Case of The Month

CASE OF THE MONTH – March / April 2025 – Printing Error

Case Presentation

At 1100 on a weekday, 911 dispatch notified the fire department of a person with “hand stuck in a printer.” Upon arrival, firefighter/paramedic crewmembers discovered a middle-aged man crouched in a narrow gap between parts of extensive, 8-foot-tall printer machinery, with his right arm entrapped between two printer rollers. Clearance between the rollers was less than a centimeter. Efforts at self-extrication prior to EMS arrival had further ensnared his arm such that it had been drawn through to just distal to the elbow. Devitalized tissues and bone fragments were visible adherent to the heated roller on the other side of the machine.

Additional rescue resources and heavy equipment were immediately requested; but the limited physical space between machine towers rendered the patient poorly accessible to rescuers and their equipment. The patient was able to insert his own unaffected hand to support the affected elbow and entrapped forearm but was unable to sit down or lean against other machinery to support himself. The initial medic unit noted bleeding from the crush site and applied a tourniquet at an accessible area just proximal to the elbow. Fire personnel were positioned next to and above the patient to support him. Paramedics established IV access in the unaffected arm and in an external jugular vein and administered Fentanyl for pain relief per Treatment Protocol 1244, Traumatic Injury  and MCG 1345, Pain Management. Paramedics established IV access in the unaffected arm and in an external jugular vein and administered fentanyl for pain relief per Treatment Protocol 1244, Traumatic Injury.

Despite attempted use of pneumatic spreaders, the industrial rollers could not be moved sufficiently to facilitate release of the entrapped extremity. The patient was awake and the owner of the facility informed response personnel that the machine was not designed for local disassembly. Brief consideration was given to cutting through the printing press. However, fire personnel on scene recognized the print shop from a previous response in which accidental ignition of a cleaning solvent had required significant fire suppression activities in the heavily machine-crowded facility. It was determined that efforts to cut through the metal could produce further injury to the patient and responders. Paramedics therefore opted to activate the Los Angeles County Hospital Emergency Response Team (HERT) to provide on-scene surgical expertise from a local trauma center.

Question: What elements of the case indicated the need for HERT activation. Select ALL that apply.

1. Entrapped patient
2. Prolonged on-scene care
3. Suspected need for amputation
4. Traumatic injury to an extremity

Explanation: HERT activation is indicated for entrapped patients and/or those who are anticipated to need prolonged on-scene care and/or advanced procedures (including amputation or procedural sedation) to facilitate their rescue and prevent worsening clinical status during and after extrication.

The fire department’s EMS medical director (EMS MD) was simultaneously notified and responded to the incident location, assuming on scene medical control pending HERT arrival. With the EMS MD on scene, additional pain medications were administered per physician order beyond the max permitted per treatment protocol. A second tourniquet was also placed between the elbow and the injury site with cessation of residual bleeding. The HERT, comprised of a Trauma surgeon, and Emergency physician, and a trauma-trained nurse, arrived on scene approximately 1 hour after the initial 9-1-1 dispatch, and assumed medical control at that time, under the fire department’s incident commander.

Question: True or False?  An on-scene EMS Agency Medical Director can provide real-time medical orders. However, these orders need to be approved by the Base before they can be carried out.

Explanation: False. Per policy 816, Physician on Scene, an Approved EMS Physician (including those from the EMS Agency, Provider Agency Medical Directors, EMS Fellows from LA based fellowship programs, and Base Hospital Medical Directors) can provide online medical direction in lieu of base hospital contact.

Question: Once the HERT has been activated, approximately how long can you expect it will take for them to arrive to the incident location.

1. 5-10 minutes
2. 15-20 minutes
3. 30-40 minutes
4. 60-80 minutes

Explanation: It is expected that HERT members, who often deploy from home or are working in the ED and have to hand-off care for their patients prior to leaving the hospital, will have all equipment and medications and be ready for pick-up within 20 minutes of activation. Transport to the scene can occur by ground or air, with transport time ranging from 10 to 20 minutes, depending on location.

HERT assessment concurred that amputation was indicated, and the patient was verbally consented for the procedure while the HERT nurse administered the antibiotic cefazolin for infection prophylaxis of the open fracture. Given the absence of significant blood loss and the heat-crush mechanism of injury, the surgeon on scene loosened the tourniquets. Meanwhile, the HERT ED physician and fire personnel discussed optimal positioning and preparation for the amputation. All parties agreed that sedation and anesthesia would facilitate the amputation. However, the poorly accessible space and standing posture of the patient presented an obstacle to active airway management. In addition, continuous pulse oximetry was unobtainable due to a thick covering of printer ink on the patient’s unaffected hand and face that prevented appropriate register of the waveform. In the absence of reliable oxygen monitoring and the emergent need for intervention, side stream (nasal) capnography and visual inspection were the available methods for airway monitoring.