Tuesday, December 16, 2014

Dr. Orthochick: Pinky

I got paged in around 23:00 the other night to reduce a kid's pinky finger. I would have been less annoyed, except it was the second time in a week that I've gotten paged in around 23:00 to reduce a kid's pinky finger. It's times like this I really wish the ER knew how to do stuff like reduce fingers. (they tried once earlier this year and then I got paged to redo it when they messed it up. So I guess they're scared of trying and honestly, redoing their crappy work was harder than if I had done it myself in the first place so I probably shouldn't complain, but seriously guys, it's a freaking pinky.)

Me: So when did this happen?
Mother: Around 19:00. So we went to (outside hospital) and they told us to come right here.
Me: Uhhh...
Mother: Well, first we went home and [patient] took a shower and then she had dinner and then we came over here.

One could make the argument that if you feel like showering and eating dinner, you probably don't have an emergency going on, you could also make the argument that doing a reduction sometimes requires sedation and if you've just eaten it makes it that much harder to do that. But I was telling this story to my sister and she brought up the time that she fell off her bike and needed stitches in her chin and mom convinced her to shower first under the pretense that she would feel better. She claimed that she did not, in fact, feel better, but this is the same sister who continued ice skating after she broke her elbow and continued skiing after she separated her shoulder. And the same mother who told me I was too old to have an earache (I was 13 or so), at which point my eardrums ruptured and leaked pus into my hair for the next week and I wound up on 2 courses of antibiotics.

Anyway, reducing kids' fingers is annoying. I'm a big fan of sedation for pediatric reductions. One of my coresidents never does it and things seem to go fine for him, but i'm of the opinion that you can only get away with that if you're convinced you can get it on the first try. And I'm not. So usually I sedate kids because it's a lot easier for me to do a reduction if they're relaxed, I can do it as many times as I need to to get it perfect, and I think the parents probably prefer not hearing screaming followed by the crack of a bone. (and sometimes it really does make a loud crack.) but if it's just a finger, it's kind of overkill to sedate the kid and the risks outweigh the benefits, so the ER won't do it for you. But you don't really have great options. I could do a hematoma block, but that involves sticking a needle in the sore area and injecting numbing medication, which burns. I could do a wrist block, but that's three needle sticks and burning. I could just do nothing, but then parents get mad. If it was my finger, I'd probably go for nothing since that numbing medication stuff seems to burn like hell and it's over quick anyway, (and I am sure my parents would be fine with that since over the course of my childhood I remember getting tylenol once and it was because I had a fever of 104 so really, mom and dad were not quick with the analgesics here) but not everyone's parents are so OK with hearing their kid yell.

So I gave the kid (and her mother) the option of hematoma block or nothing, they picked the hematoma block, and the kid screamed like hell while I did it and for a good few minutes after. This was after the 20 minutes of crying leading up to the hematoma block once i explained what it was. So once we did the stupid hematoma block we actually did the reduction (seriously, I pulled on the finger and got it straight. I would say this took under 10 seconds at a conservative estimate. We could have done this a couple hundred times in the time it took the kid to calm down from the stupid hematoma block)


At least the kid was super cute. She was actually the second super-cute girl under age 10 with a pinky fracture who I've seen in the past week, so either kids are getting cuter these days, pinky fractures only happen to cute kids, or I'm starting to get mushy in my old age.


  1. When I was in the Navy we often opted out of doing blocks on fingers because the block usually hurt more than either reducuing or stiching the finger. We either would ice until numb or have the patient pinch the sides of the finger which seems to act as a nerve block as well. However, this would be more difficult with the peds population. Would perhaps giving an oral anit-anxiety be benefical?

  2. @ Old Squid: I was thinking the same thing. Diazepam 2mg po?

  3. I remember getting my arm set in the ED when I was 4. I WISH they'd used a sedative. I was so freaked out! It also hurt a lot.

