Another Ordinary Day
Thursday, September 06, 2007
Sean Donahue, DO
“Doc this thing is stuck in my finger!” I was in the last hour of a 12 hour shift at Stanford University Hospital. Exhausted, I was hoping for a nice easy sliver, or laceration. As I looked down at Mr. J’s finger, I was shocked at what I saw: an Epinephrine Pen lodged in his thumb. Over the past 2 years at Stanford I have been mentally and physically training myself to be able to deal with any Emergency which might come through the Emergency Department doors. This encounter was a new one: trauma, heart attacks, strokes, coughs-you name it-these are givens in an emergency Resident Physicians repertoire, but an epinephrine Pen stuck in a finger? I gently tugged at the pen, “Good luck…” Mr. J replied.
Mr. J explained that he was prescribed the pen by his primary care doctor 3 days ago after he had an anaphylactic reaction to a wasp sting. He described quite perfectly the phenomenon of anaphylaxis: “My face and wind pipe swelled up like a puffer fish, and my blood pressure dropped like a rock.” The paramedics revived him with epinephrine-the drug which counters anaphylactic reactions. I like to think of anaphylaxis as an extreme way for the body to deal with a foreign substance: your blood vessels dilate and become leaky, allowing your body to release a plethora of substances to combat the toxin. People become covered in hives, airways swell, lungs and breathing become constricted, and the blood pressure can drop to extremely dangerous levels. Epinephrine works to combat the two most important aspects of this dangerous cascade: it constricts the blood vessels, and dilates the airways.
When I looked down at Mr. J’s finger I saw what I had feared: it was completely white and cold. He told me that it felt “numb” and that he had tried to pry the needle out with a pair of pliers but to no avail. Mr. J stated that he was at home, “showing my boy how to inject the medicine…I guess I had the wrong end pointed the wrong way.” Mr. J had grabbed the pen, and held it to his thigh. Pens like these are activated when a spring loaded needle is deploying after coming into contact with your skin. He had the pen turned around (as to not inject the medicine into his thigh), and accidentally pushed the spring, releasing the medicine and needle into his thumb.
I presented the case to my attending physician-who thankfully had “seen a few cases like this before.” “First we need to counteract the effects of the epinephrine on the thumb,” he said. “Slather the thumb with Nitroglycerine paste, this will allow the vessels to dilate.” “Then, call the pharmacy and have them send up 0.5 mg of injectable Phentolamine.” Phentolamine is a drug we can use to block the effects of Epinephrine.
After we obtained an x-ray (the needle was not stuck in the bone) we realized the needle had probably glanced off the bone, creating a barb on the end…no wonder we could not get it to budge. After numbing his finger we coated Mr. J’s finger with the Nitro-Paste, then injected the Phentolamine. Next with a pair of “ER Pliers” we were able to free the barb after a great deal of force. His finger “pinked up” over the next 5 minutes.
“I can’t believe I did this, I’m so stupid,” Mr. J. said over and over throughout the course of his treatment. I think he was being overtly harsh on himself-it seems like a very easy mistake to make. If it had not been for Mr. J’s mistake, I would not have learned how to treat the next person who comes in to the Emergency Room with an Epinephrine pen stuck in their finger. We have to be prepared to treat all comers-whether it’s in the first, or last hour of a busy day.
6 Comments:
At Sat Oct 06, 06:32:00 AM 2007,
Renal said…
Mind if I ask a a technical question?
Was this chap having ischemic pain?
At Thu Oct 11, 08:03:00 AM 2007,
Sean Donahue, DO said…
He was not, only pain from the needle itself. I do think ischemic pain can be quite common? Is that your experience???
At Sun Oct 14, 05:39:00 AM 2007,
Renal said…
Not personally, but I'm aware of people reporting ischemic damage caused by the use of adrenaline (+/- lignocaine) in extremities.
At Tue Nov 06, 05:23:00 PM 2007,
RoseAG said…
That's interesting.
I have an epi-pen, and the only time I've ever fooled around with it was when I got a new one because the old one expired.
I slammed the old one against the side of a trash can to see how it would work. After reading this account I'm thinking it's just as well.
My allergist instructed me to go to an ER if I ever use it, so this guy would seem to have done the right thing.....
At Thu Nov 08, 03:45:00 PM 2007,
Kat said…
I guess this guy hadn't heard the old "Fingers, nose, penis and toes" rule.
At Tue Feb 03, 11:54:00 AM 2009,
Radarseven said…
I'm a 31 year old male who recently had a similar experience with an EpiPen Jr (.15mg). I was accidentally stuck in the pad of my thumb, though the needle was not lodged.
The tip of my thumb almost instantly went numb and felt cold. A visible demarcation line was visible above the injection point where the thumb was a pale color and clearly blood flow was diminished.
After an hour or so in the ER waiting room, a resident saw me and said they had seen this before with nurses in the ER. Surprisingly to me , having after the fact read some about some similar cases online, the resident, along with the attending, decided not to use nitroglycerine paste or inject phentolamine into the thumb, making a comment about the aggressive nature of phentolamine. This was despite the fact that there was not much visual or other improvement even after several hours.
They gave me a tetanus shot and sent me on my way. Once home, I used a hot compress around my thumb for several hours. About 5-6 hours after the initial injection, I regained feeling in my thumb and normal red color appeared again.
Having sustained the numbness for 5-6 hours, should I expect any lasting effects or tissue damage? Now two days removed from the incident, feeling is nearly back to normal, though I do notice the temperature of the injected thumb still slightly decreased.
At any rate, glad I came across this post.
Post a Comment
<< Home