Fence Splitter

The patient starts crying and wondering if he has done any long-term damage. “We can’t tell you anything about that,” the medic says, “but they will examine you fully at the hospital and be able to give you a better answer.”

The crew now moistens a couple of dressing pads with warm saline. They put them up against the man’s inner thigh to let him confirm that they are warm enough, then carefully place them over the scrotum and testicles. They place some clean absorbent pads below the man and ask him to relax the area with his legs apart as they transport him to the hospital. They place a quick call to the emergency department to advise them they are en route with a man in custody and give a basic description of the injury.

The transport is very quiet. A young man who was very mean and mouthy is now remarkably silent and tearful. He asks once if some more warm water can be placed on the dressings, and the paramedic carefully does so.

On arrival in the emergency department, the staff members carefully remove the dressings. The wound is now clean, and during the transport the testicles retracted back inside the skin. The emergency physician and nurse take quite a bit of time warming some fluids, irrigating the wound and separating the skin so the testicles can be examined directly. There is no further bleeding, the clots can be irrigated away, and the physician reports to the patient that the testicles have fortunately been spared of any obvious injury.

There is even more good news over the next few hours: ED testing finds no injury to the man’s urinary tract, and he is taken to the operating room, where the trauma surgeon carefully closes the wound, finding no other damage to the genitals.

The patient makes a full recovery, although he has a large scar in an uncomfortable place. His trip to the courtroom also results in some discomfort.

Case Discussion

Certain injuries make EMS providers cringe, and the genital injury in this case certainly fits that description. With both males and females, there are several types of injuries to the pelvic area that require careful management.

This case describes an open injury from a cutting object. These injuries require providers to clean out any dirt, stop hemorrhage and preserve tissue using moist dressings. Direct cold exposure to the testicles should be avoided.

Blunt injuries can occur to the pelvis with painful and sometimes devastating consequences. Bones and soft tissue can be damaged from “straddle” injuries. These commonly happen on bicycles or other athletic equipment. Painful pelvis fractures can occur in these events, especially at higher speeds or with longer falls. Blunt injury can occur to the soft tissues and genitals, with the worst being a rupture of the testicles or penis of a male and the labia of a female. All these are extremely painful and cause a tremendous amount of swelling. They are treated by immobilizing the area and carefully applying cold compresses to areas other than the testicles. An injury unique to the male is a twisting injury to the penis, which can rupture the internal compartments. Yes, it really is called a fracture of the penis.

High-impact injuries to the pelvic area commonly occur from motorcycle accidents. These can fracture the pelvis, severely contuse soft tissues, and cause enough soft-tissue pressure that it tears tissues anywhere from the lower abdominal area to the buttocks. These are terrible injuries and commonly associated with life-threatening internal or external hemorrhage. Patients with these injuries should have the tissues cleaned quickly and returned to an anatomic position, then a pelvic immobilization device applied. Then treat shock and the other life threats.

The other common injury for EMS providers is genitals trapped in another object, like a zipper. This injury also happens in females, but much less frequently. This is an injury where the EMT really can perform simple treatment and be called a hero. The treatment is with a lot of slippery stuff: Skin caught in a zipper will release itself if given enough lubrication. The EMT can facilitate this by using trauma scissors to cut away the pants, which hold the zipper in maximum tension. If there is hair trapped in the zipper, trim it away also. Then apply a generous amount of mineral oil, lubricating jelly or ideally lidocaine jelly to the zipper and skin. Keep it moist throughout transport by applying more jelly. Often the skin will free itself by the time the patient arrives at the ED.