Trick of the Trade: Pediatric Distractors

Remember back in the day when we made simple toys for pediatric patients to focus on during the physical exam? Remember the inflated medical glove +/- a face drawn on it?

I just encountered a FREE iPhone application (Eye Handbook), which has a lot of useful features. I currently only use the Pediatric Fixation animations. They can be found under the “Testing” section. Kids (and often adults too!) become mesmerized and distracted by the cartoon animations.

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By |2019-01-28T23:45:44-08:00Jan 13, 2010|Pediatrics, Tricks of the Trade|

Trick of the Trade: Finger nailbed laceration repair

LacFingernailsmOver the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above.

Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges.

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By |2016-11-11T19:01:44-08:00Jan 6, 2010|Orthopedic, Tricks of the Trade|

Trick of the Trade: Laryngoscope lifting strength

IntubationYou are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]“, let’s focus on some basics.

How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or…

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By |2016-11-11T19:01:46-08:00Dec 16, 2009|Tricks of the Trade|

Tricks of the Trade: Diagnosing retinal detachment with ultrasound

In a sneak peek of my ACEP News’ Tricks of the Trade column, Dr. Patrick Lenaghan, Dr. Ralph Wang, and I will discuss how bedside ultrasonography can significantly improve your ocular exam.

Here is a classic example. A patient presents with acute onset right eye pain and blurry vision. She possibly has a field cut in her vision. Her pupils are a teeny 2 mm in size in the brightly-lit Emergency Department. You are having a hard time getting a good fundoscopic exam to comfortably rule-out a retinal detachment.

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By |2019-01-28T23:53:04-08:00Dec 9, 2009|Ophthalmology, Tricks of the Trade, Ultrasound|

Trick of the Trade: Subclavian line gone north

SubclavianNEJManatIn patients requiring central venous access, which vein do you prefer? In descending order, I prefer subclavians, internal jugulars (IJ), and then femorals.

There is increasing evidence that subclavian central venous lines are superior to femoral lines (JAMA 2001) with respect to iatrogenic infection and thrombosis rates. In 9% of subclavian lines, however, the line tip ends up in the ipsilateral IJ, instead of the superior vena cava (SVC) – see chest xray below. These lines are unusable in the long term because of the risk of cathether thrombosis in this low-flow area. The line must must be rewired.

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By |2016-11-11T19:01:49-08:00Dec 2, 2009|Tricks of the Trade|
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