Forearm Nerve Blocks FTW!
Emergency physicians are a fairly rare breed—in some ways, our specialty is knowing as much as possible about everyone else’s specialties and trying to do their job in their absence. Naturally, many EPs feel impelled to pick up as many skills as possible, but everything has a cost, and learning a new skill to the point of comfort using it clinically without help or supervision takes a significant amount of time and effort, of which people only have a finite amount. Moreover, even if you have the knowledge and skill to perform these types of blocks, actually doing them takes time - time that you might not have in a single coverage scenario or on a particularly busy day.
Having said all that, I had a case the other day that I can only describe as “the exact reason why you should learn how to do ultrasound guided regional nerve blocks”.
A man in his 40s (ish) presented to my ED in the early evening with a laceration to his hand. He told me he had been cutting saplings when he accidentally stabbed himself with the sharp end of one. Initially pretty standard-seeming, but there were a number of somewhat unique challenges that this specific case presented:
- The injury involved a puncture wound from an organic object.
Importance: Organic matter embedded in a wound tends to cause horrifying infections within a few days if not properly washed out. Puncture wounds in particular tend to be worse for subsequent infections as the organic material (as well as the bacteria that are along for the ride) can go deep through a small hole, and that hole can close quickly, sealing the infection inside and allowing it to form into an abscess.
- The injury involved the hand.
Importance: Hands are distal extremities, so the blood flow can, at times, be quite compromised. Both natural immunity and antibiotic delivery require blood flowing to the affected area in order to work. In addition to this, the hand has a LOT of sensory nerves, so injuries tend to be quite painful.
- The specific location of the injury presented a number of challenges for pain control.
Not a lot of space between the fingers, so I’ll need to manipulate the digits and the lacerated skin a decent bit as I’m trying to numb it up and place my stitches. It’s also a pretty deep wound, so even if I get the skin numb, the rest of the deeper structures will probably be difficult to get properly anesthetized using just local injections.
Ok, so much for the challenge. How about the solution?