Pierced Ear

There are a few injuries affecting the ear that are important for EMS providers to be trained to manage and for which they should have protocols in place

The Saturday evening call is for a child "with injuries from a fall."

Attack One comes to a stop in front of a home with a very anxious woman who reports, “My child is badly injured and has blood coming from his ear!”

The lead paramedic asks one of the EMTs to prepare the pediatric trauma bag and grab a backboard and packaging equipment. In his mind he’s already rolling through the likelihood of finding an unconscious child who’s fallen from a high place and has a basilar skull fracture. He asks the mother, “How high did he fall from? Is he unconscious? Is he breathing?”

“He is wide awake and crying,” she reports. “He fell against the wall.”

By now the entire crew is in the upstairs bedroom, where they find a 10-year-old boy crying and holding a towel over his left ear. It has bright red blood on it. Otherwise the child looks fine—he is conscious, talking and saying his left ear hurts.

Through a few tears, he describes the injury: He says he was jumping on his bed in front of his friends, who were staying overnight at his house. He put two pencils in his ears and then fell accidentally against a wall. The sharp end of the pencil in his left ear was pushed “way into” his ear, and he had so much pain he immediately pulled it out. When he did it started bleeding “a lot,” and he called his mom. He denies actually falling other than striking that side of his head against the wall and says nothing else hurts.

The paramedic quickly scans the child for injuries other than to the left ear and finds none, no other sign of head trauma and no neck tenderness. With no other trauma and a mechanism of injury that did not include a fall from distance, there is no indication for cervical immobilization.

“Thank you for letting us know exactly what went on,” the paramedic tells the child, who apparently had not yet relayed the exact story to his mother. “Please sit on the bed for us, and we can help you better if you will leave that left ear pointed down. Would you please tell us where those pencils are?”

The boy’s friends pull the pencils from a trash can—a pair of brand-new No. 2s, each about 15 cm in length, with sharp points. One is bloody. “Can any of you tell us how far the pencil seemed to be in his ear?” one of the EMTs asks. But none of the boys can estimate how far it penetrated.

The mother now looks like she’s going to pass out. One of the EMTs makes sure she is sitting down as the paramedic works to assess the child’s injury. He starts by using his flashlight to look in the uninjured right ear, and then in the child’s eyes, nose and mouth. As far as he can see, there is no injury to the right external ear or down the canal as far as his light goes. There is no blood in the nose, mouth or throat. He then removes the towel from the child’s left ear, which by now has stopped bleeding.

The outer ear is not injured, but the ear canal cannot be examined because it is full of dried blood. The medic taps his finger on the bone around the ear, and the child does not report any increased pain. When asked, the child says he can’t hear anything in the left ear, has no ringing and does not feel dizzy. The paramedic also looks carefully at the child’s eyes to see if there are any abnormal movements, and he does not see any. The other EMT assists by taking the child’s vital signs, which are completely normal.

The medic addresses the mother: “Ma’am, we are not able to tell exactly what is injured inside the ear, so we will need to take him to the children’s hospital, which has special capabilities for injured children. To keep him comfortable, we will leave his head upright and keep the left side of his head down. Any bleeding that is still going on will not go further into his ear or down into his throat—”

“Is he bleeding internally?” mom interrupts anxiously. “Is his brain injured? Is he going to hear again?”

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