27 May 2010

Vivid language

As a generalist ER doc, there are so many things that I have not done or do only occasionally.  When one of those things pops up, as they do almost every day, I have the good fortune to be able to call a specialist. If it's an item which is clearly outside of my competency, then they come in and take care of the problem.  More often, however, it's something which I am perfectly capable of doing, after reviewing the options and discussing the technique with the specialist. 

This is a nice situation to be in, since it saves the specialist the need to come in, reduces the delay in care for the patient, and allows me to learn and increase my own abilities.

But sometimes the advice I get is a little surprising, or at least couched in terms which most people would find disturbing.

For example, the other day I saw a 14-year old boy who was helping his father change a flat tire when the jack handle snapped up and hit him in the face.  One of his lower incisors (#23 for those of you keeping score at home) was avulsed.  He and his dad got into the ER within 30 minutes, and showed me the tooth.  It was intact, though it had been allowed to dry out.  We washed it in saline and threw it into a milk solution.  This is one of the few true dental emergencies: if the tooth is to be salvaged, it needs to be re-implanted within one hour.  The fact that it had been allowed to dry out greatly reduced the likelihood that it would be salvageable, but it was worth a try.  The only problem: I had never done this before, not in the thirteen years I've worked in an ER.  Intact tooth avulsions are just not that common.  Worse, on exam, all of his lower front teeth had been pushed back a bit and I couldn't even see the socket where the tooth must have come from.  I made a tentative effort to just slide it back in, to no avail.

So I called the oral surgeon.  There was no way he would be able to come in in time to fix it himself, but I wanted some advice.  This is what he told me: "At 14, his alveolar bone is still pliable.  So you need to do a really good dental block, find a likely-looking spot, and just cram that son of a bitch in as hard as you can.  Don't worry, it'll go.  I'll see him in the morning and properly fixate it."

Cram that son of a bitch in as hard as you can.  

Yeah, that made me cringe a little bit, too.  So I did.  Good anesthesia made it painless for the kid, and I picked a spot in the bloody mass of gum and shoved.  It took enough force that the kid's jaw was pushed down quite a bit, but then something gave with a crunch and the tooth slid right in like it was supposed to be there.  Which, I suppose, it was.  It seemed solid enough, and who knows if the thing will be viable, but we gave him the best possible chance.

Then the same evening, there was a nine-year old girl who fell off the monkey bars (or as orthopedists call them, the money bars).  She had a nasty fracture of her wrist:

Uploaded with plasq's Skitch!

I don't generally reduce these.  There is enough displacement as the bones over-ride (or "bayonet") that we usually call ortho in to fix them.  That's more a matter of practice style, though, and there's no reason why an ER doc can't reduce it.  I called my orthopod, who unfortunately was just going into a big case which would take him several hours.  He reviewed the film on line, and advised me that if they wanted to wait, he could do it much later in the evening, or I could just do it. I'm generally game, and asked if he had any tips.  "Sure," says he, "you need to put her under -- deeply -- and basically recreate the injury.  Don't be wimpy about it: you have to go medieval on her.  There'll be a nasty crunch as you complete the ulnar fracture; don't worry about that.  Make sure you have the parents sitting down or out of the room. But if you can bend the fracture site all the way back past ninety degrees, you can push it back onto the shaft and it should stay in place."

Hrm.  Go medieval on her.  That doesn't sound real pleasant, does it?

But I did.  It was actually just like doing tuite -- joint locks on the hand and wrist.  Got an absolutely beautiful reduction.  Her dad went a little green at the whole thing, but stayed conscious.  Truth be told I have seen this done innumerable times, so it wasn't exactly terra incognita to me.  But it was satisfying to do it myself for once.

And now, when I describe the procedures to my partners and trainees, I am sure to include the vivid language.  It really helps describe what you actually need to do to accomplish the technique.


  1. "Going medieval" is /such/ an apt term for reducing a wrist. I reduced my husband's wrist recently and it looked much worse than I expected, but it was my first time reducing a wrist. (I'd only reduced shoulders and an elbow before that.)

    Caveat: I am not a medical professional. I do not play one on the internet. I am simply a well-trained layperson with a husband that would rather have me "fix [him] up" than follow his doctor's advice. You don't want to be like him.

  2. Heart and brain surgery next!

  3. Good for you, on both cases!

  4. Is that really a wrist in that x ray?

  5. Yes, that's a real x-ray of a wrist (side view). If I remember the skeletal system correctly, it looks like a fracture of the Radius.

  6. Bloody hell, glad I'm not an ER doctor! My brother broke his leg when he was little, and I remember the doctor setting it incorrectly...instead of anaesthetising his leg to fix it up, they just cut a wedge in the plaster, stuck a cork in and used it to push the bone into the right position. I'll never forget the screaming...


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