thedrifter
10-25-06, 11:14 AM
A Marine grunt goes went to med school
Getting too big for my britches or filling the shoes?
« H E » doc Russia :
Cowboy Medicine
So today I was asked to take a look at a very cute and scared little girl who had, as I put it, "gotten into a fight with a glass shower door...and lost." The attending was off dealing with the flood of patients coming into another area of the Emergency Department, and said to consult with someone on this girl with a chunk of glass embedded in her foot. In all honesty, considering the mechanism of injury, this girl was very lucky that she wasn't getting hauled up to the operating room. I guess it's the flip side of those freak accidents that maim people; you get little girls who manage not to grow up with the nickname of "scarface" after a piece of plate glass bigger than they are explodes on top of them.
So, the X-ray of her foot reveals a chunnk of glass embedded between two bones of the foot. The upper level ortho resident chimed in that the shard is too deep, and so we should just wash it, stitch it closed and let the foreign body work it's way out. I took a look at the X-ray, and thought that it did not look terribly deep in there, and that it would probably be worth it to at least try to see if it could be visualized and removed. Not terribly likely, but I thought it would be worth a shot. So, I basically nodded along with the Ortho resident, and then after talking with the parents (who were very eager to get this thing out), decided to cowboy up and try to get the damned thing out.
Now while removing a foreign body is often a very straightforward and easy task, it can get to be tricky. Besides the medical considerations of damage to nearby structures, there is also the fact that this little girl was about 6" off of the gurney from sheer apprehension (due in no small part, IMHO, to her parents' apprehension). They tend to be especially tense when this 250 pound Marine looking guy walks in with a needle and says that he is going to start rooting around in this wound. The attending was gone, the ortho resident was gone, and so it was just myself with a PA (physicians assistant) and PA student to help. I went back over the references to double check the dosage limits of lidocaine (you need to be careful with kids; it is easy to reach a fatal dose if you aren't careful, and there are cases of kids going in to get a laceration repaired, and due to altered dosages and miscalculation, dying). I rounded the max dose down to 4mg/kg, and at 10 mg/ml figured out what she could safely take. Then I ordered the PA student to draw less than half of that. It would likely be more than enough anyway, but you have to watch stuff like that. Attention to detail will save your patient's life, and it will save your career. I then mixed the lidocaine with bicarbonate. Lidocaine is acidic, and that's what causes that initial burning sensation upon injection. The bicarb acts as a buffer, and effectively stops that burning feel. I then got the 25 guage needle. It's the smallest we've got, and the least hurtful to use.
Then, I talked to the kid, and told her that she was going to feel some pain at first, but that it would not be very long. I also told her that if she felt something painful, to just let me know, and I would stop. I swabbed an area around the edge of the wound for sterility, and then advanced the needle.
She didn't like that. She started crying a little bit, and withdrew her foot. I cursed softly under my breath. I would now have to poke this kid again. So, that's exactly what I did. I injected a local wheal of anaesthetic, and then let it take effect after a minute or two. The girl was still sobbing. It was more fear than pain, but for kids, the pain and the fear of the pain are in many ways one and the same. So, what I started to do was hide the foot from her with my left hand, and ask her if it hurt when I poked her, making sure that she could see that the needle was nowhere near her foot. She said 'no.' Then, I started moving the needle closer and closer, each time asking her "can you feel this?" Soon, I actually was touching the wheal with the needle, and she said she could'nt feel it. She was also calming down a little bit as there was no more pain. I went back into the wheal, and started to advance the needle along the skin just under the surface. I would aspirate a little, inject a little, and then advance a little. I did this along one edge of the wound that was closer to her ankle. Then, I went around the other side. It took a few minutes, but by now the girl was actually smiling and relieved since I had so far been able to make this whole ordeal relatively painless.
Next, I started irrigating the wound with sterile saline. She jumped a little at this, saying that it was cold and wet. I told her it was water in Michigan, and it only comes cold and wet. After 500 ml's of saline, I got a sterile pair of pick-ups (tweezers) from a suture removal tray, and started to probe around in the wound.
