December 25, 2023
1930 hours: A few patients enter your “GP Super clinic” (because you’re superman, after all) with only 40 minutes to go before the end of your shift. It’s Christmas Day and you feel you’ve done your call of duty, and now just want to go home. The cases aren’t life threatening, but each case nevertheless demands of you your attention and due diligence. The nurse tells you that a man in his 50s presents after dropping a table on his foot. “The foot is awful and bloodied and there’s not much we can do for it. He’ll need to go to the ED ” She asks you to see him first. So, you do. You go and see the man. He tells you that a fold-away picnic table fell on his foot. It was an accident: the handle dropped off the table and it fell straight onto his toe. It happened about 1700 hours, and he bandaged the toe when only deciding to present because the bleeding was hard to staunch. He is otherwise well. Takes no meds. Has no allergies. He tells you, after questioning, that he last had a tetanus toxoid booster vaccine a year ago. He seems in good spirits. The third toe is covered by a heavily blood-stained saline soak and there is dried blood that has stained down the sole of the foot. You slowly remove the blood-stained gauze and find that the bleeding has stopped. The tuft of the third toe is swollen but not bruised and resembles the colour of the remainder of his foot. The toe nail looks as though it may have been lifted off but remains nevertheless steadfast against the nail-bed; although appearing loosened it is not dislodged by your maneuver–your manoeuvre of removing the dressing. There is a very small near-dried clot at the tip of the digit, but he feels the bleeding came from the medial skin fold and nail fold (base) rather than tip of the digit. And, rather than tender to the touch, he says that the toe feels numb when you compress the distal digit between your thumb and forefinger. You note that you feel (and hear) no bony crepitus as you do. You do nothing else.
How will you treat this man?
Answer: Leave him alone. In a way, he’s telling you that he is ok and wants to go home; now that the bleeding seems to have stopped. Do you check his foot pulses? You can, but don’t because he is fit and well and the table landed on the tip of his toe, shearing (in-fact) the nail off from the nail fold, he surmises, as you quip that it’s good that he hurt himself. “Well, it’s good that it’s Christmas.” [Or, that life’s just good regardless.] … He doesn’t mind that you say that, and neither does his wife who, incidentally, became animated–in a pleasant way– during the interview. From here on, you avoid making eye contact with her. She settles back as you give the patient your undivided attention.
So, there you go. Any questions?
Prescribe him oral antibiotics to cover for a compound injury and, therefore, provide him with a referral for X-Ray. Give him some oral analgesia to take home. Have the wound dressed, carefully. Ask him to return in 2 days. You don’t even offer him a medical certificate because it’s Christmas. Have a nice day.
You make arrangements to review him (and his toe) in 48 hours. There, with the injury swelling down, you will review the X-Ray images yourself and look at his toe and (probably) remove the nail if it is only tenuously linked to the nail bed and replace it atop once again as a physical defense for the nail bed. If he has no signs of infection (and no fracture) you will have him reviewed twice a week for dressings until he is able to dress the toe himself, assuring him that (if the germinal matrix is not damaged), new nail will grow out in due course. This is the one time that you allow a Vaseline- impregnated gauze to come into contact with the patient’s skin. You go home and open up your Adobe Dimension app on PC, promising yourself that you’ll get a Mac soon. You have no idea what Adobe Dimension is used for but, with the extra acute care shifts that you have offered to do, you can soon afford to pay for what you already bought. After all, this is what you did Medicine for. Thank you, Adobe. With your ten toes neatly packed under your bedsheet, and still breathing, you plan to forget about the day ahead.
