Cast Cutting

The other night at about midnight I got into a genuine wrestling match with an ankle cast on a senile old lady's leg.

A patient needed her ankle cast taken off before she went home in the morning, and the nursing staff here at the hospital didn't get around to calling the PA until midnight. When I walked into the patient's room, I realized an all too frequent situation. The patient was senile. This one was practically catatonic, complete with the "O" sign.

The "O" sign is when the mouth is permanently held wide open and the lips are slightly pursed, imitating the letter O. It's only one level of health better then the "Q" sign, which is the same thing, except the tongue is hanging out to the side. Strangely enough, healthcare workers think that when the patient has the "Q" sign, death is knocking. For more on this interestingly insensitive topic and others, read The House of God in it's entirety.

Anyway, this lol (Little Old Lady) stared wide-eyed at the TV above my head during my whole introduction and explanation of what I was about to do. She was 100% unresponsive. You still should explain everything and remain polite in these situations, since you never know how much is actually sinking in. I left the room and came back in with the cast cutter, noticing she hadn't moved an inch, continuing her dedicated coverage of the CNN channel.

The 1950's cast cutter on the orthopedic floor is known as the Green Dragon. It's an ungainly contraption on two wheels that can be dragged around like a golf bag, and looks like it has tubes and cables coming off it at every angle. At the end of a large vaccuum tube is a small hand held circular saw that looks pretty intimidating - except the saw doesn't spin, it vibrates with such force and speed that it cuts into brittle stuff like plaster or fiberglass, while just tickling your skin should you punch all the way through. The vaccuum tube is to suck up the dust and crumbs while you cut. And of course it's green. Bright green. Who knows, maybe it was once used in pediatrics. With the suction and the vibrating saw on, it doesn't come across as a delicate piece of machinery.

After plugging in the dragon, I stepped back to assess the situation. I chose my cut lines carefully, knowing how easy it is to find yourself upside down and left-handed after "cutting yourself into a corner." I noticed how thick the cast was down around her ankle - there must have been 15 layers of cast there. Never the less, I flipped on the cutter, then pressed the foot pedal for the vaccuum and went to work.

Starting at the top of the cast, I pressed the rattling blade easily through the stiff fiberglass and inched down to the ankle. Once there, I realized the blade wasn't going all the way through. The fiberglass was too thick. I'd have to come back to it. I pressed on after making a 90 degree turn at the ankle and finished up by the toes. Now for the next side. Things were going well, when she suddenly jerked her leg.

I tell patients to raise their hands if they feel pain at any time since I can't hear over the saw, but this lady either didn't understand me or didn't act like she understood me. So when she jerked her leg, I turned everything off and asked her if she was alright. No response.

Sometimes the vibrating blade gets hot from the friction and can touch the patient. It happened to me while cutting a little cast off a squirming 2 year old, and we all thought he was squirming and screaming because that's what little kids do when confronted with the green dragon. When I pried off the cast there were little red tracks where the blade went through the cast padding. I had been burning him.

Needless to say, I was gunshy when it came to using dull hospital cast blades on unresponsive patients. I questioned her until I was sure the blade was cool and she just stared at the news anchor on CNN. Going back to work, she flinched again. I again turned everything off and asked her if she was OK. Nothing. I finally finished cutting my lines on the inside and outside of her cast, and reached for the cast spreaders.

Finally able to insert the tips of the spreaders into the crack lines after considerable effort, I pulled. Nothing. I pulled harder. The spreaders came out of the groove and popped open in the air. I had to cut deeper into the cast.

What happened for the next 15 minutes was horrendously tiring. I would alternate trying to saw with using the cast spreaders, slowly building up frustration and starting to sweat. Managing to cut down through the cast on one side using a combination of saw, spreaders and trauma shears. The other side was hopeless, as it was just too thick. Plus the manipulation of her broken ankle would probably cause more pain than the side I had just done.

I stepped back and thought. Maybe I could open up the cut side of the cast with the spreaders like a clam and wiggle her foot out. I tried over and over, getting the swollen old foot about halfway, then losing strength and needing about two more hands, gave up and let the cast close again with the foot inside. I was getting pretty hot and tired.

After starting off with a gentle introduction and careful manipulation of her foot, my actions had descended into a tortotous debacle of pulling and shoving, sweating and cursing. Although the patient was calmly watching TV, I couldn't help but wonder how much pain she was feeling.
At times practically forgetting there was a person attached to the foot, I had to keep reminding myself to slow down and think.

It had turned into a simple problem of physics/mechanics, with little medical involvement. I simply had to get the cast off her foot. While not hurting her. While not hurting myself. It reminded me of a home improvement situation where you get involved with a difficult task you've never done before, hitting a point where you must make a decision to forge ahead, possibly making matters worse, or call in a contractor, admitting defeat. Around the house, I am usually pretty lucky fixing things, but this was different since a patient was involved. Plus it was a goddamn cast - I have removed tons of casts. It wasn't brain surgery.

Standing there in the room, trying to simultaneously cool down and think for a minute, I heard a nearby voice say, "Things aren't working out for ya, are they?"

At last - a sympathetic, overworked nurse had arrived to lend a hand - I immediately said, "No Goddamnit". But there was no one there. It was still just me and the old lady.

But she was looking at me.

Realizing she was having a moment of clarity, and realizing I was at the end of my rope, I surprised myself with a totally unprofessional thing to say;

"What should we do?"

Without skipping a beat, and recognizing my problem was also hers, she began to offer incredibly accurate suggestions that made evident she was in fact paying attention for the past 30 minutes. I felt no pride lost in working with her suggestions, determining what hurt, and what didn't, as she pulled her foot out and I managed to wrestle the cast open further. It was still a considerable struggle, though. We both should have felt a wave of releif when her foot was finally free of the evil cast.

I asked her if her foot still felt OK, expecting an exuberant "YES!", but she was gone again. Her eyes were glued to the TV screen, watching CNN. She didn't look at me or answer any more questions that night. I stood there frozen in disbeleif, holding the broken and defeated cast at my side.

For just a breif moment in time, she was there as clear as day, and not at all grumpy. Usually old sick people are a little touchy when it comes to inexperience - I've been asked how old I am, How long I've been a PA, whether my mother knows I'm out - you name it, old folks can be pretty bitter people when they are sick or in pain. But she wasn't, in fact, she was encouraging me a little here and there, even joking around. I have to admit, after her initial surprise comment we got along as well as two people can when dealing with a problem.

When you go through something difficult with another person, there is a sense of bonding, whether it be fighting in war, climbing a mountain, or in this case, cutting a poorly wrapped cast off an old lady's broken ankle. Especially if success is the final result.

I have received more than a few "thank you's" for cast removals since it feels so good to get them off, but that night was the first time I thanked the patient; I can't be sure she heard me, but I like to think she did.