Placing a peripheral IV under ultrasound guidance is often much more challenging than it outwardly appears, especially for novice users. One of the more difficult aspects is in making sure that the target vessel is perfectly in the middle of the screen and then guessing where that corresponds to the middle of the ultrasound probe.
Traditionally in medical school, it is taught that lower extremity deep tendon reflexes for L4 and S1 nerve root levels can be elicited by tapping on the patella and Achilles tendons. It was just taught that L5 didn’t have a reflex to check. Knowing if an L5 radiculopathy existed would be especially helpful when assessing a patient for a potential lumbar disc herniation where a careful lower extremity neurologic exam is important. It turns out one can actually check for a L5 reflex.
A patient comes into the ED and you suspect septic arthritis to the knee. As you consent the patient for arthrocentesis, you can tell s/he has reservations about a needle being inserted into their knee and left in place while you aspirate. You also think in the back of your mind how tricky it is to sometimes change syringes while keeping the needle in the correct location. Is there another way of tapping the knee without a needle?
It is near the end of your shift and one of the nurses asks you to see a fellow ED staff member’s nine-year old daughter who has accidentally put a foreign body into her ear. You go see her and the otoscope reveals a small shiny jewel within the ear canal however flushing does not work to get it out. Next you try using the otoscope, while exposing the ear canal and holding the forceps to grasp the object. Unfortunately, it is difficult to get your assistant to align the light, and the otoscope speculum is limited in view and access.
Insect removal from the ear is a foreign body removal procedure with unique considerations. First, insects are friable. Have you ever squashed a house centipede? It’s like their 700 legs are spring-loaded to fall off instantly when touched. This characteristic makes mechanical removal by alligator forceps or cerumen loops less reliable. Second, they are alive which means they can move during your attempted extraction procedure.
You see a patient with a large V-shaped laceration under tension requiring suture repair. Resist the temptation to simply pull the edges together and close the laceration with simple interrupted or running sutures. Excessive tension on a flap edge during the healing process can compromise its blood supply. This causes ischemia to the healing tissue, which in turn makes that flap edge more likely to dehisce, necrose, and become infected.
One advantage of simulation as an educational tool is the re-creation of cognitive and emotional stresses in caring for patients. Doing this for a high fidelity scenario is relatively easy – add additional patients, make a them loud, combative, or otherwise cantankerous, and add interruptions for good measure. However, when training for procedures in the simulation lab, we practice the procedure in isolation on a “task trainer” without cognitive and emotional stress for context. An off-the-shelf task trainer can do a superb job of teaching the mechanics of performing a procedure, but they lack complexity necessary to train for performing the procedure under stress. (more…)