Crow mouth....

 

 

After years of practice, most of the physician would have some instinct/experience guessing diagnosis with only a small piece of history of findings. Most of the time you would be happy that you have gotten the correct diagnosis….

K was sitting with me at the desk and a 10 years old girl had sent to his side by the local rescue service. The complaint was right thigh deformity after fall during a basket ball game.

While the patient being sent for imaging, I had chatted with K and told him that most probably it would be cancer(osteosarcoma most probably) as the impact during a basket ball game is not strong enough to break a 10 years child’s femur.
Well, I regretted what I had said instantly and loaded the film once it showed up at the imaging list… Crow mouth I had…

K notified the orthopedic surgeon and after reviewing the image, the surgeon had told K to refer the patient as she would need to be managed by a multidiscipline team in a tertiary medical facility.

No one wanted to break the bad news, K had to tell the mother that the fracture is complicated and need to be managed by orthopedic surgeon who is specialized in that field.

I had regretted sharing my spot diagnosis….10 years old girl with a total hip amputation and a long course of chemotherapy waiting for her; even with such aggressive treatment she is still facing a 30% 5 years survival rate….

The incident had haunted me and I had paid my price during the level 3 IDPA competition 2 days later....

Trust no one.....

 

The central line insertion was definitely a heart pounding procedure for a medical trainee during the first few years of their training. The localization of the central vein is the most challenging part especially for patient with thick adipose tissue.

The introduction of ultrasound into ED practice had eased the process and raised the successful rate of central line catheterization.

Most of my young colleagues practice the actual ultrasound guided method, but I usually used the ultrasound to confirmed the position of vein and proceed with the procedure using the traditional method. We got a small amount of incentive if we use ultrasound to guide our catheterization. I am more confident during the venous puncture part as the imaging had given me a rough idea of the position and size of the vein. 

The catheterization was always a one man show until recent few years, the head of department had wanted the surgical aide to assist in the procedure as someone would need to hold the probe during the puncture. Well, as I did not use the probe during the puncture, frankly said, I am not very particular about having an assistant. However with an assistant, the secure with stitches part would usually be done by the aide and I would left the scenario early after fully insertion of the catheter.

I did remember in the past that one of my senior had told me that when the catheter is inserted down the guide wire, we would need to make sure that the tail of the wire is visualized and properly grabbed hold on so that the wire is not fully inserted into the center vein which might need a vascular surgery to extract out the wire.

I had always being cautious and would teach my staff that the tail of the wire needed to be secured by the operator before the catheter is fully inserted.

All of our surgical aides knew the rules as I had always insisted that part is clearly done.

However, few months ago, one of our junior colleague had met the worst case scenario above mentioned.

It was an easy femoral puncture and our junior colleague had left the table prematurely after the guide wire was being inserted. The insertion of catheter was left alone to our senior surgical aide. The wire was not secured before the catheter was inserted. When the aide noted the wire is not seen at the tail of the catheter; he got panic and removed the catheter immediately; the act had left the wire fully inside the femoral vein. What he should have done is to clamp the catheter with a forceps and remove the catheter hoping the wire would be removed with the catheter.

When notified, our junior colleague however was bold enough to do a small cut down with the aid from the senior surgical aide. The wire was noted and removed from the femoral vein without complication.

It was a heart pumping scenario which was compensated without a scratch.

When my junior colleague told me about the incident, both of us sighed and agreed that it was an narrow escape.

The surgical aide was senior enough and capable enough to perform many procedures ….but yet accident do happens..

My conclusion -----“Trust no one”