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Distract the patient with a nonpainful sensory stimulus such as rubbing the area near the injection with your other hand, as other sensory input blocks the brain’s perception of pain sensation to some extent.  (6) When anesthetizing a wound, inject through the wound rather than through the intact (sensate) skin.

Fingertip amputations: Be aware that children are capable of growing back or “regenerating” fingertip amputations through the distal phalanx (essentially as long as the nail root is still present they can grow back a pretty normal looking finger).  This occurs up to age 12 as long as the wound is not sutured.  Simply wash the amputation, leave it open, bandage it, and begin changing Band-Aids on a daily basis.  A much more cosmetic and functional result will be obtained than with debridement and closure or grafting.  

Cast burns: It is possible to burn people with the exothermic reaction of hot plaster.  Factors which increase the likelihood of this are:  (1) thin cast padding; (2) thick slabs of plaster; and (3) dipping it in hot water (not because the hot water adds to the burn, but because it speeds the exothermic reaction greatly).  If the patient complains of burning, you can try placing the cast in ice, but it may be more prudent to remove the cast or splint rapidly.  

Sawing casts: Because of its reciprocating action, the cast saw will not cut soft tissue, but because it heats up it can burn. This is significantly worse with fiberglass.  Many people who are inexperienced with the cast saw cause burns by trying to be too careful.  You must push with the saw until it plunges through and then jerk it back, so that it is not in contact with the soft tissue for more than a moment, thus it cannot burn.  If you try to be careful and cut through slowly, the hot blade will protrude slowly, rest against the skin, and cause burns.

In the Operating Room:  

Nerves: Patients are nervous. Stopping into the holding area to say hi and ask them if they have any last minute questions can really help them out - do it if you can.

Cure:  A chance to cut is a chance to cure:  

OFAT  “Obligatory Anesthesia Fool Around Time”: This frustrating period of waiting in the room while anesthesia tries this or that block before abandoning regional anesthesia and moving on to general is a prime opportunity to go over your surgical plan with the nurses (I think, “Special position? Special prep? Special drapes?” Then I envision myself making each step of the operation, i.e. cutting the skin, dissecting, retracting, reducing, temporarily fixing, permanently fixing, closing etc. in the hopes that I will see each of the instruments I envision using on the back table.  Also see “thought process” below). You can also write your post-op orders, fill out a portion of your postoperative note, and get some reading done if you have a copy of a paper or two in your back pocket.


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