Case Review: Eye-catcher

The patient opts to keep his eyes closed. He is seated on the stretcher in a forward-facing position, and the crew starts an IV line and administers morphine for pain and ondansetron for nausea. They initiate transport, with the driver working to achieve a smooth but expedient ride.

En route, they contact medical control and confirm each of the steps used to keep the patient’s head upright and eyes at rest and reduce nausea. They will contact the trauma center and have them decide about communicating with eye specialists. The patient continues to be very uncomfortable on the trip, and the crew gives him another dose of the antinausea medication.

Hospital Course

The man arrives in the emergency department stable. Crew members share the history and examination with the emergency nurses and physician, and carefully move the patient to the ED stretcher. The emergency physician has consulted the eye specialist on call, and both do an initial evaluation of the injured man. The injury to the front of the eye is obvious, but a quick set of x-rays determines the injury is actually much more extensive. A piece of metal from the fishhook, measuring almost 2 inches in length, has penetrated all the way through the eye and is sitting in the middle of the skull. The tip of the metal is stuck just in front of the brain stem, and the blood from that injury is causing the headache and extreme vomiting.

The injury will require the work of a team of eye specialists, with assistance from a radiologist, a neurosurgeon and an ear, nose and throat specialist. The team is assembled in the emergency department before the Attack One crew is ready to go back in service. They make an unusual request of the Attack One crew leader, asking if the crew can find a resource person to get a specimen of water from the area where the injury occurred. They will use that information to give the patient the right antibiotics to combat any infection. The Attack One crew contacts a representative of the Department of Natural Resources, and using information from the victim’s friend, they obtain a lake specimen later that day.

The patient goes to surgery and, in a complex procedure, has the fishing line and remnant of the fishhook removed from his eye and skull. Several eye specialists work on his eye, repairing the front portion where the line was in place. Another specialist works on the back portion of the eye, the retina, where light is actually processed and converted into signals the brain can process into what we call vision.

After a complicated recovery and an infection of the area around the brain (meningitis), the victim recovers his health and some vision in his injured eye. With corrective lenses, he maintains normal vision.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and a member of the EMS World editorial advisory board. Contact him at jaugustine@emp.com.