By now, we are all very familiar with the concept of the distracting injury. Some of our patients sustain injuries that are so painful that they mask the presence of others. The patient is so distracted by the big one that others just slip their notice.

This concept has been notoriously difficult to test, but there is a reasonable amount of data that suggests it is true. One of the more common and disturbing injury patterns occurs when there is a significant amount of chest wall trauma. When there are fractures focused around the upper chest, cervical spine injuries may be masked, then missed during the exam by trauma professionals.

I’d like to introduce a new concept: the ultimate distracting injury. This goes beyond an injury distracting the patient from another painful problem.

The ultimate distracting injury is one that is so gruesome that it distracts the entire trauma team! It could actually be so distracting that the team might miss multiple injuries!

It’s just human nature. We are drawn to extremes, and that goes for trauma care as well. And it doesn’t matter what your level of training or expertise, we are all susceptible to it. The problem is that we get so engrossed (!) in the disfiguring injury that we ignore the fact that the patient is turning blue. Or bleeding to death from a small puncture wound somewhere else. We forget to focus on the other life threatening things that may be going on.

What are some common ultimate distracting injuries?

• Mangled extremity
• Traumatic amputation
• Impalement
• Severe soft tissue injury

How do we avoid this common pitfall? It takes a little forethought and mental preparation. Here’s what to do:

• If you know in advance that one of these injuries is present, prepare your crew or team. Tell them what to expect so they can guard against this phenomenon.
• Quickly assess to see if it is life threatening. If it bleeds or sucks, it needs immediate attention. Take care of it immediately.
• If it’s not life threatening, cover it up and focus on the usual priorities (a la ATLS, for example).
• When it’s time to address the injury in the usual order of things, uncover, assess and treat.

Don’t get caught off guard! Just being aware of this common pitfall can save you and your patient!