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EMS Pulse  January 1996  Part 2
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(4)  LETTER TO THE EDITOR:
       Charlie Foxtrot comes to Mass Casualty Incidents

       Editor, EMS Pulse:

	As a participant in a rather hairy MCI a few months ago, I would
like to offer a few comments in general about mass casualty incidents.
	A few months ago, my ambulance corps, Englewood (NJ) Volunteer
Ambulance Corps, responded to an MVA on Route 9W in Tenafly.  The accident
itself made the news -- a minivan with five passengers collided with a
souped-up Porsche, killing two in the Porsche and three in the minivan. 
My crew had the 11-year-old boy who was one of the five dead.  Needless to
say, there was not much we could do, except assess, bag the patient, while
ALS ran a quick tape for an on-scene pronouncement.
	All MCIs initially begin and sometimes continue as a Charlie
Foxtrot -- the polite way of saying clusterf**k.  One big problem is the
initial EMS crew on-scene does not institute the Incident Command System
and begin triage.  Each one grabs a different piece of equipment, heads
for a patient, and when mutual aid does arrive, no one knows what has gone
on up to that point.  In a similar incident in Englewood Cliffs, the scene
was chaotic, until a passerby, who happened to be a Fort Lee firefighter,
became Incident Commander by default.  The fire service uses ICS
constantly, and goes through a distinct chain of command -- chiefs,
battalion chiefs, captains, lieutenants, etc.  In EMS, especially in
volunteer communities, bullshit titles (captain, lieutenant, even crew
chief) are given, but when push comes to shove, they crack under pressure
due to lack of exposure to ICS.
	In paid municipal EMS circles, such as NYC*EMS, University
Hospital in Newark, or Paterson Fire Dept. EMS (of which I was employed),
this is not a problem.  In New Jersey's volunteer sector, however, the
volunteer squads are not up to the job of managing an MCI using ICS. 
There are always exceptions to the rule, but most squads simply do not see
enough MCIs, or for that matter, any scene where ICS is actively used.  No
matter how many drills are conducted, no matter how many ICS courses are
taken -- if ICS cannot be used constantly, to the extent that all crews
are completely familiar with ICS, there will always be Charlie Foxtrots to
deal with.

George Olschewski
NREMT-B, Clifton, NJ
<NickFury2@aol.com >
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(5)   KEEPING YOUR EDGE:

       BODY PIERCING: EMS Concerns

       by Jeffrey T. Reilly, EMT-P
       Chief of EMS
       Harrison, New York, 

       Medical Editor:
       Robert Leviton, MD
       Director of Emergency Medicine
       United Hospital Medical Center
       Port Chester, New York

	With the resurgence of freedom of expression and the changing
forms of youthful identity comes a new, subtle and challenging obstacle
for field EMS providers.  It is not the gross injury which makes patient
care a challenge, rather it is the unanticipated, rarer forms and sources
of trauma that challenge the skills of EMS providers.
	In the 60's the youth of America were putting flowers in their
hair to show 
the rest of the world that peace was the answer.  Today those young
Americans, not to mention youth in many parts of the world, are putting
shards of tempered surgical steel through their flesh in a similarly
expressive fashion.
	This article is not about freedom of expression, or about personal
choices.  I 
have two teenage sons, and I am proud to say I was a teenager in the late
'60's & early 70's.  I understand, and support the "why" in the equation. 
Rather, this article is about how to manage an airway with a steel prong
in it, how to use PASG with a patient who has pierced genitalia, and how
to remove a rod from the tongue of a patient with a compromised airway. 
Read on, you'll be surprised!

The Different Toys

	It is important to have a fundamental understanding of how things
like 
nose rings, labial studs and tongue rods are put together before one can
determine how to safely remove them.  I readily admit that I had no clue! 
I figured that an ear ring was an ear ring.  Unhook it, right?  Didn't
matter where it was placed, just unhook it!  WRONG!!

**Nose Hardware**

	There are basically three different types of jewelry used in the
nose. 

#1: The Hoop
	The hoop is no different than the jewelry found in an average ear.
 It is a closed circle with either a clip or a small clasp on one end. 

#2: The Stud
	The stud is slightly more complex, as it has a stationary flat end
and a threaded end that unscrews much like a machine bolt.  The stud has a
flat end as well as an end that has the screw fitting. The stud varies in
length from 1.6 mm x  8/10/12 mm up to 3.2 mm x 6/8/10/12 mm and is either
made from surgical steel or Niobium.  Proper jewelry for a labret is a
labret stud with a ball on the front held by a disc on the back.  Properly
sized, it should not cause any deterioration of the gums or lip.

#3: The chain
	The chain is customarily attached to either a stud or a hoop, and
attaches to another location on the face or body.

**Septum Hardware**

	The nasal septum is the most easily hidden and deceptive facial
piercing.  A staple-shaped retainer may be worn, which flips up inside of
the nose.  The original piercing is done with this retainer. Usually the
piercing is done in the thin skin between the septal nasal cartilage and
the flesh at the bottom of the nose, but for anatomical reasons peculiar
to some people, the cartilage must be pierced.  For obvious reasons,
patients with maxilofacial injuries involving the nose must have these
retainers removed by the EMS folks if the scenario does not involve what
appears to be a penetration into the skull.  If, penetration of the
cribiform plate or cranial perforation is suspected,  immobilize the
piercing as with any other impaled object.  Airway compromise is certainly
a concern and must not be overlooked or underestimated. 

