The anatomy of placing a traction pin in the Pediatric ED.

So every now and then there's adult patients that need to go to the pediatric ED for trauma triage and whatnot. They occasionally need traction pins placed...

The first step is informing the nurses that a traction pin needs to be placed...

To which the usual response is: 'You're going to sedate for that, right?'

This is usually followed with a general sense of nursing panic...

I try and start with...

And after an indeterminable amount of arguing...

I finally relent and agree to sedate the patient, which leads to...

And what normally takes 15 minutes and a vial of lidocaine in the ED has not become a hour long ordeal involving multiple health care teams, hundreds of unnecessary health care dollars spent.  Which is why when it comes to traction pins in the Peds ED...

Me: 'I just need you to sign right here.'
Pt: 'I can't move my hand.'
Me: 'You just moved your hand by gesturing that you couldn't move your hand.'
Pt: 'Nope.'

I had my last sign-out as a second year....it...did not...go...well....

I officially start my third year on suspension starting next week...  But then again, I haven't had a weekend off in over 3 months, so....

(With any luck, death by snu-snu)

The feeling of post spica films looking beautiful...

So I'm on call from 6PM to 6AM when I have to give sign out.  This week, sign out was voted to be moved to 730...

So I haven't operated in 3 months, and head to county next month where i'll be expected to run rooms by myself.  I expect this first week to go like this with the surgical tools...

Yeah, remember that gif of me walking in to the ED to reduce a shoulder?(http://orthopedicresidency.blogspot.com/2013/06/i-got-call-from-ed-about-shoulder.html)

I just had one I couldn't reduce and scheduled for an operative reduction...

So an ED nurse was putting a moist swab in the patients mouth and said 'Open your mouth.  I'm going to put something in, it's going to be wet, just suck on it a little bit'...

Last night an older intoxicated patient was hitting on a nurse by telling her that he had a large dong, and then proceeded to bare to her his rather large manjunk as proof...

After getting report from an outside hospital tonight that the patient had a 'type 4' supracondylar humerus fracture...




















(It was a type 1, flexion type).

Call from the peds surg resident: 'Hey, I know you guys are pretty much done with the patient, but would you mind transferring her out of the ICU to your service?'

Whenever a patient leaves the ED AMA...

My female attending this morning was talking to us about ex-fixes and said: 'size really makes all the difference in the world.'  The back of the room...

So an ED resident asked if I'd be on standby while they did a distal radius reduction.  I sat and watched....it went interestingly....

Without exception, this is my thoughts to my humerus post reduction films...

So every now and then my senior will tell me to do something which my attending disagrees with.  When the attending asks what my senior told me, this is the following conversation....

As someone who tends to sweat during difficult reductions, this is usually the scene when the post films look awesome...

I just had a blasted distal radius fracture that was reduced to almost anatomic.  Looking at post reduction films...

So I went to get some cookies that a female med student was standing in front of. She kind of shuffled out of the way to let me through.
Me: 'You're fine'
Me: 'Wait, poorly worded, you're okay.'
Me: 'Wait, umm...crap.'
(back out of the room without cookies.

What it feels like to ask a question during indications which would get the attendings arguing for a while...

Me: 'Hey, so about that hip dislocation consult, I don't see any films, am I missing something?'

ED resident: 'No, the consult was just based on the physical exam.'

How most of my arguments end with attendings...

(While applying a plaster cast)
Nurse: 'You're kind of getting plaster everywhere.'

My pseudo-humble response to an ED attending that complimented my anatomic reduction the other day...

So I grabbed a nearby attending, showed them a lower extremity fracture consult in a pre-teen that i was going to put in a splint so they'd get paid....the attending had me put on a spica instead...

I had an intern point out a patella fracture on an ipsilateral tib/fib right before sign out...

 I had a patient with a hand laceration that needed repair and I was at bedside.  Direct quote from the ED nurse to the patient: 'I know your pain isn't that high right now, but we should give you some pain meds to knock you out a bit. The doctors about to touch you...'

So I tried to contribute to an ED and trauma surgeon attendings discussion on a head CT.  It went like this...

So on night float, I leave my pandora station on.  Last night, macklemore's 'can't hold us' was on when i finished the last consult at 3AM and got back to the library.  The following ensued...

Anytime an ED resident says they saw my blog...

I got a call from the ED about a shoulder dislocation they couldn't reduce.  This is pretty much how I entered the ED...

Trauma team senior: 'You guys don't do anything about transverse process fractures right?'
Me: 'Nope'
Trauma senior: 'Sweet, we don't need a consult then.'

ED nurse: 'We were waiting on you to start sedation.  Were you taking a giant poo or something?'

I had a monteggia fracture yesterday.  Got it reduced great and casted.  Went to take one last look with the c-arm to make sure the radial head was still reduced before bivalving...

.

When the SICU pages the second time asking if I'm going to transfer out a patient...

So there was a Schatzker 6 tibial plateau in the ED.  Me and the ED attending pulled on it...and ...somehow...made it worse...

My immediate thoughts while sitting with a patient waiting for the cast to set, after saying: 'Now we just sit here and wait for it to get hard'...

ED attending: 'So if you want, my scribe can write up your consult for you...'














Followed immediately by...

So an ED nurse wrote me up for taking a kid out of traction that was digging into his crotch....without....sedation...

I sometimes get hit on at work, pretty much exclusively by female patients over the age of 75.  Regardless, I still feel like this...

 Last night while I was interviewing a patient, the woman in the bed next to us had a round of (what sounded like forced) flatulence.  This is what I pictured...

I got scolded by a peds ED nurse for not consciously sedating a kid that needed his near amputated fingers only irrigated...