The digital nerve block is common performed in the Emergency Department to provide anesthesia prior to wound closure. The digital nerves are typically accessed by injecting in the webspace on either side of the finger.

Have you had patients start to get sweaty and anxious merely at the sight of your drawing up lidocaine in the syringe? Despite your reassurance that the 18-gauge needle that you used was just to move the lidocaine into the syringe and that you’ll be using a small needle for the procedure, they don’t look very reassured. Trust is key to having the procedure go smoothly.

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Frequently patients present to the Emergency Department for lacerations, partial amputations, and abscesses of the fingers. After repairing the wound or injury, however, a bandage can be a bit unwieldy to apply and difficult to secure. To me, an ugly bandage just seems to detract from all of the diligent work that you just put into a plastic surgeon-quality wound repair.

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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.”

What would you do in this trauma case?

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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.

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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.

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