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?

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?

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.


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.


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.


9 08, 2016

Trick of the Trade: Ocular ultrasound for the swollen traumatic eye

Eye swelling ocular ultrasoundYou are caring for a patient with an incredibly swollen eye – like a scene out of almost any Rocky film. This patient is likely going to the CT scanner, but regardless of the finding (retrobulbar hematoma, orbital wall fracture, etc.) you still need to evaluate for extraocular muscle entrapment and loss of pupillary response. There’s only one problem: you can’t see the eye. The old standards like getting the patient to retract their lid using paperclips or a cotton swab may help; but sometimes there is just too much swelling, and those techniques are just not enough. Without brute force – and potentially causing more trauma – you likely won’t be able to examine this patient’s eye.


20 07, 2016

Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

Tibial intraosseous lineWith the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made much easier. Securing the IO needle to the patient’s tibia, femur, or humerus, however, is a different story. After successful patient resuscitation, these needles often tenuously secured through creative uses of sterile gauze, trimmed paper cups, bag valve masks, and/or just tape. Stabilization of tibial IO lines can be difficult in a sedated, intubated patient. This can be even more difficult in an agitated, moving patient.