Friday, April 12, 2013


Today was a fantastic day for me.  I got to do some serious hands on clinical work at work today and loved every minute of it!  It all started when I noticed something a little funny about one of my patient's fingers...

There I was, sitting at the nurse's station surveying the scene.  I was feeling a little uneasy about how my day was going to turn out, since earlier a patient had flipped out on me and yelled at me because I kindly asked him not to sit on our desk.  He said I was disrespecting me and asked me if I thought I was the president or his mom.  Clearly not, or he would have been speaking to me with a much better tone.  Anyways, at about 1PM one of our out patient's came up to me and asked me if he could have a cigarette.  It was then that I noticed something funny about his finger.  I asked him if I could take a look at it, but at first he adamantly refused.  He stating he was treating it with medicine, as he furiously doused his hands with hand sanitizer and rubbed it all over.  He finally relented, and what I saw shocked me.  His hand was so swollen that his ring was cutting off some circulation to his fingers.  This is not even the worse part!  His fleshy tissue was actually bulging out of the grooves in his ring, and cutting into the dermis at the both ends of the ring.

You may have heard the story about the patient I worked with while I was doing my clinical rotations at the emergency department.  Well, his hand got smashed in an accident, and his ring was also cutting of his circulation, but at a much faster rate.  We struggled for 3 hours trying to get it off, when finally someone took my advice and called in the big guns: the fire department.  They came with bolt cutters so large, they would make you cringe.

Luckily, this "ring-ectomy" was much easier.  I helped stabilize while my coworker used the bolt cutters I found in the back of our hand guy's truck.  I did wash them with hot soap and water, and flamed them before use in attempt to sterilize.  When working psych, I have learned that improvisation and creativity is key.

Removed ring

We had to cut the ring in about 4 different pieces so we could pull it off without hurting our patient's delicate skin.  He kept insisting it felt fine and that it didn't hurt.  He was sad to see his $3 ring get cut off, but he understood that it needed to be done.  He kept trying to take the ring off himself, but we had to tell him to let us do it ourselves.  It's a good thing he did not try to muscle it off since it would have definitely torn a piece of flesh off.

Next we cleaned the finger with an antiseptic towelette.  We debated how to further clean it, and decided iodine would be the best route to take.  I did not realize that hydrogen peroxide is now contraindicated unless you are trying to do some serious microbe or dirt removal from a wound. This is because it actually kills skin cells and causes the healing process to take longer.  Supposedly lots has changed since my days of getting scrapped knees as a kid.  We were also aware that alcohol would hurt  way too much.  So we settled with iodine.  Iodine is commonly used to antiseptically clean areas before surgery. According to my microbiology class, iodine will disrupt bacteria's protein synthesis and plasma membranes, thus preventing them from carrying out normal functions such as replication. 

After we cleaned up, we wrapped him up with a loose gauze.  We wanted to keep the pathogens and dirt out, but also allow the wound to breath and heal.  I explained to him the importance of keeping the site clean.  "Use warm water and soap when washing your hands, and avoid getting your hands dirty," was my initial advice.  I also had to look him straight in the eyes and tell him the importance of calling us or seeing a doctor if his finger started to change colors, smell, feel tingly or anything unusual.  Although, for a schizophrenic, reality is often unusual.  Many schizophrenics are disorganized and struggle with personal hygienic practices.  I am a little worried that he will not properly care for his wound, so I will ask his study coordinator to call him next week to follow up and ask him how it's healing.

post ring-ectomy ring piece

I am so proud of myself for noticing such a serious, yet small and easily overlooked, condition.  His finger definitely had already started to smell a little bit, but if he had gone a little longer, he could have gotten an even more serious infection.  He could have gotten infected by Clostridium perfringens, or Staphylococcus aureus causing him to get gangrene or necrotizing fasciitis respectively.  He could have lost his finger, or worse.  We also noticed a ring on his other hand was causing a similar swelling to take place so we cut it off before it also got infected and cut into his flesh.

It's times like this that I really wonder about the marketing of "unbreakable" rings.  Serious, why would you want a ring that couldn't be come off?  One last random note to make about rings - I learned in my EMT class, if you ever come across a burn victim, the first thing you do after your quick initial exam is to take all rings and jewelry off the patient.  Hands will literally swell around rings and will cause circulation to be cut off.    

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