Trick of the Trade: Prescribing opiates
As emergency physicians, we are experts in pain control. We frequently write opiate prescriptions for patients being discharged home. Unfortunately, an occasional patient tries to forge my prescription. At times, I get a call from pharmacy for prescriptions that were suspiciously written. For instance several years ago, I had someone try to forge 100 tablets of “Mophine”. [+]
Paucis Verbis card: Strep pharyngitis
Have you heard of the Modified Centor Score for strep pharyngitis? Interestingly, it has been validated in adults and children. The methodology builds on the traditional Centor Score by incorporating the patient’s age, because this disease is more prevalent in kids than adults. In fact, you actually lose a scoring point if you are older than 44 years old. [+]
Trick of the Trade: Foley balloon be gone!
An urethral Foley catheter can sometimes become retained in the bladder, because of its balloon being unable to deflate. A malfunctioning inflation valve or obstructed channel along the length of the catheter is the cause. How can you deflate the balloon so that the Foley catheter can be removed? [+]
Paucis Verbis card: Urine Toxicology Screen
In the Emergency Department, we often order urine toxicology screens for patients with altered mental status without an obvious cause. I find that patients are often rather forthcoming about their drug use, if they are alert enough to talk. In those cases, ordering a urine toxicology screen is unnecessary. When you do order a tox screen, however, how do you interpret the information? While the result is a binary answer (positive vs negative), there are some nuances to interpretation. For instance, how long does a patient with urine toxicology remain positive for the drugs? Are there any medications that can [+]
Trick of the Trade: A tongue blade is as mighty as an xray
Patients often present to the Emergency Department for mandibular blunt trauma. Usually these patients have soft tissue swelling at the point of impact. In mandibular body fractures, the fracture line often extends to the alevolar ridge. This may cause a gap between a pair of lower teeth. In patients with jaw pain, mild swelling, and normal dentition, is there a way to avoid imaging these patients to rule-out a mandible fracture? [+]
Paucis Verbis card: Rapid Sequence Intubation
The key to success in performing procedures is preparation. This is especially true for endotracheal intubations in the Emergency Department where things are chaotic. Strategic planning and anticipation of obstacles during rapid sequence intubation (RSI) are key principles to avoiding complications. PV Card: Rapid Sequence Intubation Go to ALiEM (PV) Cards for more resources.
Trick of the Trade: OKN drum to test psychogenic coma
Occasionally, emergency physicians see patients who present because they are unresponsive despite normal vital signs and an otherwise normal exam. You detect no drugs or alcohol on board. You suspect a psychiatric or malingering etiology, but aren’t sure. They seem non-responsive to voice and minimally responsive to very painful stimuli. Is this a case of psychogenic coma or true coma (with bilateral hemispheric dysfunction)? What test can you do to reassure yourself that this may indeed be psychogenic coma? [+]
Paucis Verbis card: Penetrating abdominal trauma
When I did my residency training in Emergency Medicine and in the first few years as an attending, we regularly performed diagnostic peritoneal lavages in patients with stab wounds injuries to the abdomen. Patients also routinely went to the operating room for exploration. Now with the evolution of CT imaging technology and more clinical studies, there is now a role for a less invasive management approach. These are the Eastern Association for the Surgery of Trauma (EAST) guidelines. PV Card: Penetrating Abdominal Trauma Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Como JJ, Bokhari F, Chiu WC, [+]
Trick of the Trade: Blowing out the candle
How do you teach pediatric patients, especially toddlers, how to cooperate with your pulmonary exam? How do you get them to take adequately deep breaths in and out? [+]
Director of Growth, Strategic Alliance Initiative, Center [+]
Work NOT in progress: ACEP Tricks of the Trade column
Since 2006, I have been the ACEP News columnist on “Tricks of the Trade in Emergency Medicine.” Four years later, I’ve published and co-published 33 articles on various both low-tech and high-tech pearls. It’s official — I’ll be stepping down from the ACEP News columnist position and handing off the reins to someone with fresher ideas. Frankly, I’m running out of innovative ideas worth publishing about. [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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