Monday Morning MD: 10 things to know about Jason Pierre-Paul fireworks injury

Much has been said and written about Jason Pierre-Paul and his hand injury over the last week. Unfortunately, much of my initial worry about the severity that I penned last week right after the accident has come true. This column will summarize the top issues surrounding JPP. Most of this information has been tweeted out by me real time and discussed on multiple national radio and print interviews. When the fireworks injury required overnight hospitalization, that was my clue that the injury was worse than originally reported. Even though the Giants have been shut out by JPP to date, team brass along with their top medical staff have already analyzed the situation. The information below will not be news to them. When the Chargers second-round draft pick Terrence Kiel was shot in a carjacking attempt in Houston, I gathered information for the team and had comprehensive discussions with management. The $14.8 million franchise tag offer remains in place, but the $60 million contract has been withdrawn.  
  1. [caption id="" align="alignright" width="300"] What an index finger ray resection would look like[/caption] JPP lost his entire index finger down into the palm
There was enough damage that none of his index finger was salvageable. By definition, ray resection means the amputation of the entire index finger down into the palm. This was likely done to prevent the need for multiple surgeries and the likelihood of still ending up with a non-functional and painful finger. The silver lining is that this choice means a quicker recovery. This is akin to the decision Ronnie Lott made decades ago to amputate the tip of his pinkie finger.
  1. Worries about additional injury including the thumb
Fireworks injuries are by definition blast injuries that typically don’t cause isolated damage. With enough force to necessitate index finger amputation, what does that mean for the neighboring thumb? Reports indicate a thumb fracture that was pinned in surgery. This was not shown on the Adam Schefter tweet as JPP likely had an initial debridement surgery Sunday early morning and his thumb was pinned then. The hope is the pin was used to treat a simple fracture that could not be casted due to the skin wounds. If the pinning was for a comminuted fracture or joint instability, this would indicate a longer recovery. Any long-term thumb issues makes JPP’s return to play more difficult. Complicated skin graft procedures don’t seem to be needed. The amputation may have obviated the need for these complex graft or flap procedures. The split thickness skin graft performed on the forearm is the best type with the shortest recovery.
  1. If only loss is index finger, JPP will return to form
The loss of any finger is obviously a big deal. In everyday life, the index finger affects most tasks of daily living, including tasks requiring fine pinch, manipulation and dexterity. However, in terms of playing defensive end in the NFL, the index finger is the least important. Power grip, needed for holding and tackling, is mostly provided by the 4th and 5th (with contribution from 3rd) fingers. Just grab a golf club and you will see how little pressure is applied by the index finger. Based on JPP’s superior talent and minimal affect on grip, I believe he can be effective again in the NFL.
  1. JPP likely did not disrespect the Giants
Much was made that he refused to see the Giants officials that came to Miami to visit and apparently rebuffed the offer to have team physicians or specialists treat his hand. The initial player’s reaction is to rush to the hospital and contacting the team is not usually a first thought. When the Giants made the unusual move to come visit JPP, he had shut himself out from the world and was not even returning friends calls. Likely he was quite emotional while coming to grips with the injury and making the hard decision for amputation. The day the Giants officials left without seeing JPP is the day he had the ray amputation. It is certainly generous of the Giants to offer care as they do not have to. Unfortunately, there is likely little that could have been done to salvage the finger even had he flown to specialists in New York. I don’t blame JPP from withdrawing from the world for a while. I doubt contract leverage or immaturity where the reasons for his behavior. Lets not forget the human element involved here.
  1. Hospital has a big problem
Patient confidentiality is vitally important. HIPAA, the main laws governing health care privacy, was trending on social media after the amputation was revealed. (By the way, HIPAA is two A’s and not two P’s) There is no question HIPAA laws were violated. What appears to be an operative schedule with equipment requests was publicized. The hospital has significant exposure here and has started its own aggressive investigation. They likely will track computer access and use all methods to discover the leak. Of note, media is not a covered entity and ESPN has no HIPAA exposure. Whether there were ethical or other violations is a different question and Schefter himself addressed them.
