Posts Tagged ‘silver nitrate’

A procedure I couldn’t talk the patient out of

October 29, 2017

I looked down at the big toe

To see how the nail did grow

It sure wasn’t right

And it hurt day and night

So I fixed it, but not for the dough.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. I followed 3 years Community Health Center work with a return to traveling and adventures in temporary positions in Alaska, rural Iowa, suburban Pennsylvania and western Nebraska. After 3 months in northern British Columbia, and a month of occasional shifts in northwest Iowa, I have returned to the Arctic.  Any identifiable patient information has been included with permission.

Medical school and residency merely start the process of lifelong learning required of my profession.

In residency, I saw one ingrown toenail removal before I did three under supervision. In the Indian Health Service, a podiatrist said, “This is the procedure that’s going to put your kids through college!” and gave me some tips on speed.  In the 90’s I did quite a few, but by the time the century turned, despite a large financial motivation to the contrary, I figured out how to get the patient taken care of without shedding blood.  A bit of cotton, an orange stick (a wood implement widely used to rearrange cuticles) and a bit of povidone dione (marketed most commonly as Betadine), with patience and about a week, can usually move the flesh away from the nail a millimeter a day.

Over the summer, researching the problem while in Canada, I came across the concept of a nail spreader, which can flatten out a curved nail over the course of several months.

But the patient yesterday (who gave permission to write more than I have) had already tried everything I had to offer, yet the problem persisted.  And I couldn’t talk  the patient out of the procedure.

Finding the right equipment takes up more than half the time of an office surgery when neither the physician nor the nurse knows where anything is.

I got trained to not only take out the nail plate, but scrape away germinal matrix (the tissue that makes the nail) down to the bone with an instrument called a curette, then apply a chemical, phenol, so destructive to human tissue that the nail would, hopefully, never grow back.

We had no curette, and no phenol, and I didn’t mind: less work for me and a good deal less blood loss.  At the end, I used a stick coated with silver nitrate to burn the heaped-up inflammatory tissue growing over the nail.

During the procedure we talked about high school sports (very important in small-town America) and music while outside, the gentle snow fell.

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Cocaine, nosebleeds, and snakebites: lessons learned in a hurry and not forgotten.

January 30, 2011

Is cocaine the thing that you need,

When it comes to a nose that would bleed?

     Would some other med

    Do the same job instead?

It depends on the books that you read.

I did my residency in Wyoming.  Thirty years ago, I had a license and when I had a free weekend I could work where doctors needed help.  Most places paid fifteen dollars an hour; a seventy-two hour weekend could generate a lot of cash for a young man who had just finished twenty-one years of student poverty.  I soon found that the value of the learning experience exceeded the importance of the money.

In a large state with very few people, before the Internet, I found the pressure of dealing with medical problems outside my experience stimulated me to read, learn, and retain. 

Once, the ER where I was moonlighting got a call about a person who’d been bitten by a snake and would arrive within five minutes.  I had never seen a case of snakebite, but I went to the bookshelf, pulled down Rosen’s two volume Emergency Medicine, and read as fast as I could.  I looked up; no patient, but I had another minute before arrival.  I pulled down Harrison’s Principles of Internal Medicine and read what it had to say about snakebite.  The patient now three minutes late, I took a breath and started plowing through the books at hand.  Twenty minutes later, amazed at how much I’d learned in so short a time, I went to lunch.  The patient never arrived.

When confronted with a frightening nosebleed, Emergency Medicine provided me with a chapter that shines as a paragon of what medical writing should be: a review of the anatomy and physiology, elements of history and physical, proven techniques, and pitfalls, in a concise ten pages.

I faced an epidemic of nosebleeds at the Indian Health Service hospital where I worked fresh out of residency.  I could never determine if my hospital alone or if the area IHS hospitals in general had had their supplies of cocaine removed, nor for what reason.  I knew, for sure, that when I was confronted with the only legitimate use of the medication, nosebleeds, or epistaxis, I couldn’t get my hands on the drug of choice. 

We made do with 2% Lidocaine with epinephrine.  For a year and a half I saw a minimum of two major nosebleeds a week.  Most were the common variety, where the bleeding comes from the front part of the nose, but we also saw the terrifying bleeding from the back part of the nose.  I remember calling up the consultant in the big city at the other end of the highway and saying, “The patient has my best anterior (front) and posterior (back) nose packing job and he’s still bleeding, I’m afraid you’re going to end up ligating (tying off) his external carotid artery.”

“Nah,” he replied, “I haven’t had to do that for ten years.”

He called me the next day and said, “I had to tie off the external carotid.”

My experience with nose bleeds has stood me in good stead ever since, and yesterday I took care of two patients with that problem.  For one, I simply pinched the soft part of the nose shut for five minutes, and the bleeding stopped.  When I looked at the middle part of the nose, I found diffuse redness. 

The dry air in Barrow gets worse in the winter, and noses desiccate and bleed; most of those patients don’t need anything more than a little bit of Vaseline a couple of times a day.

When I looked at the other patient I found a snake-like varicose vein, the origin of the bleeding, about the length of an eyelash.  Numbing the area the way I’d learned in New Mexico, I touched bleeder with a silver nitrate stick for three seconds.  The nitric acid from the stick created a burn, and the vein stopped functioning as a blood vessel. It won’t bleed again.

It hurt like the dickens.  The Lidocaine hadn’t done its job as anesthetic, not like cocaine.