Have a happy and a safe 4th of July all!!!
Despite wonderful job security for myself and the rest of the ED staff, please don’t play with fireworks if you do not know what you are doing, are intoxicated, or didn’t invite me over to watch you blow your fingers off like this poor man!
An important lesson in why lack of knowledge and a little Heroin just don’t mix well...say what?! 🍻💉
This patriotic lad swore he was holding a near harmless smoke bomb when in fact it was a professional grade mortar/aerial type firework💥.
Aside from the obvious damage to both hands, he also sustained substantial degloving injuries, second and third degree burns to his chest and arms, and probably a great deal of psychological trauma.
Those who are opiate dependent have very high tolerances and the majority of the pain medications we give in the hospital setting are in fact opiates or opiate derivatives. Once A,B,C were all cleared, the priority became pain and infection control as the patient was causing further damage from writhing and understandable shock.
Additionally, the start of July is not exactly the time you want to have to come to a teaching trauma hospital if you can avoid it! For my non-medical followers, July 1st is the start date for brand new doctors to begin their residencies! July 4th is also a busy day for the hand surgery team and thus this patient was down on the list as OR was full and all the hand surgeons were with other cases.
So how do we manage the pain for a patient like this who is screaming and flailing in an ER bed for hours? Well when I called the physician with an SBAR for his new admit, he ordered 1mg of Dilaudid…..huh?? I had a talking to with him and he reluctantly ordered 1mg more. Ummm no this isn’t going to do.
I then suggested two additional options. A low dose Ketamine drip (an opioid sparing analgesic, sedative and psychotropic) used in conjunction with pain medication, or intubation with sedation. I was scoffed at and told that I was 'crazy', I defended my choices, albeit sternly, and demanded the doctor come see the patient before making such decisions.
He wasn’t happy, but once his chief found out…he got a scolding and I got an apology, the ketamine drip I wanted and that the patient needed 😝.
Due to the heavy influx of hand injuries that week, this patient actually was admitted to a med-surgical floor BEFORE he had surgery with the idea that the hand team would get to him within the hour. I found out later the next day, from the patients wife in the elevator, that he still had not gone.... in the end this poor bastard didn't have surgery until 36 hours after the initial incident! God bless those med-surg nurses who learned how to deal with an unstable traumatic injury that day ..
**identifiers altered or removed to protect patent identity ***