I couldn't see ****. Blood kept oozing into the wound, and obscuring everything. I was about to give up, but I thought I would reposition her toes in the wmanner in which they probably were when the glass went in, and noticed that a track seemed to make itself noticeable. I irrigated more water, and probed a little deeper along a crevice I had found. Then, I felt that ever so subtle scrape of contact with a solid object where only flesh should be. I asked for more irrigation and looked in before the blood returned. There, I thought I saw a dark line in the tissue. I gingerly advanced the pick-ups as a probe. The object was a little to the right, so I backed up a little, opened the jaws, moved a smidge to the right and squeezed.
I had something.
Unfortunately, I couldn't see it, and I couldn't see what it might be pressing against, or what might be wrapped around it (like a nerve or vessel). I figured that since I was going along the entrance track, it was unlikely that there was anything wrapped behind it. Still, I was suspicious, so I gently pulled it back a millimeter, let go, and then grabbed it again. I repeated this a few times,and it seemed that it was coming out. I kept at it. Around this time, the little girl started to say that her foot felt "something funny." Since she wasn't complaining of pain, I figured that it was the glass. So, I just kept pulling, and then, whaddya know? a fair sized square chunk of glass came out! The PA and the PA student vocalized their excitement. The mom visibly deflated with relief, and the little girl was wide-eyed with amazement.
I asked the PA to stitch up the wound after irrigating it, and dermabonded a shallow and short cut on the girls arm. The PA and the PA student were all smiles, and commended me on doing such a terrific job. Shortly after that, the ortho resident returned, found out that I had pulled it out, and also congratulated me on "strong work" which is the medical equivalent of an "attaboy!" Then the attending showed up shortly after that to ask about this little girl with the glass in her foot. The PAs related that I had taken care of it, already, to which the attending raised an eyebrow of pleasant satisfaction at the Emergency Medicine resident who had adroitly dealt with what might be a tricky problem.
Now, while I really don't think that I deserved all that much praise, I damned sure enjoyed it. I especially liked being able to prove to my collegues that I was capable. Let me tell you, I can tell when a PA, a nurse or a tech calls you "doctor" because they want something from you, and when they call you doctor as a form of praise. There is a difference, and the difference feels good. Mom was happy (she even asked her kid if this made her want to be a doctor), the little girl was happy. Yup; everything was all smiles and sunshine at half-past midnight.
Because it went well.
And while I am very satisfied with the results, I can't gloss over the fact that I did go out on a limb a little there. I had actually never used bicarb with lidocaine before. I had never used dermabond before. I had never tried to get something that deep out of someone's foot before. The attending had not signed off on my plan, and an upper level resident had actually advised against it. In retrospect, I had also never gotten a formal, signed consent from the parents.
In emergency medicine, there are times when you need to totally cowboy it. There will be injuries that come through your doors which are so strange and improbable that there is no manual for it. There is no algorithm, no handbook, no consultant to call. You will just have to look at it as a stand alone case by itself, and come up with a plan. That's something that I love about Emergency medicine; while so much is routine, there is still going to be the occasional case where it is nothing but improvise, adapt, and overcome. It's time to cowboy it. I went a little cowboy on this, and fortunately, it appears that everything will be roses. Still, I must be ever mindful of the seduction of success. You start to cowboy a little, then you start to cowboy a lot. Next thing you know, you overextend yourself, and things go wrong. Is there anything I should have done different? No. As long as I would be willing to stop and hand it off to the more experienced if things didn't go exactly as they should, I was okay. I could have gotten myself in trouble if I tried to force the issue, and started really mucking around in that foot just to "win." There are times to cowboy it, and there are times to call the cavalry. Often the difference between the wise and the regretful is knowing the difference. Tonight, I either got a little too big for my britches, or I started to fill my shoes, and I may never know the truth.
Alright. Time for bed. I am going to bask in the glow of this experience. You need to do that in medicine, especially as an intern. It is those little moments, and the appreciation of those moments which sustain you through many a long night on call.
