On a shift last week, we had a patient present with a spontaneous pneumothorax. Not only that, but it was a tension pneumothorax. Although the patient was hemodynamically stable, he was very uncomfortable and really short of breath. To give us more time to prepare for the chest tube, it was decided to perform a needle thoracostomy.
The digital nerve block is common performed in the Emergency Department to provide anesthesia prior to wound closure. The digital nerves are typically accessed by injecting in the webspace on either side of the finger.
Have you had patients start to get sweaty and anxious merely at the sight of your drawing up lidocaine in the syringe? Despite your reassurance that the 18-gauge needle that you used was just to move the lidocaine into the syringe and that you’ll be using a small needle for the procedure, they don’t look very reassured. Trust is key to having the procedure go smoothly.
I’m still working on my 2009 ACEP Scientific Assembly handout for the LLSA exam test prep session (which were actually due yesterday!). Even though the conference isn’t until mid-October, the handouts are always due a few months earlier. And every year, it sneaks up on me! One of the articles I’m reviewing is about the risks of CT irradiation, published in the New England Journal of Medicine in 2007.
Given all the recent brouhaha around propofol and Michael Jackson, I thought I would review the 2007 Annals of EM Clinical Practice Advisory paper on the use of propofol in the Emergency Department for procedural sedation. This is one of the 2009 Lifelong Learning Self-Assessment (LLSA) articles. Each year EM-board certified physicians are tested on 20 pre-selected LLSA articles to maintain eligibility for re-certification.
Teaching procedural skills in medical school is increasing falling on the shoulders of emergency physicians. Two common problems that arise are the equipment expenses and simulation of realism. Working with my colleague Dr. Jeff Tabas, we came up some creative ideas around the teaching of (1) the Seldinger technique for central line placement and (2) saphenous vein cutdown.
Frequently patients present to the Emergency Department for lacerations, partial amputations, and abscesses of the fingers. After repairing the wound or injury, however, a bandage can be a bit unwieldy to apply and difficult to secure. To me, an ugly bandage just seems to detract from all of the diligent work that you just put into a plastic surgeon-quality wound repair.
Nothing frustrates me more than not being able to obtain intravenous access in hemodynamically unstable patients, especially because I give a talk on “Troubleshooting the Difficult Vascular Access Patient.”