In the Emergency Department, it is important to be able to accurately estimate the length of wounds, abscesses, and cellulitis. Additionally, billing for wound closure is directly related to the length of the laceration.
One of the landmark studies in sepsis was conducted by Dr. Emanuel Rivers (Henry Ford) and published in the New England Journal of Medicine in 2001. By managing patients with severe sepsis and septic shock with an “early goal directed therapy” approach, there was an absolute risk reduction of 16%. Furthermore, the number needed to treat to save a life was 6 patients!
Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don’t have the fancy ophthalmology eyelid retractors?
Trick of the Trade
Use a Q-tip
I thought of this idea when I was rolling up a projector screen in a conference room. Why can’t we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to “roll” the eyelid out of the way.
Below are a series of photos of a woman with eyelid swelling from conjunctivitis. This technique provides a relatively painless way to retract the eyelid without placing pressure on the orbit itself. Although the images look like I am merely lifting the eyelid using the Q-tip, I am actually twirling the Q-tip.
Consent and photographs taken by Lourdes Adame
(Visual Aid Project member)
(Visual Aid Project member)
Videos are priceless when trying to teach procedures. This amazing teaching video by Dr. Michael Bailin at Mass General demonstrates a novel way of anesthetizing the airway during an awake intubation.
- Inject 3 cc of lidocaine using a small butterfly needle through the cricothyroid membrane. This causes coughing, which spreads the lidocaine throughout the upper airway.
- Inject 5 cc of atomized lidocaine through the fiberoptic scope port to anesthetize the posterior oropharynx and vocal cords.
- Slide the endotracheal tube over the fiberoptic scope.
Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren’t used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies.
For the past several years, I’ve stopped using Morgan lens and have started using something that all Emergency Departments have — nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation.
- Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached to a 1 liter normal saline bag. The IV tubing fits snuggly into the nasal cannula tubing.
- Rest the nasal cannula prongs over the patient’s nasal bridge to irrigate the eyes.
- Then open up the flood gates!
- To avoid a huge deluge of fluid onto the patient and floor, be sure to have a way to catch the fluid. Some place multitudes of towels around the patient’s head to absorb the fluid.
- As an alternative solution to towels, I like Dr. Stella Yiu’s (Univ of Toronto) adaptation of my cut-out basin approach for irrigating scalp wounds. To avoid overflow spillage, she rests a Yankauer suction tip at the bottom of the basin to collect the irrigation fluid.
Yesterday, I posted a review of an Academic Medicine education article on how to prepare medical students for their clinical clerkships, based on the Kolb learning cycle model. My blog post is now also linked and searchable from the Research Blogging network at http://researchblogging.org. Thanks to Life in the Fast Lane, who told me about the site.
Do you remember the sheer terror you felt, when you first started your medical school clinical rotations? Your first two years were probably spent in classrooms and small-group labs discussing anatomy, pharmacology, pathology, etc.
Then BAM! You are thrown into the deep end of the pool. You are now on a clinical team of medical professionals taking care of actual patients!