Consultants are hard to track down everywhere! This dude was 52 and had slammed his L thumb in a car door. He had a partial amputation, clear nailbed injury, and a transverse fx of the DIP = open fracture.
Ortho was about 2 hours from being able to come down and he said he didn’t want to wait. As a compromise he let Andrew and I put him back together. This case was at the very limit of what I would tackle in the states. It was clearly within the scope of practice of an ER doc but if you had Hand surgery avaiable it would be prudent to consult them.
Note that nail has been removed and eponychial splint made and placed. We cut the foil out of suture pack so it was sterile. Anesthesia achieved w/ digital block and the needle driver you can see is holding a sterile gloved pulled tight and then clamped at the base of the thumb to achieve a bloodless field.
Andrew saw the patient 2 days later, he was doing fine on Augmentin/Tramadol. Not only was he fine with the pics being taken he took a video of us on his cell phone as we were putting him back together.
This was a good case to remind me that in the developing world consultants are not always at hand. EM docs need to have their skills up and be ready to do things they would not do at their tertiary care center. Like being single coverage in a non-academic ED: you’re it!