a snowblower. Additional problem found with elevated carbon monoxide level. VITAL SIGNS Time HR RR Pulse Ox. 1546 120 28 99% 1555 116 24 100% 1604 110 20 100% AMPLE ASSESSMENT Allergies: None. Medications: None. Past Medical History: No signifcant medical problems. Last Intake: Ate about 4 hours prior. Event: Mangled hand and partial fngertip amputation in an accident involving a snowblower. INITIAL ASSESSMENT Hands Down A snowblower accident mangles fingers—but what else is going on? 20 DECEMBER 2014 | EMSWORLD.com