How can you eliminate this artifact? (No cheating with rocuronium.)
A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen:
- Oxygen by face mask
- Nebulized albuterol and atrovent
- Set up for possible intubation
With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask.
You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood.
After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report this to the attending.
Should you start post-exposure prophylaxis medications for HIV? You remember that if post-exposure HIV medications are recommended, you should start it immediately and definitely within 2 hours of exposure.
It’s difficult to concentrate when faced with so many questions whirling in your mind.
Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about:
- Balloonimals iPhone app to grossly assess peak flow
- Candleflame iPhone app to grossly assess peak flow
- Eye Handbook iPhone app with pediatric fixation animation targets
- Casting/splinting your buddy bear
What’s your trick on performing an otoscope exam of the ears?
A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.”
Does this patient have a septic joint?
You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous.
Is your first-line treatment meclizine or benzodiazepines?
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV).
- Place the gurney’s head of the bed down flat.
- Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney.
- Rotate patient’s head 45 degrees.
- Help the patient lie down backwards quickly.
- The patient’s head should be hanging off of the gurney edge in about 20 degrees extension.
- Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV.
I find 2 things challenging in this maneuver.
- The patient often does not like to be moved AT ALL while feeling nauseously vertiginous. This even includes trying to reposition the seated patient closer to the head of the bed. This requires them to look behind them to see what where they are going, which sets off more vertigo.
- In some of our ED rooms and hallways, the head of the gurney bed is often abutting a wall, a portable monitor, or some equipment. It takes a little fancy shuffling to make room for the Dix-Hallpike maneuver.
Trick of the Trade: A modified Dix-Hallpike maneuver
Place blankets or a pillow under the shoulders for the Dix-Hallpike maneuver.
The key is to maintain about 20-30 degrees of neck extension to align the posterior semicircular canals with the direction of gravity. Placing several blankets under the patients’ shoulders can accomplish this same position without having to scoot the patient close to the gurney edge. I’m sure the patient would appreciate keeping their head movement to a minimum.