Emergencies

No photo today, sorry folks.  So I haven't posted in a while, I think the last time I did I was still in California.  I've just finished up my month on Radiology, and I suppose now I can read a chest x-ray better than before.  Certainly better, but still not quite up to par.  I just don't know why those darn things are so difficult.

So I'm on Emergency Medicine now, and of course they started me off with a solid 8 days in a row, 3 evening shifts followed by 5 graveyard shifts.  Ugh.  I don't know if I like this hectic, fast paced type of medicine, with patients flowing in just a tad faster than I can see them.  I like a little downtime in my day, a chance to breathe...  In the ER, though, there are always more people in the waiting room, and it's expected for my resident to be juggling 5-6 patients at once.  Which means, thankfully, I'm only juggling 2-3.  Crazy stuff.

So last night, 'round eight, the ambulance pulls up and in comes the cutest 7-year-old girl sitting on a stretcher.  Strapped to her (via seatbelt) is a massive metal bedframe, made of colorful pipes welded to each other.  In a tiny hole on the side of one of the pipes (who know's what it's for) is stuck her middle finger.  She was very amused as a mass of doctors and nurses surrounded her, and my attending chats with her with a smile as he pours a generous amount of lubricant around her finger.  Doesn't work, she's still quite stuck.

Now the picture isn't quite right already - I can see there's small smears of blood on her pajamas.  She's gotten cuts around her finger already where it's inserted in the hole, which apparently was quite sharp and she's already tried to free herself.  Her finger is presumably pretty swollen on the inside.  So it's off to the pipe shop.  Pipe shop?  I didn't even know our hospital had a pipe shop.  I wonder what they do there during the day?  Tonight, however, they were going to cut that bedframe to pieces.

Of course, once I get over there (along with a very dedicated nurse and ER tech), the pipe folks (plumbers?) have their own lubricant to try - some sort of silicone grease (quite different from our stuff) - but it doesn't work either.  So we do our best to comfort the child while they tear the bed apart before our eyes.  The first few cuts are easy, using circumfrential cutters to debulk the massive thing.  The small pipes welded on come apart easily, but her finger is stuck in a huge pipe (2.5" diameter maybe?) , which requires a powersaw to go through.  We do our best to brace her hand and the pipe in a vice.  As we get closer, the nurse and I put our fingers in the way of her fingers, so if the saw missed, we'd get maimed first.  His idea, not mine.  Are all ER nurses so brave?  I was pretty scared.

Slowly her charming demeanor melted away with the increasing pain.  Each further cut got worse and worse, as the pipe started to bend and pinch her finger.  We finally cut enough of the pipe to fully expose her finger, a horribly swollen mess covered in blood and grease.  Any further cutting simply bent the pipe too much, she would cry out in pain.  We attempted to use teflon tape to squeeze the edematous fluid out of the proximal part of the trapped finger, hoping to squeeze it through bit by bit, similarly to how we remove swollen rings from fingers using dental floss.  It didn't work.  (btw, unless you're trained in it, I would not recommend trying to remove your own stuck rings this way - go to the ER!)

"Do you have any ideas, doctor?" they ask me for the 5th time in 2 hours.  Me?  I'm no surgeon!  "I think she needs to be sedated.  This is causing too much stress and we can't get good access here."  Or something like that.  The nurse recommends I go talk to my attending.  He demands of me, "Why sedation?  Is she no longer cooperative?  Has her condition deteriorated to the point where she simply can't take it anymore?"  No, and no.  Or no and maybe.  I'm not sure.  I suggest we might be able to get to her finger with a hacksaw - I'm simply not comfortable with using any more powertools at this point.  He agrees - one more try with the hacksaw, and if it doesn't work, the patient comes back to the ER for reevaluation.

I tell the nurse the plan, and he agrees.  We clamp what's left of the pipe wall, and go to work.  We simply can't hold the pipe still enough (it's really only half a pipe now - meaning it's only half the circle and so has no structural integrity).  The girl cries in pain from every single movement of the saw, and we were barely able to make a centimeter of progress before we decide it's just unsafe.  Back to the ER.  By this time the pipe guy had already called in several his maintenance friends, and they all are sad to see her go.  More so, I think they were truly disappointed they weren't able to save the day and free her finger, and I'm sure they were all wondering what more they could do.

We get back to the ER, and my attending comes over and looks at the poor finger, still stuck inside the remnant of bedframe.  He begins to try the dental floss trick, but the nurse convinces him we've already tried that.  Okay.  Time to call the hand surgeon.  The nurse starts an IV on her, something they could easily do in the operating room, but I think he too wanted to do something for her, despite everything he's already done.  I finish up all my paperwork on her - what else can I do?  I'd like to follow her to the OR at the next door children's hospital, and through to the next day and round on her, but seeing as I'm on ER, I can't quite do that.

My resident calls me over to sew someone's laceration closed.  It's been a long time since I've done stitches, but somehow they come out looking pretty nice.  I guess I learned something these past few years.  And then on to the next patient...