Firecracker

So I was in Minors, and the next card I pick up is of a 68 year old male and I read the triage nurse’s notes and…I can not understand what she means by “linulated banger wart af n left hand, wounds to thumb and index finger”. So something happened in a different language that resulted in wounds to the thumb and forefinger of this gentleman. He did something to a banger? Did she mean a badger? This should be interesting. Could she have written it in a more confusing manner? Doubtful.

I called his name and he walked into the cubicle, with a blood-stained (soaked?) dressings wrapped around his left hand. I introduced myself and admitted downright that I had no idea what had happened to him, so could he tell me in his own words? He told me he was a farmer, and essentially to scare away birds and small animals, they light up this firecracker type thing at the end of a long rope, and with the help of the rope swing it up into the sky and it lands far away into the field, and explodes with a loud bang (hence called a banger!), acts as a sort of loud scarecrow, if you will. And what had happened today? “Well I have been doing this for years: I never use the rope, I just take it and light it in my hands and then lob it off into the distance. And I just have been very lucky these past 45 years!” So he basically miscalculated the timing this time, and it exploded in his hand before he could lob it. It now dawned on me what the triage nurse’s writing meant. lighted banger went off in left hand, wounds to thumb and index finger.

So anyway, I exposed his wound after donning some gloves. As I began to unravel the dressings my nose detected the heavy smell of burnt gunpowder/spent explosive caps in those toy pistols we used to play with as children. His thumb had born the most of it, with the nail literally split down the middle, the edges flaring up and out; the soft tissue of the pulp of the thumb was shredded, and all I could think of was how I was meant to stitch the nail back together, with no rest-of-the-thumb left to hold the sutures together.

His sensations were still remarkably intact, and the wound was oozing, but not profusely bleeding. He had a similar but smaller, less extensive wound on the index finger of the same hand, and a few other small spots that had singed or burned. He had full range of motion, surprisingly, of all interphalyngeal joints; nevertheless I realised I needed to get an x-ray done to rule out any bony injury, before progressing to the matter of how to fix this.

x-rays were requested, and they showed as expected a comminuted (read shattered) fracture of the distal phalynx of the thumb (an open comminuted fracture, since the skin/flesh was denuded over the fracture segment) and a simple fracture of the distal phalanx of the index finger as well.

Orhthopedics! My job was done! I bleeped the orthopaedics registrar (with half of my brain telling me it might get shoved on to plastics) but he very kindly agreed to come down to review the patient, and that was that. I decided to go take a break after this. But he had other plans in mind for me. He requested I do a ring block around the base of both the injured digits, so the finger and thumb would become anaesthetised and he could give it a good clean. A ring block is essentially local anaesthetic injected into the base of the finger or thumb in question, on either side, which numbs the nerves supplying the finger and you achieve localised sensation loss (temporarily) used mostly for nail bed injuries or nail-related procedures. I injected his thumb, not a problem, two jabs and all was amazing. I then moved on to the index finger, first jab was alright (3rd in total, including those of the thumb) but the second (or 4th?) as I was injecting it he said oh I feel a bit hot, and i feel a bit sweaty and I feel like I maybe am about to pass out and…oh here I go. And off he went. *kerplunk* fainted right in the chair. We quickly moved him onto a trolley, he came round quickly, very embarrassed. I re-assured him, even though I had just almost shit my pants thinking please be ok please be ok. My external facade was calm and cool, you gave us quite a fright sir, but you’re alright, don’t worry about it, these things happen  while on the inside I could feel my teeth clenched so hard I thought the muscle in my temple would pop out. The orthopedic reg was still stood in a corner, and he looked like he had shit his pants. I reminded him to come forward and continue. We administered the rest of the local anaesthetic, and the ortho reg happily cleaned the wound of any debris that may have collected in the wound(s), washed it with copious amounts of saline. He then cleaned the wound and dried it and applied an impressive dressing to the hand (the thumb and index finger were deemed best to heal this way). The rest of the plan of management involved IV antibiotics stat (he opted for gentamycin and flucloxacillin), and oral antibiotics to go home with (co-amoxiclav x 7 days), and we all remembered the tetanus toxoid, which was administered, and the patient went on his way. He was to return to orthopaedics fracture clinic the following week.

Take-home message: 1) Lie patients down when injecting them with things. However macho or well-adjusted to the pain or the trauma the patient might seem, you would be surprised at what a needle and the sensation of local anaesthetic being injected into any part of your body can do for your consciousness. *kerplunk*
2) never use ‘bangers’ or any explosives in your own hands, you may think you have it covered, but a firecracker in your hands might just be a case of having too much on your hands.
3) never question a triage nurse’s writing. or any nurse’s for that matter. Karma will hit you back with such a vengeance you won’t ever forget it.

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