Nothing frustrates me more than not being able to obtain intravenous access in hemodynamically unstable patients, especially because I give a talk on “Troubleshooting the Difficult Vascular Access Patient.”
Recently on my ED shifts, there were several especially challenging endotracheal intubation scenarios.
- A patient with thick frothy sputum constantly oozing out her trachea such that we couldn’t see the vocal cords– no matter how much suction we used. Imagine the Diet Coke and Mentos backyard experiment. I’m not kidding.
- A 300+ pound agitated trauma patient with almost no neck, who eventually was found to have an epidural and subdural hemorrhage.
- A COPD patient who was increasingly lethargic, hypoxic, and hypercarbic (pCO2>115), who I knew would start desaturating quickly as soon as rapid-sequence induction drugs were given.
In various ACEP News Tricks of the Trade columns, I have mentioned the importance of adequate lighting to visualize subtle injuries or pathologies. Traditional room overhead lighting is insufficient, especially if you are looking for that needle-in-a-haystack laceration in thick scalp hair or a tiny foreign body in a wound.
If you are using a traditional Tungsten penlight, you need to invest in a LED light source. LED penlights are very small (can fit on a keychain), super-bright, long-lasting, and costs only $3-30.
Tissue adhesives for wound closure often seem to intentionally make a bee-line straight for high-risk areas such as the eye. To avoid inadvertent application of the tissue adhesive, Dr. Hagop Afarian (UCSF-Fresno) utilizes a transparent tegaderm tape with an oval cut out of the center to provide a protective barrier. Immediately after application of the tissue adhesive, the tegaderm can be carefully peeled off to reveal a still-drying, well-circumscribed aliquot of glue over the wound. Be sure that the wound is dry, and the edges are well-apposed prior to tissue adhesive application.
I just submitted my quarterly column installment on Tricks of the Trade in ACEP News on ENT dilemmas. Kids (and adults) get the most bizarre things in their ears and noses. I’ve seen a cockroach and Q-tips in the ear, and peas and pebbles in the nose. What have you seen, and what are your tricks for getting these things out?