  4. I work in a pediatric ER and we have that same problem... but the other way around. We insist on sedating children por procedures like reductions, at least give them some intranasal fentanyl or inhaled nitrous oxide but most of the time surgeons o traumas claim they do not have enough time to wait 15 minutes so the drugs can start working...

  5. In my ED, we do these reductions ourselves - usually with a ring block. Although if I had a resident with your condescending attitude about how "the ER" doesn't know how to do "stuff like reduce fingers", and having to fix their "crappy work", I would make sure to page you every single time at 2:00AM. Seriously; you're a resident. You're there to learn. If it's the standard of care at that hospital that Ortho reduces finger fractures, then suck it up. If not, then complain to your attending.

    1. I can't speak for Orthochick, but I don't think it was meant in a condescending
      manner. I think it was said "tongue in cheek." For lack of a better analogy,
      a parent may say to their child, "you're such a spoiled brat," but they're saying it with a smile in their voice.

  6. Our ED does their own finger reductions, as do most in the real world. It's hard to screw that up. But it's much easier to work with a consultant when they don't condescend to you. Remember, you did a residency in this, not me. You'll appreciate those 23:00 pages when you can bill a fortune for them.

    Also the reason we don't normally want to sedate for y'all (at my place anyway) is because the resident wants 3 tries before he calls the staff who usually takes them to the OR anyway and it's not safe to keep them down that long. Not to mention it keeps us tied up an hour or so away from a busy and crowded department.

  7. @ Anon at 3:50: I think this is a misunderstanding. If I'm not mistaken, you're hearing Orthochick saying, " those folks at ED don't know how to do a simple reduction!" However, if you listen to the "music" not the words, I'm hearing, " isn't
    it nice that they need me?" It's like Aunt Bee saying, "You made such a big mess, I don't know how I'm going to clean it all up!" The subtext though is, " It's so good to be needed."
    Does that make sense?
    - Paul

  8. By the way, to the physicians who work in the ED and residents like Orthochick, I
    know you folks are under terrible stress. I recently had a visit to the ED, and within
    a few weeks I received a survey! WTF?! I'm supposed to evaluate physicians and
    staff? It upset me that medicine has come to this. It's not enough that physicians
    are busy with administrative work and drug seeking patients! I would NEVER
    give my physician a bad evaluation. First, I don't feel I'm in a position to do the
    evaluating. Second, even if I was in a position to do the evaluating, on principal,
    I wouldn't. Third, excuse my french, SCREW YOU Corporate A-Holes that treat
    physicians like they're employees, not highly trained specialists.
    So, I hate to see you folks fight with each other. After all, you're my heroes.
    - Paul

  9. Correction: principle, not principal. I don't want you folks to think I'm an idiot.
    I own exclusive rights to that ! - Paul

  10. All of emergency rooms are not created equal. Maybe the doctors at hers don't have great training in orthopedic issues. I don't think it's a reflection on all emergency rooms.

  11. These questions of EM scope/consultant scope are endless and they will always be with us.

    When I'm frustrated at having to do/fix something I think a resident/referring doc/RN/scribe/whatever should know how to do, I try to take that moment to teach a little. If EM at your shop doesn't know/doesn't feel comfortable with doing a good finger reduction, somebody from ortho ought to take an hour and show them how.

    I mean, we don't know what we don't know. I used to be angry at consultants who sneer at EM for not knowing how to do a "simple" thing. After a few years in practice, I just laugh. Our scope is so impossibly broad, and we do so much shit because there's no one else who'll do it, that that particular lament just amuses me.

    Within the last month I have seen sick neonates, tapped ascites patients, intubated, criched (for the first and I hope the last time,) brought back an arrest, placed an introducer, sedated a violent CP kid for CT, done a femoral nerve block for a hip fracture, and treated heart attacks, strokes, sepsis and septic shock in patients from 12 days old to a hundred and three.

    If you don't want to be called for a reduction, teach 'em. I promise you they've learned to do scarier things than that.