Article

Using a rubber strip test to classify swollen fingers for ring removal

Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520 1509

Texas College of Emergency Physicians. He was formerly a stockholder of Adeptus Healthcare. Currently, he is a member of the Emergency Care Committee for HCMS and a member of the Freestanding Accreditation Task Force for ACEP.

Xu – nothing to disclose. Kao – nothing to disclose.

Cedric Dark, MD, MPH Baylor College of Medicine, 1 Baylor Plaza, Houston,

TX 77030, United States Corresponding author.

E-mail address: [email protected]

Yingying Xu Rice University, Department of Economics, 6100 Main Street,

Houston, TX 77005, United States

E-mail address: [email protected]

Emily Kao, PhD, MPA Houston Methodist Hospital, 6565 Fannin Street, Alkek 8-053,

Houston, TX 77030, United States

E-mail address: [email protected] https://doi.org/10.1016/j.ajem.2017.12.048

References

Ho V, et al. Comparing utilization and Costs of care in freestanding emergency departments, hospital emergency departments, and urgent care centers. Ann Emerg Med 2017 Dec; 70(6):846-857.e3. https://doi.org/10.1016/j.annemergmed.2016.12.006 (Epub 2017 Feb 15).
  • Simon EL, et al. Door-to-balloon times from freestanding emergency departments meet ST- segment elevation myocardial infarction reperfusion guidelines. J Emerg Med 2014 May; 46(5):734-40. https://doi.org/10.1016/j.jemermed.2013.08.089 (Epub 2013 Dec 17).
  • O’Gara PT, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myo- cardial infarction. J Amer Coll Cardiol 2013;61(4):e78-140.
  • Dayton JR, et al. Acuity, treatment times, and patient experience in freestanding emergency departments affiliated with academic institutions. Am J Emerg Med 2018 Jan;36(1):139-41. https://doi.org/10.1016/j.ajem.2017.07.004).
  • Dark C, et al. Freestanding emergency departments preferentially locate in areas with higher Household income. Health Aff (Millwood) 2017 Oct 1;36(10):1712-9. https:// doi.org/10.1377/hlthaff.2017.0235.
  • Simon EL, et al. A comparison of Acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med 2015 Apr;33(4):539-41. https://doi.org/10.1016/j.ajem. 2015.01.021 [Epub 2015 Jan 20].
  • See Dayton, JR et al. (2017).
  • Simon EL, et al. Variation in Hospital admission rates between a tertiary care and two freestanding emergency departments. Am J Emerg Med 2017;36(6):967-71.
  • Using a rubber strip test to classify swollen

    fingers for Ring removal

    To the Editor,

    We are very interested in techniques for removing tight rings from swollen fingers. As Asim Kalkan [1] has summarized, many approaches have been used to remove rings, but there is no clear standard to help clinicians choose the proper method. We use a rubber strip test to cate- gorize fingers that have swollen to the point that ring removal has be- come problematic. This method categorizes swollen fingers into four types and recommends the proper approach for removing rings for each of the different types of swollen fingers.

    The rubber strip test: While holding the finger, apply a rubber strip (2 cm wide), which can be fashioned from a rubber glove, and stretch it to the opposite side. Then, use hemostatic forceps to hold it in place (Fig. 1). Observe the plane gap between the finger and ring after 5 min (Fig. 2). This time period of 5 min is critical, as it reduces swelling, allowing us to assess the degree of finger swelling, and may also allow immediate removal of the ring (Table 1).

    The four categories of swollen fingers trapped by a ring, based on the measured plane gap between the finger and ring, are identified as follows:

    The finger plane is lower than the ring plane.
  • The finger plane is not more than 3 mm above the ring plane. (When the finger plane was over 3 mm above the ring plane, we tried to remove the ring with Noncutting techniques, but the result failed. We hope anyone who has a successful experi- ence can improve on this.)
  • The finger plane is more than 3 mm above the ring plane.
  • The ring has damaged the skin and is confined within the finger tissue. (This type of injury is not suitable for the rubber strip test.)
  • According to these principles, we have divided the removal methods into five categories:

    The lubrication approach. A lubricant and some skill are used to re- move the ring. Recommendation: The caterpillar technique [2].
  • The winding approach. This involves winding the ring utilizing differ- ent materials to increase the control of the ring. Recommendation: The two rubber bands technique [3].
  • Fig. 1. Use a rubber strip to wrap the finger with the ring, utilizing hemostatic forceps to hold it in place.

    Fig. 2. Loosen the rubber strip after 5 min and observe the plane gap between the finger and the ring. The red line in the figure indicates the finger plane; the black line indicates the ring plane.

    1510 Correspondence / American Journal of Emergency Medicine 36 (2018) 14971520

    Table 1 Recommended removal methods for the four types of swollen fingers. * indicates the rec- ommended method.

    through oxidative stress, which can lead to cardiopulmonary collapse [2]. We describe two incidents of metal phosphide ingestion with mis- communication resulting in hazmat incident failures, multiple

    Swollen

    finger types

    Lubrication approach

    Winding approach

    Winding and compression

    Cutting the ring

    Surgical removal

    I

    *

    *

    *

    II

    *

    *

    III IV

    *

    *

    The five ways to remove rings

    healthcare provider exposures, and major facility disruptions.

