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Now let's put the tools of discovery using the mechanism of injury method to use. In this scenario, we've got a maybe a six year old boy who was climbing on the bleacher system and it appears that they may have slipped and fallen. So how do we apply mechanism of injury to this? Well, the first thing that I'm going to do if he's lying on the ground is, I'm going to look initially to see if he's okay. If he's unconscious, unresponsive we may have a medical emergency of which I'm not going to delay any further. I'm going to activate emergency medical services with my cell phone or I'm going to tell somebody hey you in the plaid shirt, go call 911 and call back, I might need your help as I continue my assessment. But in this case as we can see, he's sitting upright, he's not crying. It looks like he might be holding his left knee. Every now and again he kind of rubs it, so I'm already suspecting we may have a left knee injury. But what kind of injury is it? Is it severe? Well, he's got it bent. It's not angled or misformed, so it's not something that's jumping right out at me, that it could be serious, but you never know. But as I look at the mechanism I know he climbed off this step here. I can see muddy foot tracks on the seat itself and maybe he slipped and as he slipped, did he hyper-extend his knee, causing a sprain or a strain or some kind of dislocation injury. That's my first one. Secondly, we have a rigid seat here. When he slipped, did he hit the back of his head on the actual bleacher system as well. So I might begin to ask him, "hey, does your head hurt? Do you have any pain anywhere?" If this patient is able to talk to me, I'm going to use as many open-ended questions as I can. I really don't think it's a good idea to ask specifics in every situation. Because if I do, and I say "hey, does your shoulder hurt?" "Oh, yeah yeah, my shoulder hurts." "Does your stomach hurt?" "Oh, yeah, my stomach hurts too." Sometimes we can lead the patient down a path that doesn't really exist. So I much more prefer to actually ask them, "hey, can you tell me what hurts?" And let them point those things out to me. Now, the whole time I'm going to be watching for unknowns. I already know that the mechanism of injury not only could cause a sprain or a strain of the ankle, the knee, a back injury. But I also know it could be a head injury. And if it is a suspected head injury we might start seeing a loss of consciousness or a decreased level of consciousness. So I'm going to be watching for that and obviously as soon as we have decreased level of consciousness, airway, breathing or circulation problems, any kind of numbness, tingling, or inability to move one of their forelimbs, it immediately becomes a 911 call and an emergency and they're going to be going in by ambulance. But right now we're not sure if they have to go in by ambulance. It might be that he just bumped his knee and it hurts and now I can kind of incorporate the parent or the guardian or the nanny whose on the scene. And I can start to ask them, "Is this little guy answering questions appropriately to you? Do they seem like normal to you? Or do they seem maybe more lethargic or a little bit different?" And kind of use them as a help. I can ask them "do they have any medical problems that I should know about? Any allergies to medications?" and start putting kind of an assessment together. I'm also going to make sure that I'm not completely myopic on this knee. I'm going to be thinking of other potential injuries. Did he put an arm out when he fell and therefore sprain a wrist or break a bone in his arm. And start kind of watching for those when I do my head to toe exam looking for other not so noticeable injuries that I should also be aware of.
Physical injuries run the gamut from soft tissue injuries like bruises, cuts, and burns to those involving the musculoskeletal system and/or the head, neck, and back. While injuries can vary greatly, the tools of discovery you'll use to help you assess patients will not.
When you arrive on the scene, you'll apply the mechanism of injury method to help you gain a greater understanding of what possible injuries the patient may have based, in large part, on how he or she may have sustained those injuries.
How to Apply the Mechanism of Injury Method
As always, the first thing you want to do is make sure the scene is safe and that your gloves are on. Make sure you have your rescue mask with a one-way valve handy and begin calling out to the victim.
Are you OK? Can you hear me?
If the patient is conscious and responsive, ask yourself if there are other medical emergencies that would warrant calling 911 and activating EMS? If not, continue with your assessment.
Ask yourself questions like:
- Is the victim favoring an area or limb?
- Is there noticeable bleeding, protruding limbs, or other injuries?
- Is the victim demonstrating any concussion symptoms?
- Is there an obvious cause of the injury – slippery walkway, etc.?
- Is the victim demonstrating any airway, breathing, or circulation problems?
Warning: If the patient does begin showing signs of decreasing levels of consciousness or any problems involving breathing, airway, and/or circulation – numbness, tingling, inability to move limbs – call 911 immediately.
Introduce yourself to the victim: "Hi, my name's _____. I'm a paramedic. Do you know what happened today? Are you in any pain?"
Pro Tip #1: Ask the victim open-ended questions when you're assessing them, rather than yes and no questions. So, instead of asking, does your head hurt?, ask, do you have pain anywhere? Asking yes and no questions can often lead them down the wrong road.
During your assessment, involve family members and friends who are nearby and may have witnessed the accident. They'll also be able tell you if the victim is behaving normally or has any medical problems or allergic reactions to medications. This is even more important when dealing with injuries to children.
Pro Tip #2: Don't be too myopic. Even though the injury may seem obvious, that doesn't mean another injury isn't also lurking. Keep this in mind as you perform a full head-to-toe examination of the patient.
A Word About Soft Tissue Injuries
Soft tissues include all the layers of skin, fat, and muscles in the human body. The largest organ is the skin, as it contains three layers of its own – epidermis (outer area that protects against bacteria), dermis (deep layer that protects the nerves), and hypodermis (the deepest layer that protects blood vessels).
Soft tissue injuries are classified as closed wounds or open wounds.
A closed wound is an injury that occurs beneath the surface of the skin, meaning that the outer layer of skin is still intact. There is usually internal bleeding, even if only minimally in the form of a bruise.
An open soft tissue wound involves a break in the skin's outer layer, like a cut, and usually involves external bleeding – arterial, venous, or capillary.
Burns deserve a special distinction as a soft tissue injury and are classified as superficial, partial thickness, and full thickness.
Closed Wounds
Closed wounds occur beneath the surface of the skin and are usually the result of blunt force. The contusion can be minor, like stubbing your toe, to more serious examples of blunt force trauma, like those sustained in motor vehicle accidents.
Swelling and discoloration are normal in closed wounds as these are part of the healing process. Closed wounds become more serous when they affect the deeper layers, those that protect larger blood vessels and vital organs. Heavy internal bleeding can occur from a contusion or hematoma and when it affects those deeper layers, the signs may not be immediately noticeable.
Opened Wounds
Open wounds are those that affect the outer layer of the skin. There are six types of open wounds:
- Abrasions – scrapes, rug burns, road rashes, etc. – abrasions are more painful due to the presence of nerve endings nearby but don't involve much bleeding as the capillaries are mostly affected.
- Amputations – the loss of a limb – amputations are serious injuries that rely on controlling blood loss and shock.
- Avulsions – part of skin peeled away – avulsions can be very painful, and bleeding can be heavy.
- Crush injuries – extreme weight or force crushes a body part – crush injuries can cause great internal damage to blood vessels and vital organs.
- Punctures – gun shot wounds, stabbing wounds, etc. – punctures are smaller wounds that typically close around the wound, thereby limiting the amount of external bleeding. However, the puncture can also result in internal bleeding.
- Lacerations – cut from a sharp object – lacerations vary in severity depending on several factors, including the type of bleeding that the laceration has caused – arterial, venous, or capillary.