  1. Use of alias for JPP might have prevented the leak
As a team physician in the NFL, when we had a player admitted to the hospital, we often used aliases to protect the player from autograph seekers and the media. If laws were followed, aliases would not be necessary, but hiding a player’s name removes the temptation. On the day of his amputation surgery, there were over a 100 hospital workers that potentially had legal access to what was leaked. Three shifts of nurses (consisting of a charge nurse, primary nurse and nurses aide) and multiple doctors/residents (trauma, general medicine and hand service) already puts the number at over 20. Add to that pharmacists, phlebotomists, X-ray technicians, respiratory therapists, physical therapist, occupational therapist, dieticians/food service personnel, orderlies, custodians, volunteers and the number grows. Once JPP was scheduled for surgery, another 50 plus operative personnel needed access to the information. Anesthesiologists, scrub techs, instrument techs, circulating nurses, recovery room personnel, additional sets of orderlies and custodians. This is not to count the thousands of people that have computer access to medical records who are not involved in a particular patient’s care, yet have electronic access to the entire hospital patient base. The bottom line in the routine care of a patient is that many eyes necessarily have access to sensitive information.
  1. JPP camp did not leak his medical information
The information released appears to be an operative schedule/record. It contains information on another patient undergoing wrist surgery (open reduction internal fixation distal radius). JPP and his camp would only have access to his own medical chart There is no way for them to have any information on another patient. Only one patient’s records are in each chart. They are never comingled. Based on this fact, I am confident that JPP nor his camp leaked the information. There is no way they possessed another patient’s information.
  1. JPP had at least two surgeries
Fireworks hand injuries typically result in a minimum of two or three separate operations. Hand surgeons dread taking call on July 4th because the risk is known. Most states enacted bans because of hand injury and fires. Unfortunately, C.J. Wilson of the Buccaneers lost two fingers from his same day incident. The normal course is for immediate surgical debridement. Obviously damaged/dead tissue is removed. This is likely when the thumb was pinned as well. The index finger was also likely initially pinned. It is then typical to wait two to three days to let the rest of the wound declare itself as to what is viable and will survive. Tissue that turns black and dies needs to be debrided after it declares. This is likely the reason for the delayed amputation on Wednesday.
  1. Beware of phantom pain
After amputation, it is common to have the sensation that the body part is still there. JPP will have to adapt to the initial feeling that his index finger is still there but when he looks down, it won’t be. Sometimes this sensation is felt as pain. The phantom pain in a finger that is no longer attached is a reported phenomenon. It doesn’t always happen and there are treatments if it does. The point is this is another potential hurdle in JPP’s recovery.
  1. When will JPP be back to play?
This is the question that everyone is asking. Before we rush to football, C.J. Wilson’s dad put it best when saying he was grateful his son (who lost two fingers) was still alive and is not thinking football. JPP’s return depends more on his thumb and associated injuries than his amputation. If it is really just the index ray resection, I believe he will return to play and be effective Week 1. However, with the thumb fracture, I think that would be optimistic. Missing the first quarter of the season is more likely, but we won’t know for sure until we know the extent of damage and how his recovery comes along. Remember, he has to learn to play without his finger and get back into football shape as he has been hospitalized for over a week already. JPP should be discharged from the hospital soon The fact we are talking about when he returns, and not if, is great news. I hope this is a cautionary tale for all Americans to enjoy fireworks from afar. Follow David on Twitter: @profootballdoc Dr. David Chao is a former NFL head team physician with 17 years of sideline, locker and training room experience. He currently has a successful orthopedic/sports medicine practice in San Diego..
Dr. David Chao
Two decades of NFL team physician experience including two Super Bowls and two Pro Bowls. Providing unique perspective to injuries and the NFL sideline/locker room. Successful orthopedic surgery and sports medicine practice in Southern California.

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