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

Trick of the Trade: Subclavian line gone north

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.

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

Trick of the Trade: Hum-out the jugular veins

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?

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By Michelle Lin, MD|2016-11-11T19:01:50-08:00Nov 25, 2009|Tricks of the Trade|

Trick of the Trade: The defensive arts against pimping

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.

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By Michelle Lin, MD|2016-11-11T19:01:51-08:00Nov 18, 2009|Medical Education, Tricks of the Trade|

Several times in the ED, I have needed a mirror for patient care.

Example 1

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…)

By Michelle Lin, MD|2016-11-11T19:01:52-08:00Nov 11, 2009|Tricks of the Trade|

Trick of the Trade: Easy ocular application of fluoroscein

Gently instilling a fluorescein drop into a patient’s eye requires that the patient keep his/her eye still. What do you do for a patient who can’t quite stay still enough, such as an infant? This is an innovative trick of the trade, written by Dr. Sam Ko (Loma Linda EM resident) and Kimberly Chan (Loma Linda medical student).

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By Michelle Lin, MD|2016-11-11T19:01:53-08:00Nov 4, 2009|Ophthalmology, Tricks of the Trade|

Trick of the Trade: Super-sensitive to eyedrops

We commonly encounter ocular complaints in the Emergency Department. Eye pain can result from chemical exposure, a foreign body, or infection. The first step involves instilling a few drops of topical anesthetics, such as proparacaine, to provide some pain relief. Occasionally, however, you encounter a patient who just can’t keep his/her eye open because of the fear of eyedrops.

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By Michelle Lin, MD|2016-11-11T19:01:54-08:00Oct 28, 2009|Ophthalmology, Tricks of the Trade|

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