Trick of the Trade: Easy ocular application of fluoroscein

Fluorescein-1Gently instilling a fluorescein drop into a patient’s eye requires that the patient keep his/her eye still. What do you do for a patient who can’t quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

(more…)

2016-11-11T19:01:53-07:00

Trick of the Trade: Super-sensitive to eyedrops

CornealUlcer-largeWe commonly encounter ocular complaints in the Emergency Department. Eye pain can result from chemical exposure, a foreign body, or infection. The first step involves instilling a few drops of topical anesthetics, such as proparacaine, to provide some pain relief. Occasionally, however, you encounter a patient who just can’t keep his/her eye open because of the fear of eyedrops.

(more…)

2016-11-11T19:01:54-07:00

Tricks of the Trade: Low tech solutions to esophageal foreign bodies

DoxycyclinePatients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right)  is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis.

She presents to your ED.

What do you do?

With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes and nasopharyngoscopes, you might be tempted to take a look. However, you can first take a low-tech approach to propel the pill into the stomach. Each of these options has its unique risks and complications, and the risks/benefits should be weighed appropriately.

  • Glucagon IV – relaxes lower esophageal sphincter (LES)
  • Nitroglycerin SL – relaxes LES – beware of acute hypotension
  • Nifedifine SL – relaxes LES – beware of acute hypotension
  • Carbonated beverage PO- gas forming agent to increase intraesophageal pressure

Instead of pharmacologically moving the pill into the stomach, you can also consider mechanically pushing the pill down using an orogastric tube or blindly pulling it out through the mouth using a foley catheter.

ensureTrick of the Trade: What did we do?

Before we entertained the pharmacologic options, we gave the patient a can of Ensure, because it has a higher viscosity than water. Fifteen minutes later, the pill was pushed into the stomach and the patient’s foreign-body symptoms resolved. A simple $1.50 solution.

Teaching point

Tell all your patients receiving doxycycline to drink plenty of fluids when taking the medication.

Caveat

These low-tech solutions are only appropriate for pill foreign bodies and impacted food boluses in the esophagus, which are at low risk for esophageal perforation. These are NOT applicable to special situations such as button batteries, sharp objects, fish/chicken bones, and coins.

 

2016-11-11T19:01:54-07:00

Trick of the trade: Straightening the guidewire

Screen Shot 2012-10-31 at 9.05.43 AM

Did you know that a medical guidewire consists of a flexible central “ribbon wire” externally wrapped with a coil-spring wire?

J-shaped guidewires are commonly used in many medical procedures, such as central lines, arterial lines, and pigtails for pneumothoraces. Knowing more about the guidewire makes it possible to carry out a unique Trick of the Trade. For example, let’s say that the plastic introducer is missing or unusable. Using one hand to stabilize the needle in the patient, how do you use your other hand to re-insert a curved guidewire tip into the hub of a needle?

(more…)

2019-01-28T23:53:30-07:00

Trick of the Trade: Style points in pediatric orthopedics

With this hot summer season in California, kids have been running around and getting into all sorts of orthopedic troubles. Monkey bars are a common culprit. In treating pediatric patients in the ED, it’s worth spending an extra few minutes on the subtle style points.

Trick of the Trade:

Splint the buddy bear

You should consider keeping a stash of stuffed teddy bears in the ED for those patients, whom you splint or cast. It is a nice touch to have the patient go home with a teddy bear with the same “injury” and splint/cast.

BearCastAll

It’s the little touches that will make your patient’s day a little less sucky.

2019-02-04T03:00:51-07:00

Trick of the Trade: The key to pollution is dilution

Wound care mantra: “The key to pollution is dilution.”

High-pressure irrigation best reduces the patient’s risk for a wound infection. Open fractures are unique in the ED in that they require quick, high-volume irrigation before going to the operating room for more definitive wash-out. Often times a 30 mL syringe and 18-gauge angiocatheter is too cumbersome and slow for high-volume, high-pressure irrigation.

(more…)

2019-01-28T23:53:51-07:00

Trick of the Trade: Peritonsillar abscess needle aspiration

peritonsillar abscess

How do you drain a peritonsillar abscess?

When evaluating a patient with a sore throat and “hot potato voice,” peritonsillar abscess (PTA) is at the top of the differential diagnosis list. As with all abscesses, the definitive treatment involves drainage of pus. This can be done either by incision and drainage or, more commonly, by needle aspiration.

(more…)

2019-07-02T20:50:17-07:00