Case 22: Off The Hook

Triage Note: Fish hook in eye. No bleeding. Tetanus up to date.

It’s a sunny weekend during cottage season. A young woman is rushed into the ER as she cups both hands over her left eye. She’s in shorts, and flip-flops, and she’s hyperventilating. Her friends follow, hands similarly cupped over their mouths. I read the triage note. I’ve never seen this before. I’ve removed dozens of fish hooks – it’s one of my favorite things to do – sometimes challenging, and instantly satisfying. I’ve removed many fish hooks around the eye, but a puncture of the globe itself would need exploration in the operating room.

A fish cannot lie on its back. Well, maybe a shark can lie on its back, if you tuck the famous fin to one side. But the pancake-flat fish one usually catches with a line and lure cannot lie on its back. After having fished – once – I now know this to be an evolutionary trait. It was several years ago, at a lake-side resort north of the city. I was given a fishing rod, a small tin, and a life jacket. When I realized that the tin was packed with live worms that I’d have to murder via penetrating trauma, I did what any self-respecting physician would do: I asked my mother-in-law to impale the tiny serpents. After the line was cast, and the critically-injured invertebrates had drowned, I took control of the fishing rod. I didn’t have much hope, but my four year old was confident: If we waited long enough, we’d catch something. Sadly, he was right.

Just after the second hour, the line tightened. My first instinct was to let go, and let the fish have the worm and the entire apparatus connected to it. But my son’s eyes were wide, as he grabbed the reel and spun the handle. I pulled back on the rod and helped my son shorten the fishing line until our victim was visible just below our dangling feet. A stranger appeared with a net, and soon, the fish was on the dock.

Immediately, the fish suffered a generalized, tonic-clonic seizure. Apparently, this is common. This is why fish cannot lie on their backs. They are designed to stay on their sides, or, in medical terms, in the recovery position. Should the fish vomit, the recovery position would prevent the regurgitated contents from backing up into their throats, thus minimizing the chance of choking. I realize a fish breathes through its gills, but I haven’t thought this part out yet. And although the fish had not bitten its own tongue, it was bleeding from the mouth nonetheless.  This was my fault. Disgusted at what I’d done to both fish and worm, I tried to pull out the hook. It wouldn’t budge. My son waved his grandmother over, and once she arrived, he told me I could leave.

Fish-hook injuries are more common than one might think. My first was on the palm of a twelve year old boy. Easy, I thought, as I instilled local anesthetic. When he was frozen, I pulled. The boy’s skin tented as the metal refused to let go. I made incisions around the shank and pulled again. No luck. It took half an hour to dissect the flesh around the barb, and extract the hook. As I sutured it the wound, I felt there had to be a better way.

I found a better way in a book called the Manual of Rural Practice. To obtain this book, I had to rip out an order form from another copy, complete it by hand, and send it away by Canada Post. It arrived six weeks later, as if it had been delivered by horse-and-buggy.

The “Manual” is a unique book meant to provide guidance to MDs working alone in the “Hinterlands” – remote parts of the country where access to specialized care isn’t always an option. Chapter eleven, “The Occasional Burr Hole” is a must-read. There aren’t many medical texts that describe what items can be purchased from the local hardware store (i.e. Canadian Tire) for the purpose of drilling a hole into a child’s skull. There are also chapters that detail testicular surgery, breech (butt-first) deliveries, and fish-hook removal.

I coax the young lady to lie down. She listens to each of my instructions, and quickly calms. I lift her arms away. The hook has penetrated the eyelid. I slide the lid up and down. It moves easily, along with the hook; It hasn’t penetrated the eye. Thank goodness. I’m careful with the anesthetic, barely advancing the needle. She needs a numb lid, not a numb eye-ball. I explain what needs to be done. The needle must be pushed through the lid, and then snipped with a wire cutter. “If you promise not to move,” I say, ” I promise not to puncture your eye-ball.”

Within two minutes, she’s smiling, and it’s over. Like me, she will never go fishing again. Specifically, she will never stand behind someone who is casting a line. I jot down the name of a fishmonger. “Ask for Ryan,” I say. “He’ll get you any type of fish you want. He’ll even shuck oysters for you and put them on ice.”

She thanks me, and asks me to send her a copy of the video (above).

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