Memoirs of an Emergency Nurse (6 page)

It is a common sight in the emergency department to see
people with objects stuck in their fingers, such as sewing needles or nails from a nail gun
.
Usually builders attend emergency holding their impaled hand out in the air as if they may die from having this nail through the centre of their finger. It’s always an unexpected sight as they really should be using a safety guard to prevent this from happening
.
N
ails from a nail gun are very hard to remove from soft tissue and can easily shatter delicate carpal bone
.
It often takes two people, either the patient or another nurse
,
to hold the finger stable while the doctor attempts to pull the 6 inch nail out with pliers
.
A
squirt of blood splattering up the walls
indicates
the force that is often
necessary
.

Talking of builder’s fingers, we also often had impact injuries, such as hitting fingers with hammers or dropping slabs of concrete onto fingers and it often caused trauma underneath the nail bed
.
If there is bleeding under the nail, there is little or no room for that extra swelling and liquid
.
T
his can be very painful and lead to further damage
.
An interesting way to deal with this is the same way we release pressure within a skull
-
removing some bone or trephining a hole so the blood can come out
.
Although the comparison stops there
.
P
ressure in the skull would be released by a neurosurgeon in theatre in a very sterile environment with specially made equipment.

In the emergency department
,
to release pressure from under the nail bed
,
we use a paperclip
.
Yes
,
a paperclip
.
T
his may sound odd, but I shall tell you the theory
.
The paperclip is a blunt ended metal, which is small enough to cause a hole to release pressure but
,
if
well
protected
,
will not cause infection
.
We usually sterilise the paperclip with heat in the form of a burning flame
;
it
easily burn
s
through the hard nail and cauteris
es
the edges
.
We place
the
patient’s finger on a hard surface, usually the dressing trolley
,
and put a waterproof pad underneath it to collect any blood
.
We wear protective goggles to guard against any blood spurts and then we heat up the paperclip until it is white hot
.
 
W
ith delicate accuracy and minor pressure,
we apply the paperclip and it
burn
s
through the nail quickly
.
There is usually a little give once the nail has been drilled through and as there is blood under the nail
,
it may squirt up through the pressure-releasing hole.

D
espite this sounding quite barbaric, the patient
does
not
usually
feel anything, as the nail isn’t sensitive
.
They
feel immediate relief as the blood drains out from underneath the nail
.

The ambulance service had called through
to warn us to
expect a male patient who had fallen twenty feet and now had
head,
back and left arm injuries
.
H
e had been given 10mg of
Morphine
and an antiemetic drug
called Maxalon
.
He was expected in ten minutes
.
T
he department was busy and short staffed
so
I continued to do a few minor treatments quickly
before going
to the resuscitation
room and
ma
king
it ready for the patient
.
Just as I’d finished
,
I heard the familiar ring of the paramedic doors opening
I went to the door and greeted
the paramedics,
and ascertained that this was my expected patient.
For the purpose of confidentiality
,
I shall call the patient John
.

He was strapped securely onto a spinal board and his neck was in a hard collar and his head was taped into head blocks so that he couldn’t move
his head and neck out of
alignment
.
Once in the resuscitation room, John was
transferred onto the
emergency
trolley from
the
paramedic trolley. We lined up the
emergency
trolley at the side of the narrow
paramedic
trolley
and
undid the seatbelts holding him into
the
trolley.
With two paramedics at his
left
side and two nurse
s at
his right, one doctor holding his feet and myself holding is head
and
neck, we informed
J
ohn about the process of moving him
across
without bending his spine
.
He was
advised to hold onto his elbows and on a count of three in unison we slightly lifted his right side up
with the use of the
sheet h
e
was laid on, keeping his head and spine in
line
at all times,
and
placed a
pat slide
under his right hand half of body, this would assist us to slide him onto
the
next trolley.
Once laid flat again, half on the pat slide, on the count of three
,
we all worked together and gently moved his body slowly onto the emergency trolley
.
 
T
he nurses on the right pulled him across with the paramedics on the left gently pushing his body across the slippery surface.
Once on
the
emergency trolley, we all slightly lifted his right side without breaking spine alignment and removed
the
pat slide
from underneath him.

As part of the assessment and high risk to spine after falling 20 meters
,
we began our assessment by cutting off his blood
-
soaked clothes
.
His left arm was bandaged, but it had soaked through a bright red colour
. It had the
metallic smell of blood
.
The
paramedic
s
were waiting so they could retrieve their spinal board, a hard thick plastic board that was rigid
and
offer
ed
maximum support and spine
alignment
when spinal injuries were indicated
.
With so many staff still in the resuscitation room
,
we again performed the log roll movement on
J
ohn so that his back and neck could be assessed properly by the doctor.

The paramedic at John's head gave the command
.
“Is everyone ready?
Roll
after three….
.
One
, two, three, roll
.
”

The doctor felt down John's spine from top to bottom
.
Jo
hn
said nothing hurt until the doctor pressed on L4, where
there was
a large swelling
.
John was able to feel both legs and wiggle his feet about
;
however
,
he was experienc
ing
pins and needles in his right leg
.

