Impalement Question

[NREMT-Basic]

Personally, I do not see how an impaled object could be in the oral cavity and not be in the gum line, or bony areas, otherwise it would probably fall out on its own.

R/r 911

First off, in your scenario of the pencil being in the gum line, the mandibular or maxillary bone structure would have stopped it before it went in very far and it would probably puncture the cheek, hit bone and fall out thus rendering this whole scenario moot. Quite simply, the way that a pencil or other impaled object in the cheek would be there without hitting the gum line if the mouth is open when the pencil is inserted through the cheek. If it is in the soft tissue and completely through the cheek, the tissue will have closed around the pencil or other item and would likely not "fall out." I think another question that needs to be asked here is, though this question and scenario have been around since time in memorium, how likely is this injury actually to occur. Ive only ever seen mocked up photos and I have to wonder how often this really happens. Of all the places that a person could be stabbed or otherwise impaled with a pencil, the precision necessary to accidentally impale the cheek through and through would be quite remarkable. The question still remains: if it is not impeding the airway, and bleeding is not an airway concern with proper suction, why remove the object? To prove that you can? Other than airway impedement, there really is no valid necessity for field extraction in the scenario described. In any case, in the hospital setting, a maxillo-facial specialist would likely be consulted and the possibility of cutting the pencil in two pieces, one inside and one outside thus facilitating its removal might be considered. There's also the matter of suction and tissue/vascular damage. If the tissue has "self-sealed" around the pencil and you start yanking on it, you are more likely to cause further tissue damage. The real question here in the absence of airway obstruction should not be why not remove the pencil, but rather why. As I asked earlier, do you take the pencil out just to prove you can do it. Anybody can pull the thing out, but the likelihood of further injury or soft tissue damage is much less in the controlled environment of the ER. Also, leaving the object in until arrival at the ER lessens the blood loss to the patient and also negates the argument of how to control bleeding. As I said in my previous post, it makes no sense to remove it and then have to try to conrol bleeding, etc when extraction, bleeding control and repair can all be done almost simultaneously in the ER.

[ERDoc]

The reason to remove it is because it has a very real potential to become an airway obstruction. You're better off to remove the danger and then use simple first aide techniques such as pressure. You are not likely to cause any more tissue injury since you are pulling it out the same way it went in. The damage has already been done. Please don't comment on something if you don't know the right answer since something simple like this will not need a maxillofacial surgeon. MFS would be the wrong service any way, you are more likely to call a plastic surgeon. Something as simple as a through and through lip or cheek injury does not require a specialist. It is generally a simple 3 layer closure done by the ER doc, tetanus, maybe antibiotics and out the door.