**Nasal Bridge Hardware**

	This is a particularly difficult piercing, both from a clinical
point of view 
as well as from a prehospital removal perspective as well.  The jewelry
may actually cause a surgical fistula or direct communication between both
nares as well as the outside environment.  The potential for
hypoventilation or hypoxemia is greatly increased as the integrity of the
airway has been compromised.  Management of large "holes" in the nasal
septum and above may require the use of Vaseline gauze and a pressure
dressing to reintroduce temporary integrity to the external airway. 

**Tongue Hardware**

	Let's review some basic anatomy of the tongue.  As the potential
for complication exists most greatly for patients with tongue piercing, it
is important to thoroughly understand the vasculature of this organ. 
	You may recall that there are two major arteries as well as a
network of large diameter veins that run through the base of the tongue. 
Piercing of the tongue is usually, if not always, done in the midline of
the tongue, in order to avoid hitting the major vessels in the tongue.
This fleshy organ is extremely vascular, and as such predisposes a patient
with a pierced tongue to hazards not usually encountered by the average
patient. 
	For example, deceleration injuries, such as diving accidents and
most motor vehicle accidents will significantly increase a patient's
chance for gross hemorrhage, aspiration, airway obstruction and death
should the culprit -- in this case a surgical steel rod -- not be
recognized.  Do not dismiss the lacerations to the tongue as merely due to
biting of the tongue.  It is important to think of the possibility of soft
tissue damage and airway compromise resulting from a stud which has become
a projectile inside the mouth.  Loose pieces of flesh & blood must be
suctioned aggressively in order to maintain a patent airway.  Remember,
this foreign body may also be aspirated, so include additional airway
assessment including auscultating the neck for stridor.

**Theo / Scrumper**

	These are terms for the piercing through the frenulum of the upper
lip.  These terms are hardly official, and there are likely many local
names for this piercing.  There are two primary injuries associated with
this particular piercing. 
	The first obviously includes soft tissue damage from tearing, and
the secondary injury is associated with dental injuries.  Broken or
avulsed teeth are usually seen as prehospital complications and can either
be swallowed or aspirated, so beware!.

**Flesh Tunnels**

	Highly polished surgical stainless pop-in tunnels are placed in
ears, labia and scrotums, to create an adornment for stretched or
stretching piercings.  The depth of the tunnels range from 4 mm to 10 mm. 

**Magic Wands**

	A company named Asgerd manufactures a piece of "jewelry" named the
"Magic 
Wand" and each wand is custom-made for each client.  The so-called wand is
a super-smooth steel tube passed into the urethra, held in place by a long
stud to fit a special piercing through the tube and soft tissue known as a
"Prince Albert."  This pierce is almost always done on males and will be
very obvious when the patient's clothing is removed.  The decision to
apply or inflate the PASG should be questioned for a patient wearing this
type of piercing or a "flesh tunnel."  Caution must be exercised prior to
making the decision to inflate the garment.  Contact your Medical Control,
and advise them of the situation, particularly in a patient with suspected
genitourinary trauma or blood on the meatus  The recommendation would be
to leave this particular piercing in place as removal by inexperienced
hands may further exacerbate urethral damage.  However, follow the
treatment guidelines as developed and adjudicated by your local MAC.

**Removal Tools**

	Piercing Forceps:  These surgical steel clamps are available from
surgical supply houses, and should be considered an addition to your
armamenterium.  They have egg-shaped ends and they are excellent for
removing and stabilizing all types of piercing.  They are available in 7"
and 9" lengths.  The 7" is recommended for most applications and the cost
is roughly $15.00 each.

	Kelly Clamps:  The more common tool available to the EMS provider
is the "hemostat" or Kelly Clamp.  This clamp is readily available from
all Emergency Departments, and can usually be obtained for the ambulance
from your EMS coordinator or Medical Director.

**Treatment Guidelines**

	There are parts of the country where one may never see a pierced
tongue, and then again there are locales where it is commonplace,
therefore it is important for EMS providers and Medical Directors to
develop policies and guidelines for dealing with specific injuries caused
by piercings.  There are many cases where the piercing should not be
removed, and it is incumbent on us all to explore as many scenarios as
possible to come up with realistic and efficacious treatment modalities.
	Where removal is in fact indicated, the rod can be grasped with a
finger and thumb, and the rounded end grasped with the piercing forceps or
hemostat.  Unscrew the round end in a counterclockwise direction, then
pull the rod back through the flesh in the direction of the flattened end
of the piercing.
	As with any article contaminated with blood or body fluid, extreme
care must be exercised to avoid cross-contamination from the piercing. 
Should removal of the piercing be indicated, save it in a container for
further examination by the hospital staff.  Recommended containers would
include a small, one-time sharps container, a red top blood tube, specimen
tube or urine cup with screw top.
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(6)  CREDITS

Editor:                   William Storm, MA, EMT-D
Advisory:               Jeffrey T. Reilly, EMT-P; Chief, HVAC
                              Steven Kuhr, CEM, EMT-P; Deputy Chief, 
		     Queens Borough, NYC EMS
Medical Advisor:   Dr. Victor Cohen, M.D., FACEP;  Director, E.D., 
                                 St. Agnes Hospital, White Plains, NY 
Web Page Designer/Coordinator:  Scott Savett, NREMT
			 
EMS Pulse can be contacted by phone, mail, fax, or e-mail.: 

HVAC, Box #5 
2 Pleasant Ridge Road 
Harrison, NY 10528 
 
Phone:  (914) 921-0100 
Fax:      (914) 921-0102 
Internet:  Editor:   wasems@aol.com 
HVAC:  hvacems@aol.com 

Past issues available at our 
World Wide Web URL: 

<http://www.ncemsf.org/hvacnews.htm>

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Copyright 1996 Harrison Volunteer
Ambulance Corps, All Rights Reserved. 
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End  Part 2