Pen in the eye

There are certain things you like and certain things not so much. I dig just about anything trauma related. But eye trauma is one of those things that I just find sort of creepy. Well, in a recent trauma lecture we had a great Head & Neck surgeon come and talk about facial trauma...which of course included eyes. It was great to learn the nitty gritty of Le Forte fractures, which we see quite often in facial fractures, but the orbital trauma makes me want to squirm.

Apparently jail inmates place an empty pen shell over a real pen. So what this means is when they stab someone, they pull the pen out and everyone thinks that what went in came out, but really the pen shell got pulled off and left behind. This matters anywhere a person is stabbed, really. But we saw video of a this being next to the eye. A patient stabbed to the eye complained of pain to the eye and initial providers sewed the lac without further imaging. There was some mild edema near the medial canthus, however no overt signs of a large foreign body. Yet once transferred, further imaging revealed a large portion of a pen, which was subsequently removed surgically.

It was quite interesting seeing howing eye trauma, and facial fractures, are repaired. An incision is made on the inside of the lower lid until the bone underneath is accessed. And then that opens a whole eyeball world. The topic was interesting and enlightening, although it still makes me squirm.

Pilon Fractures

It seems we've had a rash of pilon fractures come through lately and it prompted me to share here. Really this is something the ortho guys love, but as well all know ortho and trauma work pretty closely together. So first off, what's a pilon fracture? It's a comminuted fracture of the distal tibia that usually occurs from vertical/axial loading which drives the talus into the distal tibia. It generally seems that the axial loading mechanism we see is a jump from a height. There are probably a multitude of ways to break your distal tibia other than a jump. A motor vehicle crash is another frequent method.

The picture above is lateral x-ray of a pilon fracture and the picture to below is an A/P (anterior/posterior) view. Treatment can be either non-op or operative repair, and I generally see the Ortho guys go for operative fixation. This, of course, depends on age, comorbidities, and all the other factors that go into deciding if a patient is a surgical candidate. Nonetheless, they are practically always splinted and made non-weight bearing. Bone union usually occurs in 2-3 months. Apparently it's reported that those without surgical complications can expect about a 75% chance of a good outcome, yet I think clinically I see it higher than 75%.


When the mechanism is a low-energy impaction, it's not uncommon to find this as an isolated injury, or at least limited to the ipsilateral extremity. This tends to be the case for the jumps I mentioned, but those can also include bilateral extremity injuries and back injuries if it was from a descent height. A motor vehicle crash would be a high-velocity impaction and then you can certainly have a whole host of other problems. This could be to the extent that the pilon fracture is now small potatoes compared to the chest, abdomen, or head injuries that are immediately life-threatening. But it's always good to give a shout out to the bones too.

Can I get a drink?

It is not uncommon to see chronic drinkers end up on the trauma service. When it comes to trauma, it seems just about anything goes. "Fall" or "found down" are common catch-all types of trauma we see, when in fact there may be no trauma. My favorite was "found down in bed." Hum...most of us are. At least I am; every morning in fact. Anyways, the fall or found down group will often bring in a drunk. And generally, if they do have a "traumatic injury," it tends to be abrasions, lacerations, contusions, and hematomas/cephalohematomas. Not all, of course, but more often than not. So clearly the plan would be to clear their cervical spine, i.e. get the neck collar off of them once the radiology read is back and negative, and then discharge home, or street.

That plan can be delayed if they are still drunk because they can't answer your questions, because they can't walk straight yet, or because they just won't wake up enough to leave. But then, if they drink a lot, you only have a window to get them out once coherent enough to talk, walk, and eat. If they actually had injuries, you tend you run into problems. This is because caring for the injury tends to take longer than that special coherent window. Even if caring for their injuries was essentially consulting another service (say Plastic surgery for a nasal fracture), and they say the patient is non-op and ok to dc, but it took until the following day to get that answer, then you may have missed the window. Then ensues the withdrawal, and what would have been a short hospitalization turns out to be longer than a week, sometimes requiring them to go to the ICU for management of severe withdrawal.

One thing we do at our hospital that some people seem surprised by is that we give chronic drinkers beers with meals in the hospital. This is with the thought they can be discharged soon and they will go back out to drink again. In order to stave off the DTs, and in turn avoid a long hospitalization, we give them beer. Ativan is always made available prn, too. If they have significant injuries and will be in the hospital a while, that tends to change management. Generally then the choice is to go with a Librium taper. But we rarely start a Librium taper on an overnight drunk with minor abrasions. I do think it is a bit sad that they don't get intervention. It is, however, true that most of them go straight from the hospital to go look for a drink. They'll even tell you that's their plan. So in those cases I suppose beers with meals is a proper plan. But I think it would be nice if we also had a routine of offering our drunks the option of a Librium taper prescription if they'd like to kick the habit. But now you know, some hospitals do indeed give patients alcohol.

A super union

I've been excited reading about the creation of what's been touted as the "RN Super Union." And then I read that 1 week ago, on Oct 1, that Massachusetts has joined the team. Now leaders of 3 major nursing organizations have formed the National Nurses United (NNU). It is now the largest union for registered nurses with 150,000 members. It is the United American Nurses, Massachusetts Nurses Association, and California Nurses Association/National Nurses Organizing Committee that have come together to form this professional association aimed at improving patient care conditions, protecting RNs, and expanding patients' rights and RN practice.

I think this a great move. I am in complete support of this union formation and think it will only help nurses gain a national voice. As part of the California Nurses Association, I see the benefits that a union can provide at the state level. And it was this voice in CA that helped establish the successful RN-to-patient ratios for safe staffing law. Taking a union to the national level can only help raise awareness of issues that nurses face every day, enhance our advocacy for patients, and collectively join on common goals and issues no matter your state.

NP-MD model

Well, I've returned and thought I'd share a bit about my trip to another trauma job. I think it is always interesting to see how other hospitals run their business compared to what you're used to. I know my hospital has been interested in the idea of an NP-MD practice model, but not sure how to approach it. I can see why. When you sit in your own bubble, used to the problems and bureaucracy of your institution, it's hard to envision it different. But when you visit another place, you see what they've tried. The difficulty in going to an NP-MD model is what happens to the residents? Obviously they need to train and need to be there. But then how can you run a service with only the NPs and an attending physician?

So what I saw at this other hospital was that they separate the residents from the NPs right out of the gate. They have an entirely different set-up, where the trauma patients are on one floor and that floor is covered by the NPs. Somewhere else the residents are off managing other patients, trauma patients I assume that didn't get a bed on the trauma floor. The way I'm used to is I meet up with the resident/intern every morning and we divide all of the trauma patients, no matter what floor they are on. I see and interact with the residents all day. By all appearances, the NPs at the other hospital never see the resident, except for sign out at night to the on-call resident. There the NPs completely manage the floor almost entirely alone and round only with the attending, and there are no layers of residents. It's a more autonomous situation I think for those NPs. But every method has ups and downs. Just as they are downsides of less autonomy where I am, there are upsides of consulting the chief resident on specific issues and the opportunity to do more teaching.

So what's my take on the whole experience? I think it's a great job....but I'm not sure if I'm willing to leave what I have for it. Maybe had I actually been looking for a job, I'd be inclined to make all the sacrifices to go for it. But like I said, I already love my job and why leave it for an unknown? It may have worked well with school, but I'll just have to sort out that situation later if school opens up.