Trick of the Trade: Ultrasound-guided injection for shoulder dislocation


Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?


By |2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|

Trick of the trade: Nebulized naloxone

NaloxoneOverdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.

Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.


By |2019-01-28T22:35:16-08:00Nov 1, 2011|Tox & Medications, Tricks of the Trade|

Trick of the Trade: Nasal cannula oxygenation during endotracheal intubation


You are managing a 300-pound patient with a long history of severe COPD, who now requires intubation because of a pneumonia and COPD exacerbation. You anticipate that the patient may be a difficult airway intubation and may desaturate quickly during laryngoscopy. While you are setting up to orotracheally intubate this patient, you preoxygenate this patient as best as you can with a non-rebreather mask.

What can you do to prolong the patient’s time-to-desaturation so that you aren’t as rushed to place the endotracheal tube?


By |2019-01-28T22:35:50-08:00Oct 25, 2011|Tricks of the Trade|

Trick of the Trade: Opioids for air hunger

BipapA patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:

  • Oxygen by face mask
  • Nebulized albuterol and atrovent
  • Solumedrol
  • Bipap
  • Set up for possible intubation

With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask.



By |2016-11-11T18:51:57-08:00Oct 4, 2011|Tricks of the Trade|

Trick of the Trade: Needlestick hotline 888-448-4911


You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood.

After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.

Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.

It’s difficult to concentrate when faced with so many questions whirling in your mind.


By |2019-01-28T22:38:19-08:00Sep 27, 2011|Infectious Disease, Tricks of the Trade|

Trick of the Trade: Pediatric ear exam


Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:

What’s your trick on performing an otoscope exam of the ears?


By |2019-02-19T18:08:03-08:00Sep 20, 2011|ENT, Pediatrics, Tricks of the Trade|
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