Calling in a specialist to help with an unusual injury
Fifteen-year-old Justin Villard lies on the exam table and nervously crosses and uncrosses his legs. His long, brown eyelashes bounce slowly up from his ruddy cheeks as he tells what happened. His voice is matter-of-fact, even though what he's talking about sounds horrible.
"I picked up the staple gun to move it and accidentally pulled the trigger. The safety was off and the staple went into my arm. I didn't feel it for the first 30 seconds, but everyone was looking at me, saying 'Oh my gosh! You've got a staple in your hand.'"
This isn't just any staple, but an industrial, two-inch-long staple used to penetrate wood. Justin's mother, Joanne, looks on, barely able to glance at the painful-looking injury. Justin was helping a friend repair a roof when the accident happened. Now, the staple has punctured his arm clear from one side to the other. Two thick, steel points protrude about a quarter-inch from his bloody inner wrist.
Kathy Wussow, MD, a pediatric emergency medicine specialist at Children's Hospitals and Clinics - St. Paul, is in charge of Justin's care in the emergency room. She seems unsurprised by the injury. Because they only treat children, staff members at Children's two emergency rooms are specialists in the unique. "In general, we see lots of the unusual injuries," says Wussow. "Kids come up with all sorts of interesting things to do."
One important aspect in treating patients' out-of-the-ordinary injuries is the availability of subspecialist physicians. Subspecialists have years of extra training in highly specific fields of medicine. A surgeon, for example, is a specialist. A pediatric surgeon, on the other hand, is a sub-specialist. A comprehensive range of specialty and subspecialty physicians is available to Children's ER patients on short notice.
After looking at Justin's arm, Wussow calls Jeff Weil, MD, of Metropolitan Hand Surgery* of St. Paul, who specializes in injuries to the hand. A short while later, Weil joins Wussow in Justin's room. Weil presses and taps on Justin's arm, hand, and fingers. Justin winces with pain. "I'm sorry to hurt you," Weil says, "but it tells us a lot if you can feel the pain."
The exam reveals some good news that Weil shares with Justin and his mother. "The staple goes by a lot of vital structures in the hand, but it may have missed them all. This may be one of these that dodged the bullet. He has sensation, he has blood flow, and it looks like the tendons are good." Justin's mom sighs with relief, but isn't completely consoled. There's still the matter of removing the staple.
The medical team decides to try a technique called conscious sedation, which lessens the pain and mental trauma of a painful treatment. A combination of drugs deadens a patient's nerves and obscures the memory of the treatment. If conscious sedation works, the team can remove the staple from Justin's arm without surgery.
Justin takes a drug cocktail of morphine and a potent sedative. His eyes haze over as the drugs take effect. "I'm looking at my feet and they look like they're deforming," he says woozily.
"Should we give you more medicine?" asks Susan Nygaard, RN. Justin narrows his eyes, concentrating hard on nodding, but his head only moves a few inches. She administers more of the medication.
Justin's mom visibly tenses and fidgets in her seat as a dark red solution is painted on her son's wound to sterilize it. "I'm a nurse – in surgery – but I can't stand to watch," she says. Justin's eyes close.
Wussow and Weil consult over a tray of instruments near Justin's bed. Each team member takes their place and the room grows quiet. Weil counts to three and pulls hard on the staple. Justin groans in pain. Weil gives it one more try – counting and then pulling again – but Justin groans even louder and struggles despite the heavy drug doses. The physicians agree: Conscious sedation isn't enough, and Justin needs surgery. He is wheeled upstairs to an operating room at Children's.
Once Justin is completely sedated, Weil is able to tug out the staple within a matter of minutes. Justin spends the night at the hospital, and by morning, the pain is gone and he's ready to go home. Later in the day, he even goes fishing.
Weil speaks matter-of-factly about the surgery's success. Although the injury may seem rare, it's the kind of thing he's seen before. "Power staples usually miss everything. You don't have to do a lot of reconstruction because it seems to find its own way," he says.
Within a week, Justin is shooting hoops in the driveway of his house. Joanne, his mother, sums up the family's sense of relief. "We're glad it all turned out as well as it did. We couldn't ask for a better outcome."
* Since this story was written, Metropolitan Hand Surgery has merged with Summit Orthopedics. Services are provided through Summit Orthopedics' Downtown St. Paul Hand Clinic.