Respectfully Submitted,
-doc Russia
posted Tue, 10/24/06
Ellie
Getting too big for my britches or filling the shoes?
« H E » doc Russia :
Cowboy Medicine
So today I was asked to take a look at a very cute and scared little girl who had, as I put it, "gotten into a fight with a glass shower door...and lost." The attending was off dealing with the flood of patients coming into another area of the Emergency Department, and said to consult with someone on this girl with a chunk of glass embedded in her foot. In all honesty, considering the mechanism of injury, this girl was very lucky that she wasn't getting hauled up to the operating room. I guess it's the flip side of those freak accidents that maim people; you get little girls who manage not to grow up with the nickname of "scarface" after a piece of plate glass bigger than they are explodes on top of them.
So, the X-ray of her foot reveals a chunnk of glass embedded between two bones of the foot. The upper level ortho resident chimed in that the shard is too deep, and so we should just wash it, stitch it closed and let the foreign body work it's way out. I took a look at the X-ray, and thought that it did not look terribly deep in there, and that it would probably be worth it to at least try to see if it could be visualized and removed. Not terribly likely, but I thought it would be worth a shot. So, I basically nodded along with the Ortho resident, and then after talking with the parents (who were very eager to get this thing out), decided to cowboy up and try to get the damned thing out.
Now while removing a foreign body is often a very straightforward and easy task, it can get to be tricky. Besides the medical considerations of damage to nearby structures, there is also the fact that this little girl was about 6" off of the gurney from sheer apprehension (due in no small part, IMHO, to her parents' apprehension). They tend to be especially tense when this 250 pound Marine looking guy walks in with a needle and says that he is going to start rooting around in this wound. The attending was gone, the ortho resident was gone, and so it was just myself with a PA (physicians assistant) and PA student to help. I went back over the references to double check the dosage limits of lidocaine (you need to be careful with kids; it is easy to reach a fatal dose if you aren't careful, and there are cases of kids going in to get a laceration repaired, and due to altered dosages and miscalculation, dying). I rounded the max dose down to 4mg/kg, and at 10 mg/ml figured out what she could safely take. Then I ordered the PA student to draw less than half of that. It would likely be more than enough anyway, but you have to watch stuff like that. Attention to detail will save your patient's life, and it will save your career. I then mixed the lidocaine with bicarbonate. Lidocaine is acidic, and that's what causes that initial burning sensation upon injection. The bicarb acts as a buffer, and effectively stops that burning feel. I then got the 25 guage needle. It's the smallest we've got, and the least hurtful to use.
Then, I talked to the kid, and told her that she was going to feel some pain at first, but that it would not be very long. I also told her that if she felt something painful, to just let me know, and I would stop. I swabbed an area around the edge of the wound for sterility, and then advanced the needle.
She didn't like that. She started crying a little bit, and withdrew her foot. I cursed softly under my breath. I would now have to poke this kid again. So, that's exactly what I did. I injected a local wheal of anaesthetic, and then let it take effect after a minute or two. The girl was still sobbing. It was more fear than pain, but for kids, the pain and the fear of the pain are in many ways one and the same. So, what I started to do was hide the foot from her with my left hand, and ask her if it hurt when I poked her, making sure that she could see that the needle was nowhere near her foot. She said 'no.' Then, I started moving the needle closer and closer, each time asking her "can you feel this?" Soon, I actually was touching the wheal with the needle, and she said she could'nt feel it. She was also calming down a little bit as there was no more pain. I went back into the wheal, and started to advance the needle along the skin just under the surface. I would aspirate a little, inject a little, and then advance a little. I did this along one edge of the wound that was closer to her ankle. Then, I went around the other side. It took a few minutes, but by now the girl was actually smiling and relieved since I had so far been able to make this whole ordeal relatively painless.
Next, I started irrigating the wound with sterile saline. She jumped a little at this, saying that it was cold and wet. I told her it was water in Michigan, and it only comes cold and wet. After 500 ml's of saline, I got a sterile pair of pick-ups (tweezers) from a suture removal tray, and started to probe around in the wound.