We pulled the spinal
board
out
from beneath him and he was laid on
the
emergency trolley. He had no neck pain but due to the mechanics of his fall
,
the
doctor wanted to
err
on
the
side of
cautio
n
and wait
for
x-rays
of
his
neck before removing the collar.
I began recording observations on the patient
;
blood pressure
and
pulse while
the doctor assessed his injuries
.
John was talking and indicating where it hurt
.
He stated that he was still in a lot of pain and therefore the doctor ordered another 5mg of morphine.
I grabbed a 10ml syringe and a white
drawing
up needle and
proceeded
to check out a 10mg vial of morphine from our controlled drug book
.
I
snapped a plastic vial of 10ml of saline and drew up 9ml
.
I
placed this to one side and
,
with my thumb and first finger
,
held the top of a pear
-
shaped glass
vial
and snapped off the top
.
I
the
n
drew up the 1 ml of morphine into my 9ml of
saline,
making it 10ml.
I
added an
orange
morphine sticker and I locked up the rest o
f it up. I
took
the syringe
to
the
doctor
and while he was administering
it,
I asked
J
ohn what
had
happened
.

He had been up three lengths of ladder and was on a roof
when
he lost his footing and fell onto his left side
.
H
e didn’t
lose
consciousness at the scene but he couldn’t move his left shoulder at all
.
No relatives knew that he was here, so I asked who he would like
to
contact
.
He
gave me his
sister’s
number and I got through to her
the
second time I tried.

All John wanted to do was sleep
.
He
kept asking for more painkillers and if we could put him to sleep
.
The doctor gave him the 10mg of morphine slowly as a bolus dose and I monitored him. Initially
,
the doctor suspected that
J
ohn had dislocated his shoulder and had a probable compound fracture, a broken bone that pierces the skin to his left elbow
.
H
owever
,
preliminary x-rays done in the resuscitation room couldn’t rule out a fracture of his spine and more accurate x-rays
had to
be done in radiology
.
The doctor and I packed up John
’
s x-rays, notes and
morphine;
I made the observation machine portable by taking it off its stand and attaching it to the side of the bed
, and then I
pushed
John’s
trolley around to radiology. Many series of x-rays were requested and it took half an hour for the films to be processed and looked at by the doctor
.

I stayed with John throughout his trauma x-rays series, just nipping behind the lead shield when each x-ray was taken and I talked him through the whole process
.
Once the x-rays had been completed, one of the radiographer assistants helped me push the trolley back around to emergency. John remained flat on the trolley with his head taped down
.
He
had to wait for the doctor to be free to review his x-rays before he could change position
.
Luckily
,
after
two
hours of constant treatment and numerous x-rays, the emergency doctor could see no fractures in
John’s
neck and gave the go ahead to remove his collar and head blocks
.
However
,
the orthopaedic consultant needed to review John as he did have fractures elsewhere
.
John was still in pain and another 10mg of morphine
was
given to him after his
x-rays
.

The orthopaedic consultant had just come back from holiday and was happy to come down to emergency to assess John
.
He had
fractures
in
his left
humerus
and
a
compound fracture of
th
e
left
elbow
.
D
espite the swelling in his back
,
the doctors were happy that there were no
spinal
fractures seen on his x-rays and the pins and needles in his leg had disappeared
.
After the doctor
had
spoke
n
with John to inform him about his condition and the good news about his neck
,
I talked John through how I
was going to
take off the collar and gentl
y
sit him up
.
After being laid flat for
two
hours
,
he would feel very dizzy
at first
and I told him step by step what I
was going to
do and also again
while
I was doing the task
.

The paramedics had put a gauze swab on John
’
s skin before taping his head to the spinal board
so
he didn’t have a painful waxing of his eyebrows
. O
nce the tape was removed and  Velcro
on the collar
undone
,
I slid the hard collar under the back of his neck the same way that it would have been applied and started to slowly sit John up bit by bit on the emergency trolley.
John still had pain in his arms from his injuries and
was
feeling
dizzy, hence
communication
was
essential to get
him
into a comfortable position
while he was waiting
for a bed
.
John had a total of twenty-six mg of morphine over his time in the emergency department
.
I went in to give
him
a drink of iced water after he was sat up to ease his dry throat
.
He would need to go to theatre to have his compound fracture washed out under anaesthetic and pinned into a better position to heal, but that would have to wait until
the next day
as all theatres were booked up
.

John’s left arm was in a poly
sling
,
holding his fractured arm across his
chest
and he
awoke when I came into the room
.
I asked him how he was feeling and his reply was “
M
uch better now that I've seen you
,
sweetheart
.
”
Amazing
!
A
fter all he’
d
just been through he
was
trying to chat up the nurse
.
T
he morphine must have gone to his head!