• Fingernail Lac

Trick of the Trade: Finger nailbed laceration repair

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

Over the years, I have been frustrated by how inelegant finger nailbed closure is. Nailbed lacerations are often sustained by a major crush injury, resulting in a stellate and irregular laceration pattern. This typically also requires the crushed fingernail to be removed. Cosmesis is never ideal because pieces of the nailbed are often missing, as seen in the photo above. Occasionally, nailbed lacerations are caused by a cutting rather than a crush mechanism. In these cases, I use a different technique. I leave the fingernail on. In fact, I use the fingernail to help reapproximate the nailbed edges. [+]

  • Hip flexion strength testing

Trick of the Trade: Hip flexion strength testing

By |Categories: Tricks of the Trade|

Testing lower extremity strength is a crucial part of the examination in patients with low back pain. In Emergency Departments, however, some patients provide a suboptimal effort because of general fatigue or malingering. How can you differentiate whether asymmetric hip flexion weakness is from suboptimal effort or true weakness? [+]

Paucis Verbis Card: CNS Infections

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

PV Card: CNS Infections Here is another installment of the Paucis Verbis (In a Few Words) e-card series on the topic of CNS infections from EM Clinics of North America 2009.    Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Somand D, Meurer W. Central nervous system infections. Emerg Med Clin North Am. 2009;27(1):89-100, ix. [PubMed]

  • Pocket Contents Cards

Paucis Verbis Project: A peripheral brain e-card series

By |Categories: ALiEM Cards, Cardiovascular|

A few days I wrote about my "peripheral brain" note cards that I carry with me on each ED shift. These cards contain brief summaries of updated guidelines, evidence based literature, and clinical pearls. I constantly get requests for a copy of them, but they are fairly outdated now that I'm out of residency. So starting today, I'm going to start periodically posting new note cards in Word and PDF format that can be printed on any 4x6 inch index card. These will be posted every Friday. Feel free to download, edit, change font or font size, and use. You [+]

  • Laryngoscope Grip

Trick of the Trade: Laryngoscope lifting strength

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

You are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]”, let’s focus on some basics. How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or… [+]

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. [+]

  • Humming US

Trick of the Trade: Hum-out the jugular veins

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

Placing an IV in the external jugular vein requires venous distension maneuvers. This means having the patient perform a Valsalva maneuver or be placed in a Trendelenburg position. Have you ever had a patient who didn’t quite get the Valsalva maneuver concept, or couldn’t tolerate a head-down position? [+]

  • 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 [+]

Shuhan He, MD
ALiEM Senior Systems Engineer;
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
Shuhan He, MD