I couldn't see ****. Blood kept oozing into the wound, and obscuring everything. I was about to give up, but I thought I would reposition her toes in the wmanner in which they probably were when the glass went in, and noticed that a track seemed to make itself noticeable. I irrigated more water, and probed a little deeper along a crevice I had found. Then, I felt that ever so subtle scrape of contact with a solid object where only flesh should be. I asked for more irrigation and looked in before the blood returned. There, I thought I saw a dark line in the tissue. I gingerly advanced the pick-ups as a probe. The object was a little to the right, so I backed up a little, opened the jaws, moved a smidge to the right and squeezed.
I had something.
Unfortunately, I couldn't see it, and I couldn't see what it might be pressing against, or what might be wrapped around it (like a nerve or vessel). I figured that since I was going along the entrance track, it was unlikely that there was anything wrapped behind it. Still, I was suspicious, so I gently pulled it back a millimeter, let go, and then grabbed it again. I repeated this a few times,and it seemed that it was coming out. I kept at it. Around this time, the little girl started to say that her foot felt "something funny." Since she wasn't complaining of pain, I figured that it was the glass. So, I just kept pulling, and then, whaddya know? a fair sized square chunk of glass came out! The PA and the PA student vocalized their excitement. The mom visibly deflated with relief, and the little girl was wide-eyed with amazement.
I asked the PA to stitch up the wound after irrigating it, and dermabonded a shallow and short cut on the girls arm. The PA and the PA student were all smiles, and commended me on doing such a terrific job. Shortly after that, the ortho resident returned, found out that I had pulled it out, and also congratulated me on "strong work" which is the medical equivalent of an "attaboy!" Then the attending showed up shortly after that to ask about this little girl with the glass in her foot. The PAs related that I had taken care of it, already, to which the attending raised an eyebrow of pleasant satisfaction at the Emergency Medicine resident who had adroitly dealt with what might be a tricky problem.
Now, while I really don't think that I deserved all that much praise, I damned sure enjoyed it. I especially liked being able to prove to my collegues that I was capable. Let me tell you, I can tell when a PA, a nurse or a tech calls you "doctor" because they want something from you, and when they call you doctor as a form of praise. There is a difference, and the difference feels good. Mom was happy (she even asked her kid if this made her want to be a doctor), the little girl was happy. Yup; everything was all smiles and sunshine at half-past midnight.
Because it went well.
And while I am very satisfied with the results, I can't gloss over the fact that I did go out on a limb a little there. I had actually never used bicarb with lidocaine before. I had never used dermabond before. I had never tried to get something that deep out of someone's foot before. The attending had not signed off on my plan, and an upper level resident had actually advised against it. In retrospect, I had also never gotten a formal, signed consent from the parents.
In emergency medicine, there are times when you need to totally cowboy it. There will be injuries that come through your doors which are so strange and improbable that there is no manual for it. There is no algorithm, no handbook, no consultant to call. You will just have to look at it as a stand alone case by itself, and come up with a plan. That's something that I love about Emergency medicine; while so much is routine, there is still going to be the occasional case where it is nothing but improvise, adapt, and overcome. It's time to cowboy it. I went a little cowboy on this, and fortunately, it appears that everything will be roses. Still, I must be ever mindful of the seduction of success. You start to cowboy a little, then you start to cowboy a lot. Next thing you know, you overextend yourself, and things go wrong. Is there anything I should have done different? No. As long as I would be willing to stop and hand it off to the more experienced if things didn't go exactly as they should, I was okay. I could have gotten myself in trouble if I tried to force the issue, and started really mucking around in that foot just to "win." There are times to cowboy it, and there are times to call the cavalry. Often the difference between the wise and the regretful is knowing the difference. Tonight, I either got a little too big for my britches, or I started to fill my shoes, and I may never know the truth.
Alright. Time for bed. I am going to bask in the glow of this experience. You need to do that in medicine, especially as an intern. It is those little moments, and the appreciation of those moments which sustain you through many a long night on call.
Respectfully Submitted,
-doc Russia
posted Tue, 10/24/06
Ellie