Testing lower extremity strength is a crucial part of the examination in patients with low back pain. In Emergency Departments, however, some patients provide a suboptimal effort because of general fatigue or malingering.
How can you differentiate whether asymmetric hip flexion weakness is from suboptimal effort or true weakness?
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You 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…
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.
In 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.
Placing an IV in the external jugular vein requires venous distension maneuvers. This means having the patient perform a Valsalva maneuver or be placed in a Trendelenburg position.
Have you ever had a patient who didn’t quite get the Valsalva maneuver concept, or couldn’t tolerate a head-down position?
Thanks to Dr. Rob Roger’s podcast on EM-RAP Educator’s Edition series, I learned of one of the funniest publications EVER in a medical journal. It was published on April 1, 2009 in JAMA. The article focuses on teaching medical students the essential skill set– how to survive “pimping”.
Pimping traditionally occurs when an attending physician poses a difficult question to a learner in a public forum, such as board rounds or in the operating room. As a student or resident, you know that this will happen during your training, and you should be prepared. If you think of pimping as a form of battle, you will need a good defense, and you should mix it up to be successful.
Several times in the ED, I have needed a mirror for patient care.A moderately intoxicated patient presents with a facial or scalp laceration. S/he adamantly refuses to have it repaired in the ED, because of the disbelief of that there is indeed a laceration. You want to show the patient, using a mirror, but you don’t have one. (more…)