29 October 2010

Friday Flashback - Showmanship

I have been practicing a style of Okinawan Karate for a number of years now.  It's a simple, practical fighting style -- nothing showy or acrobatic, which is good for me since flexibility is not one of my strong points.  One of the key features of this style is a heavy emphasis on joint locks and grappling techniques, called tuite.  Frankly, this is my favorite part of training.  When someone has grabbed you and thinks he is controlling the situation, you can easily and simply use his own grip against him to turn the tables and put him on the floor.  I am continually amazed at the inventiveness of the old masters: how they understood body mechanics and topology and applied that to develop techniques in which one can place leverage on a joint in an unusual and powerful manner with only a simple and subtle movement.

You may think I'm a little off-topic, that I have become confused and think I am on the KaratePage Today site.  Not at all, my friends.  You see, I have had occasion from time to time to put my karate skills into more ... direct application ... in the ER.  Mostly it has been intoxicated or psychotic patients who needed a little focused pain to restrain them until an intramuscular injection of Haldol could take effect.  Once, a belligerent drunk attacked a nurse and I took him to the floor until security could get there and put on four-point restraints (followed by the local police applying handcuffs).  But, frankly, most of these have been psychosocial, not medical, applications of karate.  But not always.
 


I was working not terribly long ago at a site where we have double-coverage, and my partner asked me to help out with a dislocated shoulder.  We generally tag-team these procedures.  One of us plays anesthesiologist while the other does the procedure.  That way one doc can focus on the procedure without worrying about the patient's depth of sedation, ventilatory status, airway status, etc., and the other doc can focus on performing sedation safely.   

When you are doing the sedation, though, it's really not too engrossing, and like any good short-attention-span ER doc, I tend to watch the "main show" with interest.  This particular patient happened to be a rather obese woman, who unfortunately was so plump that we couldn't even palpate any bony anatomical landmarks.  After an uneventful induction of deep sedation with Diprivan, I watched "John" go through the standard maneuvers to reduce the offending joint.  He applied traction, external and internal rotation, extension and elevation with traction, and even some futile attempts at humeral/scapular manipulation.  He pulled and pulled until his face was red and his scrubs were stained with sweat.  He never got that satisfying "clunk" that indicates a positive reduction, but we both wondered if it might be in anyway.  The post-manipulation range of motion seemed normal, and sometimes if the shoulder is loose enough, you really don't feel the joint reduce.

The "post-reduction" film dashed our hopes.  Still out, despite all John's close-to-heroic efforts.

With a hint of malice in his voice, he said, "This time I'll push the drugs, and you can pull on the arm."

Fair enough.  I like a good reduction.   I stood by the bedside, while the various choreographed motions went on to re-induce sedation, and pondered the procedure.  John is more muscular and likely stronger than I am.  I had just watched him do every usual technique that I would have tried.  How was I going to reduce this one where he had not?  My mind wandered and entered one of those lateral drifts.  I thought about some tuite I had recently worked upon in karate class.  There was one nasty technique, involving a wrist-elbow-shoulder lock.  Not too useful in a fight, I had thought at the time, but it put a lot of very uncomfortable pressure on the shoulder if you could get it.

In the interim, a small crowd had gathered at the bedside.  (The ED was near empty, and a difficult reduction is always a popular diversion.)   A nurse nudged me, interrupting my reverie, "She's ready.  Let's see what you've got."   Still thinking about that joint lock, I picked up her right hand with my right hand, threaded my left beneath her forearm, up through the crook in her elbow, then over and behind her humerus.   I pressed down on her hand, levering against my left arm, while lifting and pulling a bit on her humerus with my left.  Immediately, without any hesitation, the shoulder popped in with a satisfyingly audible clunk.

Mildly surprised, I said, "There, that seems to have done it."   The crowd dispersed, murmuring appreciatively.  John was staring at me.  "What the hell did you just do?"   I explained that it was just a trick with leverage and showed him how to do it.  I elected not to tell him where I had come up with it and that I had never tried it before.  It would have ruined the moment.  

Now he thinks I'm some sort of genius.

I can live with that.

Originally Posted 2 November 2007

5 comments:

  1. Could you draw a diagram of how you did that?

    ReplyDelete
  2. A diagram or video would be really helpful ... I, too, seem to struggle with shoulder reductions more than my peers.

    ReplyDelete
  3. I can't wait to try this next time I'm stuck ... in my documaentation I'll refer to the "ShadowFax Method" of shoulder reduction.
    :)

    ReplyDelete
  4. That is an awesome story - loved it!

    ReplyDelete
  5. Seriously, I want a diagram! Especially because brute strength will never be my, um, strength.

    ReplyDelete