Tricks of the Trade: Diagnosing retinal detachment with ultrasound

By |Categories: Ophthalmology, Tricks of the Trade, 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. […]

Article review: Neuro exam documentation

By |Categories: Education Articles, Medical Education, Neurology|

Medicolegal woes often can be tracked back to poor documentation by the physician. This article is a retrospective chart review of 384 EM resident charts, focusing on the documentation of the neurologic exam. Charts were selected if their chief complaints were neurologic or psychiatric in nature. A non-validated measurement tool for evaluating a neurologic exam was created based on discussions with attending emergency physicians. I have to agree with the chosen criteria. Documentation in each of the following criterion receives 1 point for a maximum score of 8. […]

  • Finger In Fossa

Trick of the Trade: Subclavian line gone north

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

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. [...]

  • laughing

Trick of the Trade: The defensive arts against pimping

By |Categories: Medical Education, Tricks of the Trade|Tags: , |

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 radiology pearl: A subtle orthopedic diagnosis

By |Categories: Orthopedic, Radiology|

A man recently presents with knee pain after pivoting and torquing his knee while falling. He complains of concurrent mild ankle pain. He presents with this tib-fib xray. Realizing that a proximal fibular fracture can present concurrently with a medial malleolus fracture or deltoid ligament rupture, we obtained xrays of the ankle. We were looking for a Maisonneuve fracture. Do you see an ankle injury in these four images? […]

  • Tripod Fx

Trick of the Trade: Don’t have a mirror in the ED?

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

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. […]

  • fluoroscein drop

Trick of the Trade: Easy ocular application of fluoroscein

By |Categories: Ophthalmology, Tricks of the Trade|

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). […]

  • eye drops ped

Trick of the Trade: Super-sensitive to eyedrops

By |Categories: Ophthalmology, Tricks of the Trade|

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. […]

  • ensure drink

Tricks of the Trade: Low tech solutions to esophageal foreign bodies

By |Categories: Gastrointestinal, Tricks of the Trade|

Patients can present to Emergency Departments with esophageal foreign bodies. Recently, a patient presented with a doxycycline pill stuck in her esophagus at the mid-chest level. She was taking it for pneumonia. Despite drinking deluges of water for the past 12 hours, the pill remains stuck. You know that doxycycline (pills shown on right)  is one of several medications (along with iron or potassium supplements, quinidine, aspirin, bisphosphonates) known for causing erosive pill esophagitis. She presents to your ED. What do you do? With so many direct visualization tools in the ED now available to emergency physicians such as Glidescopes [...]