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?”
The paramedic answers honestly: “We cannot answer those questions, but it is really good news that he is not hurt in any other way, that we see no bleeding in his nose or throat, and that he is acting so well. It will require some time at the hospital for them to figure out what is injured and what will happen in the long run. We have an excellent children’s hospital, and their care for all injured children is outstanding. Let’s give them a chance to examine him.”
At this point the paramedic can do no further assessment of the injury, so the crew places the boy on the stretcher and asks him to keep his head still against the raised seat back. The parents of the other friends arrive to take those boys home, and the injured boy’s mother agrees to ride in the ambulance to the hospital. One of the EMTs quietly wraps up the pencils in a towel to take along.
Once in the ambulance, the paramedic begins to distract the boy by gently asking him to talk about the baseball stuff on his bedroom walls and his favorite subjects at school. He leaves the ear open, with the right side of the boy’s head upward. He wants to see if any further bleeding takes place. He calls the pediatric trauma center to advise staff there on the nature of the injury and asks to speak directly to the emergency physician.
After he describes the mechanism and limited exam that could be done, they agree the current treatment plan is adequate, and keeping the head elevated and the injured ear down will be the best way to reduce pain and assess if any further bleeding is occurring. The crew does not let the child talk too much, and makes sure he doesn’t have any increasing pain in his ear or head.
On arrival at the pediatric trauma center, the medical control physician is anxious to see the child. She examines him completely away from the injured left ear, and particularly examines his eyes and sense of balance with his eyes closed. She takes the examining scope for the ears and does her best to look inside the left ear canal, but cannot see far due to dried blood. She examines the pencils that were involved and again asks the young man how far the one may have gone into his ear. Again, the boy can’t help at all in estimating the distance.
At this point the physician reassures the young man and his parents. She brings out a diagram of the ear to show the boy, the parents and the Attack One crew, and as she describes the injury to them, she uses the diagram to explain the various parts of the ear.
“I am sorry this injury happened, but my exam so far shows the best possible condition,” she says. “There is obviously some injury to the ear canal, and very likely to his eardrum. Those are injuries that can heal well. I find no evidence of injury to the inner ear, which is the important center of hearing and balance. He also doesn’t have any blood draining into his throat, which would indicate a more severe injury to the middle ear. I need to talk to you about doing a special scan of his head, which will give us the closest possible look at his middle and inner ear, and once we have the results of that, we will talk to the ear specialist. I am also glad to examine the pencil and see that the end did not break off in his ear. We cannot clear the blood out of his ear, as that would likely only push the damage further into his ear and make him more uncomfortable. I am going to give him some pain medicine, and then we will make sure he stays comfortable with his head up.”
That is good news to the Attack One crew, and they excuse themselves to return to service. They ask the child to come visit them and let them know how he is doing. The mother appreciates the concern shown for her child and the expertise in dealing with a crisis event.
The child has a scan done and read by the emergency physician, radiologist, and ear, nose and throat (ENT) specialist. It reveals a punctured eardrum (tympanic membrane), but there is little blood in the middle ear and no sign of injury to the inner ear. The immediate treatment is to place the child on pain medicines and antibiotics, and release him home with restricted activity. He is checked by the ENT specialist two days later and then each week after that. The dried blood is carefully cleared out of his ear, and over a couple months his eardrum heals itself. By the time he comes to visit the Attack One crew about two months after his injury, he’s hearing and acting perfectly fine. With his mom at his side, he also promises not to put anything in his ears again.
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.
A child can injure the external ear, the pinna, with either a blunt or penetrating mechanism. The pinna is a very specialized structure, and any type of injury can end up damaging the cartilage that forms the external ear’s unique shape. Pinna injuries rarely bleed much, but pose a higher risk for infection. Of special note for EMTs is that if a pinna is partially amputated, any tissue that can be found should be transported to the ED. If a fragment is big enough, it may be replanted. Blunt injuries are very dangerous to the pinna. Any hematoma can break down the cartilage, resulting in a permanent deformity of the ear. Long-term deformity is called a cauliflower ear and is very common in wrestlers and others who sustain repeated blunt injuries to the pinna.
A child can also injure the ear canal or have an object in the ear canal that causes pain or other problems. A common emergency is when an insect of some type is in the canal. The presence of a live bug in the ear is very troubling to the patient and to parents. A simple and effective EMS management protocol would call for EMTs to fill the ear canal with a clean and viscous fluid, like mineral oil, K-Y jelly or vegetable oil. This will suffocate the insect, stop any movement and allow ED staff to eventually flush the insect out. Other objects in the canal, including beads, small parts of toys, small batteries and pieces of food, should be left alone until a physician can use appropriate tools in the ED to remove them safely. If the child complains of pain, some liquid lidocaine placed in the ear canal will begin to numb it.
A child can injure the eardrum, or tympanic membrane. This can occur from penetrating injury or with blunt injury. The patient may have pain and will be sensitive to sound. Either form of injury can cause bleeding, which is never severe unless a basilar skull fracture has occurred. Potential injuries to the eardrum should be transported with the patient in a head-elevated position and the injured ear facing downward to allow any blood to drip out.
A severe injury can occur when the inner ear is affected. The inner ear participates in both hearing and balance, and an injured inner ear will cause symptoms like hearing loss or intense ringing in the ear and dizziness. It can also cause an intense movement of one or both eyes, called nystagmus. This will cause some patients to complain of blurred vision or double vision and be very nauseated. Inner ear injuries are very rare, but again are usually managed by elevating the head and tilting the ear so the injured one drains outward.
Customer Service Opportunity
Children are extraordinarily adept at finding dangerous opportunities around them. Injuries can be very unpredictable. Unless an adult is present when it occurs, the history may not be very accurate.
Children’s caretakers and parents will get very distressed with painful or bloody injuries. It is ideal if the complete state of the injury is obvious to the EMS provider, and the parent or guardian can be reassured the child is going to do well. This happens in situations like lacerations from sharp objects that are completely visible to the EMT, where the bleeding is completely controlled and no deep structures like muscles, bones, blood vessels, nerves or tendons are injured. In these types of injuries, children and parents can be comforted and communicated with very directly: “I can see the entire injury, and the child is going to do well with a little bit of treatment.”
Much more difficult is when an injury cannot be fully evaluated, and the child and parents are very fearful for the child’s well-being. This case demonstrates an injury that cannot be evaluated in the field, where the EMTs will need to give a little assurance to the parents but not be able to say, “Everything will be just fine.” In this type of ear injury, it will even be difficult for the emergency physician to completely identify what is injured in the ear and what the long-term outcome of the child’s ear and hearing will be.
As always, prevention of childhood injuries is much more rewarding than their treatment. In appropriate circumstances, EMS providers may be able to communicate with children and parents about dangers in the home and give simple messages to prevent future injuries, poisonings or illnesses. If EMS providers can offer a few ideas to the adults in the house on safety measures, it may prevent a later tragedy.
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 an editorial advisory board member for EMS World. Contact him at firstname.lastname@example.org.