• Ingrown Toenail Lift

Trick of the Trade: Toenail splinting for ingrown toenails

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

 It is 4 a.m. You pick up a chart. Toe pain. Thinking this could be an easy injury, you walk over to the patient, only to discover: bilateral ingrown toenails. Your heart sinks. In your head, you are thinking: Lateral nail resection? Nail removal? This could take a while. Is there a less invasive method for treating an ingrown toenail? [+]

  • Cardiac Echo ultrasound

Paucis Verbis card: When murmurs need echo evaluation

By |Categories: ALiEM Cards, Cardiovascular|

Have you been in a situation where you are the first to detect a cardiac murmur in a patient? If you are hearing it in a busy, loud Emergency Department, I find that it's at least a grade III. Should you order an echocardiogram for further outpatient evaluation? It depends on the grade and characteristic of the murmur, in addition to the patient's symptoms. For instance, all diastolic murmurs require an echo. There is a useful ACC/AHA algorithm which helps you decide. PV Card: When Murmurs Need Echocardiography Evaluation Adapted from [1] Go to ALiEM (PV) Cards for more resources. Thanks [+]

  • Tegaderm Dressing

Trick of the trade: I got ultrasound gel in my eye!

By |Categories: Tricks of the Trade, Ultrasound|

Bedside ultrasonography is increasingly being used in the ED to examine the eye. For instance, it can be used to detect a retinal detachment, vitreous hemorrhage, and high intracranial pressure. The technique involves applying ultrasound gel on the patient’s closed eyelid. A generous amount of gel should be used to minimize the amount of direct pressure applied on the patient’s eye by the ultrasound probe. Sometimes, however, no matter how careful you and the patient are, some gel accidentally contacts the eye itself. [+]

  • Pertussis Organism

Paucis Verbis card: Pertussis

By |Categories: ALiEM Cards, Infectious Disease, Pulmonary|

Is your Emergency Department administering Tdap immunization boosters instead of dT boosters? Patients with wounds are getting updated not only for tetanus and diphtheria, but also now for pertussis. Apparently there has been sharp rise in the national incidence of pertussis (Bordetella pertussis shown in image) in 2010. The infection has been documented in both infants (underimmunized less than 3 months old) and adolescents/adults (loss of immunity after 10 years). In fact, the CDC has issued an epidemic warning in California. How do you diagnose pertussis ? What are the classic symptoms? Better yet, how do you rule-it out clinically? You won't like [+]

  • Rectal Prolapse Diagram

Trick of the Trade: "Pour some sugar on me" | Reducing a rectal prolapse

By |Categories: Gastrointestinal, Tricks of the Trade|

Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits. How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach. Trick of the Trade: Pour some sugar on it. Def Leppard may have been right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. [+]

Paucis Verbis card: TIMI risk score

By |Categories: ALiEM Cards, Cardiovascular|

How do you risk-stratify undifferentiated chest pain patients in the Emergency Department? There are a multitude of causes for chest pain. We are always taught to think of the 5 big life-threats: ACS, PE, aortic dissection, tension pneumothorax, and pericardial tamponade. So how do YOU risk-stratify your patients for unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI)? STEMI's are usually obvious. UA and NSTEMIs -- not so much. Fortunately a 2000 JAMA article and a followup Academic Emergency Medicine 2006 study have solidified the TIMI risk scoring system as a reasonable risk-stratification tool for all-comer ED patients with chest [+]

Trick of the Trade: Increasing students responses to the differential diagnosis

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

Anyone who teaches medicine asks students to list their differential diagnosis when discussing a new clinical case. It’s also part of several models for education including the One-Minute Preceptor and SNAPPS. For the most part, students are good at coming up with answers to the differential, but what do you do when they strike out? Or what if the answer is always the same, i.e. chest pain = myocardial infarction? [+]

Paucis Verbis card: Croup

By |Categories: ALiEM Cards, ENT, Infectious Disease, Pediatrics|

The most common cause of stridor in pediatric patients is croup, or laryngotracheobronchitis. The distinct high-pitched, seal-like,"barky" cough can be heard from outside the patient's room often. https://www.youtube.com/watch?v=0lepci-YheI Check out the YouTube clip above. Go to the 1:15 mark (near the end) to hear the barking cough. Poor but cute kid. What is the current treatment regimen? Did you know that the traditional treatment with cool mist or humidified air have shown to be of no added benefit? PV Card: Croup  Go to ALiEM (PV) Cards for more resources.

  • scalp laceration

Trick of the Trade: Modified HAT trick revisited

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

I finally tried the Modified HAT (Hair Apposition Technique) trick for the closure of scalp lacerations. I have used the traditional HAT trick multiple times but not the modified technique. What's the difference? Instead of using your fingers, the modified approach involves the use of two instrument clamps to help twist and pull the hair strands taut. It turns out that this makes a huge difference, especially for short hairs. The clamps allow you to grab the hair strands so much more securely, before instilling a tissue adhesive at the twisting points. The nice added benefit was that my chubby [+]