Trick of the Trade: Making the NG and NP procedures less painful

When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anesthetized. Getting things pushed up your nose is so profoundly irritating that most patients only give you 1 or 2 changes to get it right.

One option is to use nebulized lidocaine, although it takes a while to prepare and anecdotally tends to numb mainly the hypopharynx, placing the patient at risk for aspiration later on. Another option is to use viscous lidocaine to coat the NG or NP tubing, but this is fairly messy and only mildly helpful. Commercial intranasal atomizers, which disperse lidocaine over the nasal mucosal surfaces well, are generally effective, but may not be available in some emergency departments.

2019-02-22T13:34:02-08:00

Trick of the Trade: Rapid Oral Phenytoin Loading in the ED

A 57 y/o, 75 kg male presents to the ED after a witnessed seizure. He describes a history of seizure disorder and is prescribed phenytoin, but recently ran out. A level is sent and, not surprisingly, results as < 3 mcg/mL (negative). After a complete ED workup, the decision is made to ‘load’ him with phenytoin 1 gm and discharge him with a prescription to resume phenytoin. An IV was not placed.

Can you rapidly load him orally?

Trick of the Trade: No pelvic bed? No problem

Pelvic SpeculumOften finding a pelvic examination bed for a female patient needing a speculum exam can be challenging. Without the elevated foot stirrups, the bed under the patient’s buttocks obstructs the pelvic speculum handle so that it can’t rotate completely into a 6 o’clock position.
Some people place an upside-down bed pan to elevate the patient’s buttocks slightly in order to create more space for the speculum. Not only is the position uncomfortable for the patient, it seems a waste of a perfectly good bed pan. Fortunately there is an alternative approach.
2019-01-28T22:00:26-08:00

Trick of the Trade: Ambient noise and creative cognition

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For many of us in academia and medical education, we accomplish a tremendous amount of work outside of the workplace. This can be in our home office, on the public transit system, or in the library.

Interestingly, creative cognition occurs best with a moderate amount of ambient noise (not too much and not too little), according to a 2012 article from Journal of Consumer Research.

(more…)
2019-02-19T18:04:59-08:00

Trick of the Trade: External jugular tourniquet

Paitents can be a challenge when trying to obtain peripheral IV access. The vein may be collapsed from dehydration or scarred because of IV drug use or repeated cannulation. Before thinking about an ultrasound-guided deep vein IV or a central line, take a look at the external jugular (EJ) vein.

There are, however, a few problems that exist when trying to cannulate this site:
  • There is no tourniquet for the neck.
  • To distend the vein, you often need to put the patient in Trendelenburg, which may be uncomfortable or intolerable for some
2016-11-11T11:17:20-08:00