When in Doubt, Improvise - @ JEMS.com

When in Doubt, Improvise


Howard Rodenberg, MD, MPH, Dip(FM) | | Monday, December 3, 2007

In an effort to be an up-to-date, hep-cat kind of guy, I've now got a personal digital assistant. I bought it because I thought I could be better organized, and because someone else was paying for it. Apparently it can do a whole lot of things that are going to revolutionize my life. I just don't know what they are.

After two months, I've discovered I can keep addresses and phone numbers in it, and that it has a calendar that doesn't accept entries crossing midnight (apparently, nobody with a PDA is supposed to work nights). I've also found that I can play Breakout and Minesweeper, and that when I push a button marked HOTSYNC, it makes a really cool, Star Trek kind of noise.

I mention my PDA because I bought a case for it. The case came with a stylus (computerese for "cheap plastic stick") that you use to write on the screen. The stylus came enclosed in a plastic sheath, which in turn was sewn into the lining of the case.

What a nice gesture, I mused. The folks who have just received 29 hard-earned U.S. greenbacks for making oppressed Chinese workers sew together small scraps of vinyl have given me a bonus piece of plastic (Kathy Lee, where are you?). It might be fun to take the stylus out and use it, I thought.

That's when I noticed a problem. The stylus has a small circumferential indentation about a quarter of the way from the end. However, the poor oppressed workers (I feel strongly about this) had sewn the sheath in so tightly that when I tried to pull out the stylus, the edge of the sheath caught the indentation, making the stylus impossible to remove.

One of the things I've admired most about EMS personnel is their ability to improvise. I've seen all kinds of unlikely objects used as splints and supports. I've watched as oxygen cannulae morphed into endotracheal tube holders. I've learned a new appreciation for tape. So I figured that, as a trained emergency healthcare professional, I could forge a solution to this knotty problem.

The first thing I did was use a pair of small forceps to try to stretch out the sheath. The forceps I chose had teeth -- sharp little projections on the tips that are wonderful for holding tissue and (as I discovered) ripping through little pieces of vinyl. After five minutes of trying to insert the forceps under the lip of the sheath in order to dilate the cover, I had a sheath with multiple small tears in the end, each of which then became individually wedged in the offending notch.

I then had a flash of clinical inspiration (which should have been my first sign of danger). There is a medical condition called paraphimosis, in which the foreskin of the uncircumcised male becomes stuck behind the glans on the penis. It forms a band behind the head of the male organ, and to release the obstruction to blood flow caused by the constriction, one makes a vertical incision through the foreskin.

(If I had been smart, I should have realized I was in trouble the moment I went for the tools. I am a person who managed to spend more than $350 to unsuccessfully replace a door threshold. It's a long story, but let it be said that within the space of 12 hours I learned about door sizes, masonry screws, high-speed drills and concrete. After not using the front door for the following four months, I also learned that most door problems can be fixed by having someone who knows what they're doing spend five minutes adjusting the hinges.)

Using the tooth forceps, I gently lifted the edge of the sheath (oops another tear, but that was okay considering what I was about to do). Using the iris scissors, I made a small, 1 cm vertical incision over the stylus. So far, so good. Now I would just have to draw back the sheath around where I had made the cut and presto! the stylus would be liberated.

No luck. It was still stuck. The only thing that had happened was that the bigger flaps of the sheath were getting snagged.

At that point, science flew out the window. Testosterone took over. It was me versus the vinyl, and only one of us would come out alive. If one cut is good, two are better, I reasoned. Or maybe three. Bigger cuts. LOTS bigger. Still no luck. I decided to dilate the sheath with forceps. Not delicate baby tooth forceps, but real forceps, 10 inches long and shaped like a bayonet. When that didn't work, I realized that I wasn't pulling on the stylus hard enough. After all, you can't get a good grip on plastic with fingers alone. What you need is a clamp. Not just any clamp, but an 8-inch-long heavy bone clamp. Yeah, that's the ticket. I pulled on one side and when that didn't work, I pulled on the other. And when that didn't work, I looked back and noted that since I'd done real live damage to the case, there was no way I could return it. As the heat of the moment wore away, I reflected that I'd spent an hour of time abusing 15 cents' worth of vinyl and $50 in sterile supplies (I didn't want the case to get infected) in failing to remove a stylus that didn't want to move and that I really didn't need.

I'm sure there's an EMS lesson in this for me. Maybe we should think twice about improvising without knowing what the end result might be. Perhaps this tale is a cogent reminder that our first duty as healthcare providers is primum non nocere, or "first, do no harm." It could be a warning that more technology is not necessarily better, and that high-tech is not always the best tech. But the only thing that occurs to me is that I've got a PDA case with the stylus still stuck in it, and now it's damaged beyond repair. Glad it wasn't a patient.

Amusing EMS Note of the Week: Since I've previously raised the specter of manhood in the above essay, let me refer you to the "Doorway Diagnosis" picture quiz feature in the June 2003 issue of Emergency Medicine News. This month's quiz presents the sad story of an adolescent male found in his car clutching at his groin (yes, that was my first thought too, but apparently no magazines were found). The photo shows a set of male genitalia with the functional extension (I'm out of clean aphorisms) pointing to the left.

The actual diagnosis was testicular torsion (a true, honest-to-goodness emergency), and the diagnostic feature was that the position of the testicle on the affected side appeared different than the other. However, an alert EMT reading over my shoulder noted that the real lesson here was that the patient had a positive Throckmorton's Sign. For the unenlightened, Throckmorton's Sign is analogous to Peter's Sign, where the (you're way ahead of me) member points to the side of the lesion.

In an effort to be academic, I've looked through a dictionary of medical eponyms to find Throckmorton's Sign and Peter's Sign. I couldn't locate these terms, but I did find Throckmorton's Reflex (I'm almost afraid to find out what that is), Peter's Anomaly, Peter's Method and Petersen's Bag (we're not going there). I regret that I am unable to contribute further to the intellectual discourse surrounding these crucial points in the physical exam. However, I do wish to note that Peter's Sign is not to be confused with the Peter Principle, a management axiom which states that people rise to the level of their own incompetence.

On second thought, maybe there is a link...

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