it was a jaw dislocation – the jaw slips out of socket, usually after a big yawn, and the end result is you can’t close your mouth. Even though it was the first time I’d actually seen it, it was an easy diagnosis to make, since the patient was staring at me like I’d just dropped my scrub pants and peed on the bed.
I quickly leafed through an emergency textbook, out of sight from the patient (who wants to see their doctor doing that?), to confirm what I thought I knew — wrap some gauze around your thumbs, put them on the back bottom teeth, and push down hard.
Gloves on, gauze wrapped, fingers in mouth, and I started pushing.
Hmm, the textbook didn’t mention what to do when the patient screams and grabs your wrists. I thought some medicines for pain and muscle spasm were in order.
4 milligrams of versed, 100 micrograms of fentanyl, and some beads of sweat on my part later, though, she was still sitting there mouth gaping open.
Time to bring out the big guns, a conscious sedation. Usually I use etomidate, but one of its side effects can be masseter spasm, which would make reduction all but impossible. So instead I went with propofol, a med I used extensively in residency but not since for a couple of reasons including I don’t think we’re really supposed to.
Usually you give a slug of this and people immediately go out, sometimes so deeply that they stop breathing momentarily. But with her, nothing, she just continued to stare at me as alert as if we were chatting at a coffee house. IV’s working, fluids are running wide open — what is it with this girl? Another big slug, and finally her eyes start to go heavy. And then they reopen, but her eyes are distant now, and looking around the room at me, the nurse, and the respiratory tech she says in a perfect stoner voice “hey ya’ll wanna get somethin to eat after this?”
I’d never seen anyone react to propofol like that before. I stuck my thumbs in her mouth one last time and clunk back in place it went, her mouth now closed. Stepping back to admire my work, she — with all of her sedating meds on board — started to unleash a giant yawn. No, I yelled, and quickly put one hand on the top of her head and the other under her chin, pushing her mouth back shut. Fortunately it didn’t pop out again, and I wrapped her head up in a bandage for good measure.
Shut my Trap [Ten out of Ten]