The Quiet Ones Dying

   It's a beautiful afternoon when Attack One responds to a report of a "house that exploded." The crew pulls into a recently completed neighborhood of two-story family homes. Crew members have performed several walkaround tours of the nice homes in the neighborhood, and are aware that they all have one unusual feature: propane heating systems.

   There are at least four victims, along with some bystanders, and several of the victims are screaming. One is lying on the ground near the home, very quiet. The second paramedic on the crew immediately moves toward that victim, but it's not until he reaches him that he notices the patient's right leg is missing. The victim is severely burned, with signs of trauma to his chest and abdomen, and his leg has been amputated below the knee.

   The crew leader reports a multiple-casualty incident due to the explosion, and requests additional EMS resources and law enforcement control of a wide perimeter. His last exploding-house incident was caused by an illegal drug lab in the basement, and he wants to protect against any risks to his crew. They quickly determine there are just the four victims, no one else is in the home, and the incident was likely the result of a gas explosion, because the worst-injured victim is a worker who was at the house trying to fix a gas leak.

   The EMT has moved quickly to the victims who were screaming on the crew's arrival. His quick triage work and report to the crew leader allow appropriate calls for additional ambulances. One victim has an injured hand, another an injured leg. A third victim complains of difficulty breathing. All are moved quickly away from the house, where fire crews work to extinguish the fire.

   The EMT organizes the care of the three lesser-injured victims while the two paramedics rapidly initiate treatment of the man with the amputation. The second paramedic works quickly through the care. He applies a tourniquet to the leg and stops the bleeding. Knowing intravenous access will be difficult to secure, he administers a dose of morphine through a mucosal atomization device in the nose. He inserts an endotracheal tube and begins assisting ventilations with oxygen. The man has burn injuries to both arms and is in frank shock, so the paramedics insert an intraosseous device and begin fluid resuscitation with warm saline. They cover the patient's burns and prioritize him for transport to the regional burn center.

   The crew then organizes care of the remaining three victims, whose injuries are less severe. They establish a rehabilitation area for the ongoing firefighting operation, and arrange for counseling resources for neighbors shaken by the appearance of the badly injured man.

Hospital Course

   On arrival at the burn center, the burned and injured patient is unstable. It is difficult to ventilate him, and the lead surgeon decides to perform a surgical procedure called an escharotomy to release the compression of the burned skin on his chest. Once this is accomplished, the patient will be much more easily ventilated. He is taken to the operating room, where he has multiple procedures done, including a cleanup of his right leg. He has a series of followup operations, then burn care and rehabilitation.

Case Discussion

   The crew discussed the case when they arrived back at the station late in the day. The lead paramedic found the care provided by the second paramedic to be exceptionally well-organized, and the EMT was amazed at how that paramedic, upon arriving at the scene, had decided immediately to go care for the critical victim, bypassing the other victims who were much more verbal.