The Subungal Hematoma Lesson

A young man, accompanied with his father, consulted Dr. Dev (Fictional name) at his clinic. He was in great pain. The young man had accidentally hit his thumb with a hammer, leading to subungal hematoma (Painful Blue Nail).

In this condition, due to some forceful injury, the tiny blood vessels below the nails get ruptured, leading to leakage of blood between the nail bed and the nail. The accumulation of blood in the limited place causes great pain. You can imagine someone tearing your nail from your finger with pliers to get an idea about the intensity of the pain.

Drainage of the collected blood leads to rapid relief in pain. The conventional technique is to give local anesthesia with injection around the thumb base, and cut a piece of nail to give a path to the blood to drain out.

Dr. Dev had read a simple solution in one of the American surgical manual. In this the doctor simply straighten out a paper clip, heat its one end on flame and apply the heated end to the center of the nail over the hematoma (collected blood). Due to heat, the nail gets melted, creating a small hole, through which the blood drains out. Also, the flame destroys any bacteria over the clip.

Dr. Dev thought of applying this simple and instant solution, instead of subjecting the patient to lengthy procedure.

After cleaning the patient’s hand and thumb with an antiseptic solution, he picked up a paper clip lying on his desk and straightened it. The patient and his father looked at Dr. Dev suspiciously.

Then he asked his assistant to heat and bring it. The suspicious looks now were added with a worried looks. Dr. Dev, unaware of this, applied the heated end of the paper clip to the nail. Due to process of heating it in another room and bring it, the temperature of the clip has decreased and it required 2 more trips.

With each trip, the look of suspicion and worry deepened on the father and patient’s face, whether they have come to a quack or a surgeon.

Finally a big enough opening was created in the nail and the blood drained out. With the draining of blood, the pain of the patient decreased, giving him instant relief.

Dr. Dev applied a dressing over the opening to absorb more blood, prescribed some analgesics and antibiotic and asked to patient to review with him after 48 hours. Due to simplicity of the procedure he just charged Rs. 100 (approx. 1.5 US dollar).

As the patient and his father were leaving, they could not hide their misgivings and distrust and asked, Dr. Dev, ‘Doctor, if I had consulted you in the hospital, would you have used a paper clip there also, instead of proper instruments?’ 

Dr. Dev effort to explain that this method is from a famous American Surgical textbook was met with disbelief.

Dr. Dev learnt his lesson.

Next time, a patient of subungal hematoma came to him, he took him to the hospital to which he was affiliated.

In the minor OT (operation theater) of the hospital, he cleaned the patient’s hand and thumb with antiseptic solution, wrapped it in sterile operation towels, and using a surgical blade drilled a hole in the center of the nail over the hematoma to drain it. The charge of the procedure now was Rs. 1000 (approx 15 US dollar).

Result: Happy Patient, Happy Doctor and Happy Hospital Management.

Practice of medicine has in part become showmanship. The patient’s tendency to get impressed by unnecessary showmanship and distrust towards simple treatment is also responsible for it. Cheaper and more affordable care will result if patients start using their head instead of heart and evaluate the end results objectively.

(Based on true incident)
— NKD

© Author. All rights reserved. 

Similar Article on Use of Costly Drugs at: http://agnipathdoctors.blogspot.com/2015/04/practice-tip-use-of-costly-drugs.html

DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 


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Transparent & Explicit Record Keeping with Second Opinion Friendly System

Sometimes doctors are faced with situation where the diagnosis is in doubt or there are more than treatment options available. Often the attendants of such patients are very much concerned and they may directly or indirectly hint at getting a second opinion. One of my friends has developed a system for dealing with such situation.

He clearly states the facts to attendants, including the doubts regarding diagnosis and the different treatment options available and importantly explicitly mentions it in case record that he had done so.

He takes care to record in case sheet the reason for choosing any given treatment option, especially where there are can be more than one line of management.

He takes care to record even negative events, i.e. things not done and the reason for it.

For example, a patient required CT Scan (Computerized Tomography Scan)  to make a correct diagnosis but it was not done, as the patient was having kidney failure which may get increased by the drugs (contrast media) used for the CT scan.

A patient may require MRI scan, but as his general condition was very poor, he could not be shifted outside of ICU for the lengthy MRI scan.

A patient may have been prescribed a cheaper drug although a better but costlier drug may have been more appropriate as the patient could not afford the drug. This fact should be record that patient was prescribed Drug X as he could not afford Drug Y.

Such reason for not doing certain things should be clearly mentioned in the daily clinical notes. Sometime the case-sheet may come under investigation months and years later by the time everyone has forgotten the actual events and reason for the decisions made. What remains in black and white are written records.

If the patient or his relatives wish to get second opinion, instead of throwing a temper tantrum, that how are they questioning his judgement and treatment, he makes it clear that they are free to consult any doctor of their choice, whether in the city or outstation.

He provides them photocopy of the full hospital case-sheet and investigations in original and also provides a comprehensive, computerised case-summary, for easy and rapid consultation.

As he knows, that any of his case-sheets may come under scrutiny by the best brains in his field, he is extra careful and explicit in maintaining his case record.

He also makes himself available for telephonic conversation with the outstation doctor, so that any doubts can be directly cleared. 

This approach pacifies attendants and creates an atmosphere of trust by the impression that he has nothing to hide in the treatment and care of the patient. Whatever being done is according to accepted standard of care.

The patient attendants also feel that they are doing something concrete for the patient

Once the outstation experts reviews the case record and they give their stamp of approval for the treatment undertaken, the patient attendant's are satisfied that the best possible care has been taken of the patient.

If there are any minor differences of opinion, he courteously incorporates them in the treatment.

If there are any major differences, he is most happy to transfer the patient to reviewing doctor's care and even helps in arranging rapid and safe transport of the patient.

He has found that usually the doctors in big places are supportive of doctors working in resource constrained environment and many praise his effort for the level of care given under such trying situation.

He knows that he may lose a few patients to other doctors, but he avoids lots of unnecessary medico-legal complications, and is able to work in a tension and suspicion free atmosphere.

— NKD
© Author. All rights reserved. 
DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 

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The Lucky Resident

Medicine Resident:         “My consultant scolds me for the silliest reasons.”

Surgery Resident:          “How lucky you are! My consultant scolds me even without any reason.”

— NKD
© Author. All rights reserved. 

More of Surgery Residents at:  Religious Residents



DISCLAIMER: This article is intended only for fun purpose. The author does not promote or recommend any behavior illustrated here or claim it to be useful. Use of the information herein is at you one's own risk. Before trying to emulate or follow anything the reader is well advised to take into account ethical, moral, legal and other considerations. The author recommends that Medical Practice should be of the highest ethical and moral level keeping in mind the interest of the patient as foremost. 
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