Article review: Neuro exam documentation

Medicolegal woes often can be tracked back to poor documentation by the physician.

This article is a retrospective chart review of 384 EM resident charts, focusing on the documentation of the neurologic exam. Charts were selected if their chief complaints were neurologic or psychiatric in nature. A non-validated measurement tool for evaluating a neurologic exam was created based on discussions with attending emergency physicians. I have to agree with the chosen criteria. Documentation in each of the following criterion receives 1 point for a maximum score of 8.

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By Michelle Lin, MD|2013-06-27T13:54:49-07:00Dec 7, 2009|Education Articles, Medical Education, Neurology|

A radiology pearl: A subtle orthopedic diagnosis

A man recently presents with knee pain after pivoting and torquing his knee while falling. He complains of concurrent mild ankle pain. He presents with this tib-fib xray. Realizing that a proximal fibular fracture can present concurrently with a medial malleolus fracture or deltoid ligament rupture, we obtained xrays of the ankle. We were looking for a Maisonneuve fracture.

Do you see an ankle injury in these four images?

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By Michelle Lin, MD|2016-11-11T19:01:52-08:00Nov 13, 2009|Orthopedic, Radiology|

Trick of the Trade: Easy ocular application of fluoroscein

Gently 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).

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By Michelle Lin, MD|2016-11-11T19:01:53-08:00Nov 4, 2009|Ophthalmology, Tricks of the Trade|

Trick of the Trade: Super-sensitive to eyedrops

We 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.

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By Michelle Lin, MD|2016-11-11T19:01:54-08:00Oct 28, 2009|Ophthalmology, Tricks of the Trade|

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

Patients 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.

Trick 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.

By Michelle Lin, MD|2016-11-11T19:01:54-08:00Oct 21, 2009|Gastrointestinal, Tricks of the Trade|

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.

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

By Michelle Lin, MD|2019-02-04T03:00:51-08:00Sep 23, 2009|Orthopedic, Pediatrics, Tricks of the Trade|

Must-know toxicology website for emergency physicians

With recent discussion about the potential closing of California Poison Control Centers due to budget cuts, I suddenly became shockingly aware of how much Emergency Departments depend on these centers for assistance. They are always so knowledgeable and helpful in managing various ingestions and poisonings.

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By Michelle Lin, MD|2016-11-11T19:01:57-08:00Sep 10, 2009|Tox & Medications|

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