He wasn't what I was expecting. Sometimes when I walk to the waiting room to call a new patient into the hand clinic, I try to imagine what the person will look like and then identify the person, before calling out his or her name. But, this new patient did not fit my expectations.
This 72 y/o gentleman was referred for fingertip desensitization. But I could see no one in the waiting room with a fingertip dressing on. Not even a Band-Aid. I called out his name; he looked much younger than his accumulated years. He had a twinkle in his eye and a toughened exterior with a hearty and pleasant laugh. He had calloused palms on his right and left hands. I asked him (never assume) if he was working, and he stated, "of course, I work more than full-time, I own and manage my own business, a machine shop." I asked- after a few standard questions - "What seems to be the problem?"
"The doctor said I had to come to therapy, because my fingertip is so painful."
He was about 3-4 weeks status post closure of distal third of distal phalanx crush injury, with partial nail bed injury. I noted how it could be sensitive and how the fibrin healing/dried crusty skin was overgrowing the incision. It looked healed. But how could one tell? And furthermore, how could I desensitize a fingertip, more than everyday life? And in a machine shop? Why was it so painful?
Routine tools of evaluation allowed me to observe and gave me time to think. I measured sensation, grip and pinch strength and range of motion, and discussed daily use and skin care. The nail provides protection for the fingertip, offers the ability to pick up small objects and plays a role in tactile sensation. It also serves as a counter force when the finger pad touches an object; The nail looks healthy, with the eponychium and lunula normal. I decided to start with skin care, as most hand therapists, at least I know I do, want to see what lurks beneath. In following physician's orders, I accomplished this with a light surgical scrub to soften and desensitize for a minute; but the patient had been washing normally and I knew this wasn't the problem.
I pulled out my sterilized tweezers and scissors, and started lightly debriding beneath the nail and around the incision. (I feel like a salon specialist at this juncture). A little soft tissue mobilization, no adhesions, but, what was this? A suture? I pulled out a non-absorbable suture. Like a lion with a sore paw, this kindly gentleman immediately felt better and grateful. I thought, "He doesn't need a treatment program, just a little investigation and detection!"
But my story doesn't end here. I was surprised to see him return the next week, having thought his finger would continue to feel better as he healed, and he might cancel. I checked the fingertip again, delighted to see improvement, but the gentleman, patiently explained that there was still pain. We together repeated the whole process, and what-do-you-know? A second suture materialized. Maybe next time I will look a little further.
He returned his hands to their hard working job without further problem.
P.K. Miller, OTR/L, CHT
Clinical Specialist
Cleveland Clinic Health System
Lakewood, OH
Submitted April 16, 2009
Tell Us Your Story!
ADVANCE Online is seeking stories about the best part of OT--a challenging diagnosis, a tough decision, or that moment where you realize you've truly touched a patient's life. We want to showcase your talents and experiences. We'll choose the best stories to appear in our web edition. And if we choose your submission, you'll also receive $25!
Click here to enter your submissions!
|