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Crazy FB removals


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I work in a CHP in the western US

 

Last year I had the craziest Foreign Body removal I have ever done

older, gentleman comes in saying he wants "it removed"

Has refused to see anyone else (love the value of PCP relationships)

 

He had self implanted a piece of plastic a few years back in the dorsum of his penis under the skin........

He did not want anyone else to remove it - even after i explained I am not a surgeon or urologist.  had him sign basically an AMA saying that I was recommending against me doing the removal procedure and that he should see Uro.  He signed it, then signed a consent form for me to do.  Quick phone consult to Uro to make sure I did things correctly.   15 min later it was out, dressing applied and he was on his way.

 

Never in a million years would I has suspected I would do this in my career - removing self placed body art in the penis/foreskin.....

 

Gotta love primary care and  my visit probably saved the system some 5-10k (heaven forbid that he have and EKG and Cardio recommends useless interventions) in that he would have likely needed a preop, and then surgical clearance, then inpatient post op..... all for a quick numb, slit and remove....  no matter your beliefs, letting a PCP function as such is certainly important to the efficiency of the system.

 

Question to everyone in the primary care fields..........

What things have you done at the edge of your skill set (I have a lot of suturing and minimally invasive experience from years in IR and ER so I was comfortable with the process so it was not reckless) where it felt good to help someone and fueled your mental fire for a little bit?  Great Dx, great finds, management strategies that helped?  Lets hear them, ring your own bell, shows us that PA's rule!!

 

Edited by Border
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Boatswain2pa,  I agree with your first sentence.  Without seeing exactly what was done but reading the post, I would have done the same thing.  "Judicial Hell" begins the minute you shake a patient's hand and begin your job to help and heal.  I think Border knew his limits and just did it with consult call to Uro.  It was the tip of the penis in foreskin.  Suppose it was a splinter.  Refer?  Maybe on a case by case basis.  IMHO

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He performed a procedure that he recommended HE NOT PERFORM.  If sued, how is that defensible?

I did a similar thing once sewing up the face of a literal international (former) beauty queen.  I wanted to send her plastic surgeon >1 hour away, she didnt want to and begged me to sew her up.  I did, and in hindsight shouldnt have.  

Her choice to go to plastic surgeon or leave it open.  My choice to do it myself or not.  I made the wrong choice.  Fortunately I wasnt sued, and I have no idea of the outcome.

Edited by Boatswain2PA
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Removed a sewing needles from a thenar palm that had been in place 20 years. My PA colleague, a complete nervous wreck about everything with anger issues, said I was crazy and cavalier. It was close to the surface and no tendons involved. Everyone else thought it was awesome that I did a median nerve block in clinic and took something out that had been in 20 years. I was pretty pleased with myself for my first year in practice.

i agree with some of what is said medicolegally, and also not. If I’m going to do something, I OFFER them a higher level of care. Just like an ER patient can refuse transfer based on risks of crash, delay in care, etc, that doesn’t mean I don’t treat them. Totally would have taken it out and documented the patient was given the risks and benefits of higher level care transfer/referral and if the procedure was within my scope, which foreign body removal of subcutaneous tissues is, then I would document we had a  shared decision making discussion. they desired to proceed now based on their concerns of XYZ. Given my respect for patient autonomy and self determination while also respecting their need for alleviation of suffering, I proceeded(add  in consultation with if necessary).

I do things in consultation with all the time now in residency. Legally speaking I’m not protected like a resident, and I often have other off service residents teaching me procedures that some of my attendings are less comfortable with, like peritonsillar abscess aspiration and drainage. Al this to say is I agree with what you did, would have documented differently, and personally don’t worry about being sued all the time. I do what’s right for the patient and the rest usually falls in line. Just my opinion on that.

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Yea I think if it is in your comfort zone...why not? I know all the arguments against and I'm a pretty conservative guy but I recently re-assessed my own sense of trepidation because, in a word, I felt like I had become a coward. 

I'm not going to manage something that needs to be managed at a higher level of care but I'm also not going to defer something I'm comfortable with just because somewhere there may be someone who could do it better.

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I've wondered, would a contemporaneous video recording of the consent process help?  That is, videoing (and saving forever, obviously) you going through, in detail, all the list of things that could possibly go wrong with the patient.  Of course, no sooner do we all have cell phones that would enable that, then we have deepfakes such that anything so documented could legitimately be challenged.  Sigh.

