- Who will be in the audience?
- How can I make my talk more worthwhile to audience members, beyond their just reading the material/handout/articles on their own?
- Am I giving a talk before or after Dr. Amal Mattu? If so, just be resigned to being second-best.
Occasionally, I get a rare – “Hey congrats on the article!” comment from residents or students. It’s usually in reference to my ACEP News column that comes out every 3 months on Tricks of the Trade. However, I got about 3 shout-outs in the past 2 days. How odd.
Then I saw one of our office staff who was reading EM News. “Hey cool!” she said. Totally confused, I realized that I was quoted on the front page of this week’s publication about iPhone applications in EM. Many months ago, I had done a brief telephone interview with the writer.
On any given day in the ED, I use my super-bright penlight 2-5 times a day. It is amazing what things I’ve almost missed without a bright LED flashlight.
- Subtle HSV-2 labial ulcerations in a female patient with dysuria
- Additional scalp lacerations hidden in the hair
- Tonsillar exudates in a patient with strep pharyngitis
- Unequal pupillary responses in a brightly lit trauma room in a head-injured patient
I wanted to revisit a prior post about the importance of changing your Tungsten penlight to a LED light.
Have you ever performed a lumbar puncture (LP) in a patient, only to have them return the next day for new debilitating headaches? It’s worse when sitting up, and much improved when laying down. You hate adding more problems for the patient, put you are certain that s/he now has a post-LP headache.
As great as tissue adhesives are in wound closure, they come with some risk. For instance, liquid adhesives, such as Dermabond, can “run” and contact undesired areas such as eyelid margins. Careful application of tissue adhesives is critical.
How can you minimize the amount of seepage of tissue adhesive to undesired areas?
Trick of the Trade
Create an impermeable tape barrier
I already mentioned this in an earlier post in July, but I now have more experience with this technique. Here are some recent photos of this trick in action.
- Cut out a circle from a transparent tape adhesive. In this case, I used a transparent Tegaderm which can be found with peripheral or central line IV kits.
- Adhere the tape to the patient’s skin primarily along the circular edge to prevent glue seepage under the tape. You don’t need to stick the ENTIRE transparent tape to the patient, unless you want to pull off some eyebrow and eyelid lashes!
- Apply the tissue adhesive glue over the wound while ensuring that the wound edges are closely approximated. Excess glue will run off onto the tape. You only need to wait a few seconds after glue application before peeling the tape off.
This idea was contributed by Dr. Hagop Afarian (UCSF-Fresno).
Thanks also to my Visual Aid Project photographer, Lourdes Adame, who photographed and consented the patient’s father for these photos. Her speaking fluent Spanish made them feel at ease and understand that we were photographing for educational purposes.
Often patients with scalp lacerations have clotted blood in their hair. While we can irrigate the wound itself (and unavoidably soaking the patient in cold irrigation fluid), a lot of blood remains stuck in their hair. It would be nice if we could completely wash out the blood. This would further allows us to detect occult scalp lacerations.
I got a nice email from Dr. John Fowler from Turkey who recently published a modified version of the Hair Apposition Technique (HAT) trick in the American Journal of Emergency Medicine in 2009.
Read more about the traditional HAT trick.
The HAT trick allows for scalp laceration closure by using scalp hair and tissue adhesive glue. Contraindications to this technique for wound closure include hair strands less than 3 cm, because it is difficult to manually manipulate short hair.