• Eyelid Retractor

Trick of the Trade: Retracting Swollen Eyelids

By |Categories: Ophthalmology, Tricks of the Trade|Tags: |

Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don't have the fancy ophthalmology eyelid retractors? Trick of the Trade Use a Q-tip I thought of this idea when I was rolling up a projector screen in a conference room. Why can't we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to "roll" the eyelid out of the way. Below are a series of photos of [...]

  • Irrigation Scalp

Trick of the trade: Eye irrigation setup

By |Categories: Ophthalmology, Tricks of the Trade|

Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren't used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies. For the past several years, I've stopped using Morgan lens and have started using something that all Emergency Departments have -- nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation. Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached [...]

  • ABG radial

Paucis Verbis card: ABG interpretation

By |Categories: ALiEM Cards, Endocrine-Metabolic, Pulmonary|

I have yet to find a better arterial blood gas interpretation review article than the 1991 Western Journal of Medicine summary by Dr. Rick Haber. This installment of the Paucis Verbis (In a Few Words) e-card series reviews ABG Interpretation. The recent addition of an ABG machine in our ED has made a tremendous difference in our ability to care for undifferentiated patients. This is a refresher in making heads and tails of mixed acid-base disorders. […]

  • Viscous Lido Nose

Tricks of the trade: Anesthetizing the nasopharyngeal tract

By |Categories: Tricks of the Trade|Tags: |

Nasogastric tube placement is one of the most uncomfortable procedures in the Emergency Department. Why can’t we find a painless way to do this? Now that I am doing more fiberoptic nasopharyngoscopes, this issue is coming up more and more frequently. I’ve been using NP scopes mainly to check for laryngeal edema in the setting of angioedema. These recent photos visualize a normal epiglottis and normal laryngeal anatomy, respectively. […]

  • FB Cornea

Great teaching video: Corneal FB removal

By |Categories: Ophthalmology|Tags: , |

Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings. The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?! […]

  • Angioedema

Paucis Verbis card: Angioedema

By |Categories: ALiEM Cards, Allergy-Immunology, ENT|

Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy. […]

Trick of the trade: Ear foreign body extraction

By |Categories: ENT, Tricks of the Trade|Tags: |

A 6-year old boy has placed a hard bead in his ear and presents to the ED for care. How do you remove this foreign body as painlessly as possible? You can just barely see the edge of the bead by just looking at the external ear. By experience, you know that mini-Alligator clips and forceps will not be able to sufficiently grab the edges of the bead. Additionally it may push the bead in even further. […]

Paucis Verbis card: Knee exam

By |Categories: ALiEM Cards, Orthopedic|

How accurate is the clinical knee exam? JAMA published a meta-analysis trying to answer this question. Although they include patients with acute and chronic knee pain, it’s a good general review of the knee anatomy, historical clues, and exam elements. In the ED, the knee exam is challenging because we see very acute injuries where knee pain and swelling often preclude an accurate exam. For patients with an equivocal exam, be sure to refer for orthopedic follow-up. A repeat exam should be performed once the pain and swelling subside. […]

  • Injection

Tricks of the trade: Chemical sedation options

By |Categories: Tricks of the Trade|

 You walk into a room where a patient is screaming and thrashing about in his/her gurney from some stimulant abuse. PCP, cocaine, methamphetamine… or all of the above. When the number of people (police officers, security guards, nurses) is greater than the patient’s pupil size, you KNOW that you’ll need some chemical sedation. What intramuscular sedation regimen do you use? […]

Paucis Verbis card: Hyperkalemia management

By |Categories: ALiEM Cards, Endocrine-Metabolic|

Hyperkalemia is a common presentation in the Emergency Department, especially in the setting of acute renal failure. In one shift, I had 4 patients with hyperkalemia! All had from some form of renal failure. This installment of the Paucis Verbis (In a Few Words) e-card series reviews the treatment options for hyperkalemia. […]