I took care of a patient with a messed-up foot recently. He had been driving a 4-wheeler while wearing sandals. There was some alcohol involved. He broke his foot and got a bad laceration. He was taking it pretty well, but had a lot of pain.
I gave him some fentanyl to help make him comfortable, then proceeded to remove the bandaging the paramedics had put on. I wasn’t prepared for what I found under there. There was so much gravel in the wound, it was difficult to make out any of the anatomy. He continued to cry out in pain, but the medication wasn’t working well enough for him. I ordered more medication, hydromorphone, a potent narcotic. He was able to lie still briefly but whenever I would try to examine the foot, he would scream and cry out. But, during the short time when his pain was controlled, I could examine the wound. Tendons were exposed and moved whenever he flexed his toes. A faint beeping could be heard from the monitors. I brushed it aside in my mind. He tendons moved! This was at least a good sign, telling me his tendons were mostly intact. The x-ray was reminiscent of those times I have seen victims of a shotgun blast; brightly lit objects all over the x-ray film, making it hard to see anything else. Was there a fracture there? Was it dislocated? While looking at the x-ray the beeping became more pronounced. It took the nurse to tell me that his oxygen saturation had started dipping. That’s the narcotics working. They help with pain but they decrease the body’s drive to breathe. He was crying out in pain again. He needed more medication, but not at the expense of his breathing.
After my brief look, I could tell that this patient would need the orthopedic surgeon. I called and he asked me to wash out the wound while he would take a look. He planned to operate in the morning. Due to his continued pain, I decided to do a regional block. This is when I inject medication around the nerves that give feeling to the foot. This can be a huge help with pain control as it doesn’t stop the breathing. I got ready to go, but to my amazement, I couldn’t find the normal landmarks of the ankle. Everything was off. The skin had been stripped away and shredded to such a degree that there was no good area to inject. I realized that he needed to go to the operating room, get put under, then have this wound cleaned and stitched up ASAP. I called the anesthesiologist to the ER to help with sedation, to put him to sleep for the cleaning. Anesthesia had some concerns about doing the sedation in the ER. Luckily for the patient, the anesthesiologist suggested that we go to the operating room rather than try to repair in the ER. It made sense to only put this person under once rather than once in the ER and once in the OR again.
My problem was that I got narrow-minded. I looked at only the foot and missed that his breathing was slowing down. I wanted to be the hero and to the crazy repair of the foot, but I didn’t have the experience. I wanted the glory but I lost sight of the patient.
Only when I could take a step back and assess the situation was I able to make a good judgement. I thank the anesthesiologist for guiding me.
Don’t Let Your Focus Blind You to Other Possibilities
How many times have I suffered from this problem in the past? I want to keep Authority for myself, to decide for myself, to do it myself, and I do a poor job. I’ve told you about my first-ever flip experience. I wanted to do everything myself. I spent a whole summer in that house, tearing out asbestos-tile in a sweaty protective suit, painting, putting in new counter tops, rerouting plumbing. I did it all because I thought I would do it the best (not to mention how much money I’d save!). In the end, it costed more for me to do it then for a professional, mainly because I took 5 times longer than they would have. I only realized later that there are considerable expenses that must be paid when you own a place. These ‘holding costs’ can tank your deal as fast as narcotics can drop a person’s oxygen level.
Sometimes, we have to give Authority to other people. We keep it at our own peril. It makes us decide poorly and makes us not seek help when we should. It happened to me in the ER and it happened to me in the flip that I lost $8,000. When in those moments, we always need to pause, take a breath, and step back. Then ask the question, “What am I missing?” Answer that question and you’ve nearly won the battle. Don’t just rush in and try to fix it alone. Realize that there might be better people to do it than yourself. Get help when needed. You’ll go way farther once you embrace this simple thing.