    A 36-year-old Spanish-speaking male arrived to a small rural Emer- gency Department 2 h after an unknown overdose. We later learned he ingested 750 g of 60% aluminum phosphide pellets. On exam, the pa- tient did not exhibit a specific toxidrome. He was alert. His pupils were reactive and normal in size, he was slightly tachypneic but not tachycardic. His systolic blood pressure was above 110 mm Hg and his axilla along with mucous membranes were moist. He quickly deterio-

    Winding and compression. A variety of materials are used to compress or wrap the swollen tissue around the ring to reduce finger swelling and aid in ring removal. Recommendation: The two Penrose drains technique [4].
  • Cutting the ring. The ring is removed directly utilizing a cutting tool. Recommendation: ring cutters.
  • Surgical removal. Surgical dissection is first employed to expose the ring confined within the skin tissue. Upon exposure, the ring is cut with a cut- ting tool, similar to the case reported by Kumar et al. [5].
  • Of course, the choice of method should not be limited to the extent of tissue swelling. The patient’s condition should first be considered, in- cluding the subjective requirements of the patient, injury, infection, proximal interphalangeal joint thickness, compliance of the patient, de- gree of pain, and pain tolerance of the patient. Lastly, we hope this ap- proach to classify swollen fingers and ring removal methods will help in selecting the proper methodology. This is a preliminary study, which we hope to further improve in the future.

    Chao Cui Department of Hand Surgery, Central Hospital of Yingkou Economic and Technological Development Zone (The Sixth People’s Hospital of Yingkou),

    Liaoning, China

    Corresponding author.

    E-mail address: [email protected].

    Rong-Ming Zhang

    Division of Plastic Surgery, The First Affiliated Hospital of Jinzhou Medical

    University, Liaoning, China

    17 December 2017

    https://doi.org/10.1016/j.ajem.2017.12.049

    References

    1. Kalkan A, Kose O, Tas M, Meric G. Review of techniques for the removal of trapped rings on fingers with a proposed new algorithm. Am J Emerg Med 2013;31:1,605-11.
    2. St Laurent C. The caterpillar technique for removal of a tight ring. Anesth Analg 2006;

      103:1,060-1.

      Kingston D, Bopf D, Dhanjee U, McLean A. Evaluation of a two rubber band technique for finger ring removal. Ann R Coll Surg Engl 2016;98:300-2.

    3. Chiu TF, Chu SJ, Chen SG, Chen TM. Use of a Penrose drain to remove an entrapped

      ring from a finger under emergent conditions. Am J Emerg Med 2007;25:722-3.

      Kumar A, Edwards H, Lidder S, Mestha P. Dangers of neglect: partially embedded ring upon a finger. BMJ Case Rep 2013. https://doi.org/10.1136/bcr-2013-009501.

      Metal phosphide ingestions: How the hospital became a HAZMAT incident

      Aluminum and zinc phosphide are among the cheapest and most ef- fective rodenticides and fumigants available [1]. Not only are metal phosphides corrosive, but they also produce phosphine gas on contact with moisture and acid. The reaction is accelerated in the stomach. Phosphine disrupts the electron transport chain and damages cells

      rated requiring aggressive resuscitation including intubation, central and Arterial lines, and multiple vasopressors and atropine.

      As the Laryngoscope blade was inserted into the mouth, a large quan- tity of gray, semi-solid material returned from the esophagus. The mate- rial was thick and granular, with an acrid/garlic-like odor that clogged the suction tubing. The odor also caused immediate pulmonary and oc- ular distress in the providers. The patient, providers and resuscitation equipment were evacuated to the open Air ambulance bay. Resuscitation efforts continued for another hour before he died. Simultaneously, a co- ordinated mass evacuation of other patients from the emergency de- partment to other regional healthcare facilities was performed.

      Personnel used gloves, gowns and N95 masks when interacting with the patient. Higher levels of Personal protective equipment were not available. The regional hazmat response team was initially activated but called off by the incident commander because he misunderstood the exposure to be to “phosgene.” The incident commander later reactivated two hazmat teams and the National Guard.

      The treating physician described having transient bronchospasm and a burning sensation in the eyes. One of the primary nurses experienced respiratory distress over the next day, and was briefly hospitalized.

      The body was left outside for 11 days to off-gas phosphine to create a

      safe work environment for the Office of the Medical Investigator. The ED’s ventilator and ultrasound were left outside and damaged by rain along with monitors, gurney & pumps due to the lack of ability to assess their contamination level. After 36 h, the main ED reopened.

      In a second incident, a 28 year-old male with a history of mental ill- ness, seizures and substance abuse presented to a tertiary hospital after being found unresponsive with a white powder on his face, a suicide note, and a container of zinc phosphide. Upon presentation his vitals were in normal without odor or specific toxidrome identified. The pa- tient was intubated for airway protection. A gastric lavage returned 200 mL of a white substance. A rectal tube was inserted and whole bowel irrigation was initiated with all the waste being double bagged. Although the Poison Center recommended a negative pressure isolation room, miscommunication led to the patient being admitted to a regular ICU bed. The patient remained intubated and hemodynamically stable without any changes in his lab work for the next several hours.

      Approximately 18 hour post-admission, “a strong odor” was report- ed in the room, providers were unable to enter and the patient self- extubated without providers present. A negative pressure room was established and phosphine sensors detected a level of 24 ppm (STEL15 = 1 ppm), and the ICU was evacuated [3]. It was later discov- ered that the only sensor reading over the STEL had been placed under the sheets near the patient’s rectum. Once this area was ventilat- ed, ambient phosphine was no longer detected.

      The patient had a drop in hemoglobin from 11.2 to 8.2 g/dL and was transfused at 30 h. The patient had transient pulmonary complications without an obvious pneumonia. The remainder of the care was un- eventful. He was discharged to psychiatric care on hospital day 11. There were no illnesses from health care workers providing care.

      These incidents highlight the danger to providers, health care facilities and others of secondary exposure to metal phosphides and how miscom- munication can compound the problems. Sound alike compounds, unfamil- iarity with these agents on the part of both medical caregivers and incident commanders, assessment and management procedures, a lack of required

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