Overdue Op Report

Last June I did surgery on my own toe, at home.  Sound ridiculous?  Well it was.  There's no getting around that fact.  But it seemed justified at the time, and even sounded kind of fun.      

Background  

a few days post-injury

Six days earlier I smashed my left big toe with a door.  It bled a little, and a few days later it was still painful and oozy.  Further investigation (trimming the nail back) revealed the flesh underneath was red and raw, and a pretty classic example of what's called a "subungual hematoma” (That just means excess blood causing pressure under the nail).  I'd experienced this once before, in 2004, when a basketball player landed on my toe—the same toe—with most of his weight.  A few days later I visited a podiatrist who removed the nail, releasing the pressure and allowing proper healing.

With that experience under my belt, not to mention my podiatry training, I figured I pretty well knew how to handle the situation.  So after observing the nail for a few more days, I decided it would be best to remove it completely.  The nail was already somewhat loose, and the flesh underneath would heal better with it gone.   

supply table

Now, removing a toenail is easy....if you have the proper supplies.  That includes certain surgical instruments (which I had, since I'd purchased some during school) as well as local anesthesia (which I did NOT have, and couldn't think of any way to get), and appropriately-sized needles and syringes (didn't have any of those, either, but figured I could scrounge some up).  

Obviously I could have gone to a podiatrist's office and let them do it for me.  But suffice it to say that I was cheap (and my insurance wouldn't have covered anything), and feeling kind of adventurous.  After all, it was right up my alley.  And all I needed was a a little lidocaine (that's the local anesthetic), and I'd be good to go!  

But where could I get lidocaine, other than the black market?  And where exactly is the black market?  I would have been perfectly willing to buy some there, had someone provided the location.

A breakthrough 

the O.R.

The problem of my absent anesthetic was solved when I read online that in the case of a drug allergy to lidocaine, an injection of diphenhydramine (aka benadryl) can be used in its place to provide anesthesia.  Um....really??

By the way, this is really bizarre because, as you probably know, benadryl is an antihistamine that's typically used by people with seasonal allergies, or as a sleep aide.  I'd certainly never heard of its being injected to produce anesthesia, and neither had my podiatry classmates (now in residency) that I subsequently mentioned it to.

Preparation 

Supplies!

Even with this breakthrough, getting supplies was trickier than I expected.  Benadryl abounds, but not in an injectable form.  I hypothesized that I could buy it in pill form, crush the pills in my handy mortar and pestle (which didn't exist), dissolve the powder in some water, and then inject that solution.  (This was a stupid idea for various reasons, but we'll get into that later). 

So I bought some benadryl tablets.  The only needles and syringes I could find were single-use, 1ml (small!) insulin syringes with 29 gauge (tiny!) needles attached, sold in a box of 100.  These were not at all ideal, but better than nothing....actually even that's debatable.  I also picked up some distilled water and alcohol swabs to further furnish my operating room.  

The Operation

The day had come, and it was kind of invigorating.  I was less invigorated when I realized that my crushed pills didn’t stay dissolved in the distilled water, instead settling to the bottom of whatever container they occupied.  As a result, it was nearly impossible to draw the mixture up into those insulin syringes before the diphen resettled to the bottom. (Not to mention it's nearly impossible to draw anything up into such small-gauge needles!  A 25 gauge needle is typical for such activities.)  It was equally challenging to actually inject the solution into my toe, due to both the settling and the smallness of the needles, which kept getting clogged by tiny pill particles.   Even when I did successfully inject fluid, some of it wasn’t as concentrated as it needed to be, due to the settling problems I mentioned.  So in case you hadn't gotten the message, that part was difficult.  But after a couple hours of finagling, most of my toe was numb, and I was ready for the fun part.

And it would have been pretty fun.  Except that despite my best efforts, one edge of the nail bed still had sensation.  I loosed the nail and separated it from the bed for the most part...but it was too painful to separate it on the edge that wasn't numb.  So I eventually yanked it off without having separated it 100%, and ripped off a chunk of flesh with it for good measure.  Yes, it was quite painful.  If you're having trouble relating to the experience, imagine sticking a butter knife under a small toenail to pry it up, only not being able to do so completely because it's too painful, and then ripping it off with pliers.

post-op

{Technical details:  Injected ~10cc's of impure solution, variable and unknown concentration.  Achieved numbness over 90% of surface area.  Loosened majority of nail with an elevator (all except medial edge), extracted whole nail and some adhered tissue from nail bed with a hemostat, observing proximal "feathery" edge.  Scraped proximal nail bed with currette to smooth and flatten, in hopes that the nail would grow back more smoothly and uniformly than it had since its prior avulsion in 2004.  Applied generous triple antibiotic ointment, followed by somewhat-sterile dressing.  Including application of anesthetic, op time ~3.5 hours.} 

Aftermath 

My toe was in a lot of pain that evening at the ward party, but I was very glad to be done with the surgery.  My biggest concern on day one was infection--my technique had been anything but sterile.  And for a couple days I thought I had one, due to a pattern of redness on and around the injection sites.

To make a long story (everything that happened after the surgery) fairly short, over the next few days I carefully assessed the spread and movement of the redness and ascertained that there was no infection, but only a local reaction of some sort to the various impurities I had injected along with the benadryl—read the ingredients in sleep aid pills sometime and imagine the possibilities.  Redness, swelling, and pain remained for several days, which was worriesome.  I nearly went to see a doctor.  But after a couple weeks it improved enough that I was comfortable and functional once again.  Gradual change continued and still does.  Even now, over 10 months later, there lingers a mild degree of redness and puffiness around the nail, but it’s rarely painful.  The main difference is that I have to trim the nail much more aggressively to avoid over-encroachment by the puffy skin around it, which otherwise results in pain, ingrown-toenail-like symptoms, and eventual ulceration (all of which are awesome). 

tracking possible infection

Do I have any regrets in life?  Yes.  Do I regret surgerizing my toe?  Maybe.  The goods and ills are nearly a wash.  One of the most important things I learned:  If you're thinking about crushing up oral benadryl pills that contain a million ancillary ingredients using a non-existent mortar and pestle in order to inject the produced solution into your own toe using tiny insulin syringes...it may not be the best idea you've ever come up with (though it could possibly be in the top ten).