Trick of the Trade: Opioids for air hunger
A patient presents with significant shortness of breath from a COPD exacerbation. His room air saturation is 80%, respiratory rate of 30, and is uncomfortably seated in a tripod position. You administer the usual regimen: Oxygen by face mask Nebulized albuterol and atrovent Solumedrol Bipap Set up for possible intubation With the Bipap mask on, the patient’s subjective sense of dyspnea and “air hunger” seems to make it harder for him to tolerate the tight-fitting mask. [+]
Trick of the Trade: Needlestick hotline 888-448-4911
You are a fourth-year medical student and super-excited to be doing your first supervised central line procedure on an actual patient. You have done so many central lines on mannequins and simulations. You feel ready. In your excitement, however, you stick yourself with the 22 gauge finder needle after you successfully get a flash-back of the patient’s venous blood. After handing off the procedure to your senior resident, you go into a mild panic. Your patient is a known HIV patient with an unknown CD4 count and viral load. After taking off your gloves and washing your hands, you report [+]
Paucis Verbis: Does this DM leg ulcer have osteomyelitis?
We sometimes see diabetic patients in the ED for a worsening foot ulcer. Sometimes it's the chief complaint. Other times, however, you just notice it on physical exam. So, be sure you examine the feet of your diabetic patients. Occasionally, you'll be surprised by what you find. Several questions come up with diabetic foot ulcers: Is it a true diabetic foot ulcer, or is it an arterial or venous insufficiency ulcer? Is there underlying osteomyelitis? How can I best diagnostically work this foot ulcer up for osteomyelitis? What is the Wagner grade of this ulcer? (I think it'd be Grade [+]
Trick of the Trade: Pediatric ear exam
Performing a physical exam on frightened pediatric patients can often be challenging. I am always thrilled to add more child-whisperer techniques to my arsenal of tricks. I have written in the past about: Balloonimals iPhone app to grossly assess peak flow Candleflame iPhone app to grossly assess peak flow Eye Handbook iPhone app with pediatric fixation animation targets Casting/splinting your buddy bear What’s your trick on performing an otoscope exam of the ears? [+]
Paucis Verbis: Legionella pneumonia
Did you know that there was an unexplained spike in Legionnaire's disease (pneumonia caused by Legionella pneumophila) during the 2009 H1N1 flu pandemic? Since the flu season is rapidly approaching, I thought I would review what Legionnaire's disease looks like. Yes, they will have a fever, cough, and pneumonia on CXR. These patients are generally pretty sick and almost always need hospitalization. What makes it unique? The trick is to look for extrapulmonary findings, which help to distinguish it from other atypical pneumonias. Relative bradycardia is a sure tip. Why do we want to differentiate it from other pneumonias? Legionnaire's [+]
Trick of the Trade: Synovial lactate in septic arthritis
A 55 year old woman presents with rheumatoid arthritis presents with monoarticular joint pain in her left knee for the past 3 days. She has a low-grade fever of 100.2 F and a significantly warm and tender knee. “It feels different than my RA flare.” Does this patient have a septic joint? [+]
Paucis Verbis: Distracting injuries in c-spine injuries
"Distracting injury" is a frequent cited reason for imaging the cervical spine in blunt trauma patients, per the NEXUS study. In the Journal of Trauma in 2005 and 2011, studies aimed to narrow the definition of "distracting injury". Although both are studies at different sites, both conclude the same: Chest injuries may be considered "distracting injuries" because of their proximity to the cervical spine. Example So let's say you are caring for a non-intoxicated motor vehicle crash patient with an isolated tibia fracture (i.e. a "long bone fracture"), no chest injuries, and no neck pain/tenderness. Per the NEXUS criteria, you might [+]
Trick of the Trade: Epley maneuver
You diagnose a patient with benign paroxysmal positional vertigo (BPPV) based on the Dix-Hallpike maneuver. This is caused by otoliths and debris in the posterior semicircular canal. Now what? The patient still feels miserably nauseous and vertiginous. Is your first-line treatment meclizine or benzodiazepines? [+]
Paucis Verbis: Antibiotics for Cystitis and Pyelonephritis in Women
You diagnose a 35 years old woman with uncomplicated cystitis. She is not diabetic and not pregnant. Which antibiotics should you give? What if she had pyelonephritis? Answer: It depends on your local antibiogram. San Francisco General Hospital 2010 Antibiogram Today, go find out about your hospital's local resistance rates for uropathogens to various antibiotics. For San Francisco General Hospital, I found our antibiogram publicly posted online. Urine isolates of E. coli demonstrate relatively high resistance rates to trimethoprim-sulfamethoxazole and ciprofloxacin: Trimethoprim-sulfamethoxazole resistance rate = 33% Cefazolin or Cephalexin resistance rate = 12% Ciprofloxacin resistance rate = 16% So based on the [+]
Trick of the Trade: Dix-Hallpike maneuver variation
The Dix-Hallpike maneuver is used to help diagnose benign paroxysmal positional vertigo (BPPV). Place the gurney's head of the bed down flat. Reposition the patient so that s/he is sitting another 12 inches or so closer towards the head of the flat gurney. Rotate patient's head 45 degrees. Help the patient lie down backwards quickly. The patient's head should be hanging off of the gurney edge in about 20 degrees extension. Observe for rotational nystagmus after a 5-10 second latency period, which confirms BPPV. I find 2 things challenging in this maneuver. The patient often does not like to be [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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