Trick of the Trade: Less traumatic nasopharyngoscopy

A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. Depending on the diameter of your fiberoptic cable, it may be fairly uncomfortable for the patient despite generous viscous lidocaine instillation through the nares and nebulized lidocaine. Alternatively or additionally, you can make your own lidocaine-oxymetazoline nasal atomizer which works well.

What if the patient is STILL not tolerating the procedure well?

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By Michelle Lin, MD|2016-11-11T19:02:31-08:00Jul 16, 2013|ENT, Tricks of the Trade|

Trick of the Trade: Stimson technique using wrist restraints

A patient presents with an anterior shoulder dislocation on x-ray. Your ED just received 5 new patients via ambulance and you are trying to prioritize your patients as they come in the door. What can you do for your patient with the shoulder dislocation in the meantime? (more…)

By Michelle Lin, MD|2016-11-11T19:02:30-08:00Jul 10, 2013|Orthopedic, Tricks of the Trade|

The Dirty Epi Drip: IV Epinephrine When You Need It

You’re a recent graduate picking up an extra shift in a small ED somewhere north of here. At 3 AM an obese 47 year-old woman presents with shortness of breath and difficulty speaking after eating a Snickers bar an hour earlier. She admits to history of hypertension, peanut allergy, and a prior intubation for a similar presentation. She is becoming more obtunded in the resuscitation room as you are collecting your history. A glance at the monitor shows:

HR 130
BP 68/40
O2 saturation 89% on room air

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By Zlatan Coralic, PharmD|2021-02-01T09:19:17-08:00Jun 27, 2013|Allergy-Immunology, Tox & Medications, Tricks of the Trade|

Trick of the Trade: Got a shoulder dislocation? Park it

ShoulderDLxray

Myriad techniques exist to reduce shoulder dislocations, which includes scapular rotation, Hennepin, Snowbird, Cunningham, and Legg maneuvers. They are nicely reviewed at ShoulderDoc.co.uk. You can also supplement any technique with ultrasound-guided intraarticular lidocaine for improved pain control.

Recently, Dr. Jay Park (Beth Israel Medical Center in New York) contacted me about his novel approach to shoulder reduction which anatomically makes sense. If his animation video doesn’t convince you, check out the video of an actual reduction.

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By Michelle Lin, MD|2019-01-28T21:59:02-08:00Jun 25, 2013|Orthopedic, Tricks of the Trade|

The Case: A 8-day-old, uncircumcised male is brought to the ED with fever, irritability, and decreased urination.

The Problem: Getting a clean catch urine in a timely, non-invasive manner

The Solution?

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By Salim Rezaie, MD|2016-11-11T18:38:43-08:00Apr 30, 2013|Genitourinary, Pediatrics, Tricks of the Trade|

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.

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By Michelle Lin, MD|2019-02-22T13:34:02-08:00Apr 23, 2013|Tricks of the Trade|

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

A 57-year-old male (75 kg) 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 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?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2020-02-16T14:45:12-08:00Apr 16, 2013|Neurology, Tox & Medications, Tricks of the Trade|

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