13 02, 2017

Trick of the Trade: Rapid Insertion of Orogastric Tube

We have all been in the situation: an intubated patient needs an orogastric (OG) tube and no one has been able to place it successfully. Unfortunately, we typically find out about this situation after several failed attempts, when the patient is bleeding and/or the anatomy is distorted. It may coil in the mouth or esophagus. Here I present a novel technique to rapidly place an OG tube within seconds.
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7 02, 2017

PEM Pearls: Calming techniques while repairing a laceration

Most children who come into the Emergency Department present with pain or experience pain during their ED stay.1,2,3 Pain and distress during a procedure can leave a lasting impact on a child and contribute to mistrust of the medical system and compliance with future procedures.1 ,4,5 Children who use active forms of coping report less pain and distress during a procedure.3 To help with coping, when feasible, involve parents or family, nursing and a child life specialist. If the parents are willing, try to get them involved in all parts of the medical procedure.2,3 This includes positioning the patient with a parent in a secure parental-hugging hold or maintaining close physical contact throughout the procedure.6 This can easily replace immobilization of a child or the use of restraints which can cause increased fear and escalate the degree of anxiety in a child.2

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30 12, 2016

Trick of the Trade: Warfarin tablet strength identification

warfarinMedical providers commonly encounter patients in the emergency department who state they are anticoagulated with warfarin, but they have no idea what dose they are taking. “I know that I take two pills of warfarin daily.” Dosing becomes critically important especially when continuing their medication as an inpatient, refilling their medications, or adjusting their outpatient dose because of an inappropriately high or low INR level. How can you determine the patient’s warfarin dose?
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29 12, 2016

Trick of the Trade: A cleaner way to apply dental cement for a tooth fracture

dental cement for tooth fracture The management of a dental fracture is a core skill of the emergency physician.1 When the enamel is violated and the underlying dentin is exposed (i.e. Ellis Class II or greater), the dental pulp becomes at risk.2 Protecting the exposed dentin in a timely manner, therefore, is paramount. This is best accomplished through the use of dental cements.

The application of dental cement to a fractured tooth, while a relatively rare procedure, is one often fraught with difficulties. With many of the formulations requiring the rapid application of a fast-drying cement, time for accurate and clean application is limited. This often clumsy, haphazard spackling of the patient’s tooth with cement rarely feels smooth or confidence-instilling. Isn’t there a better way?
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1 09, 2016

Trick of the Trade: Simple finger traps using gauze roll

Finger trapsClosed reduction of fractures or dislocations in the hand and wrist can be difficulty to achieve. Gravity can serve as an assistant. Commercial finger traps are available, but can sometimes be hard to find in the Emergency Department. An earlier trick of the trade describes the use of a gauze role to build your own finger trap setup. The following describes a simpler way to build finger traps using a gauze roll.

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22 08, 2016

Trick of the Trade: Paraphimosis – Pour Some Sugar On Me

paraphimosisParaphimosis occurs when a retracted foreskin can’t be reduced back over the glans of the penis. Risk factors for paraphimosis include scarring, vigorous sexual activity, chronic balanoposthitis, and forgetting to replace the foreskin after catheterization or manipulation.

Paraphimosis can be a urological emergency as the tight ring formed by the foreskin can cause ischemia to the tip of the penis and eventually gangrene. Timely reduction is of high importance. Treatment involves gentle compression of the glans and gradual manual foreskin retraction.1 Unfortunately, as time goes on, more swelling occurs making traditional reduction techniques more difficult.

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18 08, 2016

Trick of the Trade: Ear Irrigation in the Emergency Department

Ear pediatricEar irrigation is an important tool for adult and pediatric patients in the Emergency Department (ED) with ENT complaints. Irrigation can be used to clear ear cerumen, visualize tough-to-see tympanic membranes, and remove foreign bodies. This may reduce the need for subspecialist care and improve the patient’s hearing and quality of life.1 Commercial electronic and mechanical devices are available for irrigation and have been studied. Moulton and Jones presented the improved efficacy of foreign body removal using an electric ear syringe in an (ED) population.2 In this trick of the trade, we present a low cost and effective way of  “ear-rigation” taught to us by one of our veteran nurses using easily available tools in the ED.

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