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my way of thinking

 

what attorney would sue if there was a signed form in the chart detailing that the patient should go somewhere else, and that this is against medical advice to have the provider here do it, and then a consent outlining possible complications.   Just doesn't seem like a risky thing as long as the patient is informed and signs.  This of course only works if the provider is comfortable with the procedure, and has made sure they will accomplish it the same way the specialist would (phone consult with the specialist).

 

Simply ignoring the patients desires is not good medicine either...  Maybe they were unable to even get to any other provider and this was the only choice they had???

 

so as long as a nice paper trail with signed consents seems like a reasonable way to do it.  

 

 

Back to the OP - anyone take anything out??

 

I swear I was the reattach finger tips on little boys whom got the tip of their finger caught in a door when I was in the ER - must hve done 4-5 of them over a year - first one plastics coached me on, then I did them in the ER my self...

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My greatest patient treatment mistake that I made was when I treated the Mayor candidate of my village for an allergic reaction to shellfish. He trusted me more than the local hospital and I had all the supplies at home with the exception of a tracheotomy tray, oxygen and a back-up. I went though the treatment procedure of a patient in the early stages of anaphylaxis but post treatment I could not beleive that I let my ego get the best of me. What I did was absolutely stupid as no malpractice insurance that I have would have protected me. I was a Lone Ranger without Tonto.

It's tempting to meet the patients demands or trust but can be foolhardy. since you brought up the scenario, it's up to you to judge your motivation. My patient did well but he could have expired in my living room.

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  • 2 weeks later...

I have a pic somewhere of a huge hunk of cinnamon bun I McGilled out of someone's larynx under direct laryngoscopy...surprisingly hasn't turned me off one of my favorite comfort foods.

A not me one, but a kid from my home town got a javelin through his chest at a track meet when I was in high school - went in behind his (R) clavicle, out (L) rib cage - paramedics had to hacksaw a couple feet off each end just to get him into the ambulance.

MM

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I've done about 10 removals of nail gun nails from fingers.  I always ask about the manufacturer of the nails & gun - just because my wife works for one of the manufacturers and I can tell her how well the nail held.  I've pulled a carrot out with McGills - why anyone would feed a whole carrot to a demented person is beyond me but that's why I call them ECF's not SNF's.  Most interesting was a young man who put his lower leg through a glass panel in a screen door.  Had to incise through skin & fascia to get down to a 4x1" glass shard then a multi-layer closure.  No way to just pull it out.

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"what attorney would sue if there was a signed form in the chart detailing that the patient should go somewhere else"

Have you met an attorney? If you look around you can find an attorney who will sue for anything...

 

I used to have a great collection of things I had extracted over the years many from kids ears and noses. Toy cars, batteries, paper clips, bugs beans, corn you name it. BTW don't try lavage dried vegetables out with water. They swell. 

On the traumatic side I have seen more than my fair share of nails from nail guns often in someone who had intentionally disabled one of the gun's safety mechanisms so they could go faster. Fingers nailed together, one guy shot himself in the butt cheek trying to pass his nail gun around behind himself from one hand to another.

Gyn wise...it wasn't mine...but almost 40 years ago a woman came into the ER (I was a medic) with a glass bottle stuck she had been using as a sex toy. The bottom of the bottle was holding the introitus open. ER doc took a cautery and melted a hole through the bottom of the bottle which broke the vacuum seal and allowed easy removal.

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A few years ago, solo coverage at a critical access hospital down on the coast.  Guy in his upper fifties walks in around 2300.  Says he has something stuck in his rectum.  

Me: What is it?

Him:  A wooden dowel?

Me: How long has it been up there?

Him: Three days.  I was hoping it would just come out.

He didn’t try to make up some oddball story about how it got there.  Shot an xray.  Nothing concerning.  Double gloved, KY,  and with two fingers I was able to grasp the end of it.  Fumbled a couple of times, then pulled it on out.  Interestingly it was a turned wood dowel (think of a leg off an old coffee table) about ten inches long and two inches in diameter with various tapers.  Asked him if he wanted it back, and said he was through with it.  Into the red bag with ya.

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4 minutes ago, CJAdmission said:

The guy that used to work opposite my shifts in the ER had a guy come in with a drumstick (the chicken kind, not the musical kind) stuck up his hiney. I think he got it out with an Allis clamp.

well, you know " you can get anything you want (with allis's) , excepting alice"

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33 minutes ago, CJAdmission said:

The guy that used to work opposite my shifts in the ER had a guy come in with a drumstick (the chicken kind, not the musical kind) stuck up his hiney. I think he got it out with an Allis clamp.

That reminds me, I need to order this T-shirt

 

IMG_2648.JPG

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