Trick of the Trade: Radial Gutter Splint
How do you splint 2nd or 3rd metacarpal fractures? A short arm volar splint is usually applied, because a fracture should be immobilized one joint distal and proximal to the injury. This splint, however, unnecessarily immobilizes the 4th and 5th fingers. It makes gripping things with your hand difficult. [+]
Paucis Verbis card: Skipping the CT prior to LP for meningitis
With increasing awareness of CT’s irradiation risk, I thought I would review a classic 2001 article from the New England Journal of Medicine. Head CT’s previously were commonly performed prior to all lumbar punctures (LP) to rule-out meningitis. When can you safely go straight to an LP without imaging? Caveat: This review only applies to those patients in whom you suspect meningitis. This does not apply to those being worked up for subarachnoid hemorrhage. [+]
Trick of the Trade: A "handy" ruler
How long is this neck laceration? In the Emergency Department, it is important to be able to accurately estimate the length of wounds, abscesses, and cellulitis. Additionally, billing for wound closure is directly related to the length of the laceration. [+]
Paucis Verbis card: Early goal directed therapy
One of the landmark studies in sepsis was conducted by Dr. Emanuel Rivers (Henry Ford) and published in the New England Journal of Medicine in 2001. By managing patients with severe sepsis and septic shock with an "early goal directed therapy" approach, there was an absolute risk reduction of 16%. Furthermore, the number needed to treat to save a life was 6 patients! This installment of the Paucis Verbis (In a Few Words) e-card series reviews Early Goal Directed Therapy algorithm. The layout is borrowed from a Cleveland Clinic Foundation (CCF) flowchart. Adapted from [1] Go to ALiEM (PV) Cards [+]
Trick of the Trade: Retracting Swollen Eyelids
Eyelids can become edematous from blunt trauma and local inflammation, making it difficult to visualize the orbit. How do you retract the eyelids, if you don't have the fancy ophthalmology eyelid retractors? Trick of the Trade Use a Q-tip I thought of this idea when I was rolling up a projector screen in a conference room. Why can't we use this rotational concept on the upper eyelid to retract it? Rest the Q-tip on the surface of the upper eyelid and slowly rotate the Q-tip to "roll" the eyelid out of the way. Below are a series of photos of [+]
Trick of the trade: Eye irrigation setup
Morgan lens are placed to irrigate eyes splashed with foreign substances. Whenever I place them, images of horror and torture movies arise. Especially for patients who aren't used to having something touch their eyes like contact lens, the Morgan lens gives them the heeby-jeebies. For the past several years, I've stopped using Morgan lens and have started using something that all Emergency Departments have -- nasal cannulas for oxygen administration. They are perfect for high-volume eye irrigation. Instead of attaching the nasal cannula to an oxygen port, attach it to the end of IV tubing, which in turn is attached [+]
Paucis Verbis card: ABG interpretation
I have yet to find a better arterial blood gas interpretation review article than the 1991 Western Journal of Medicine summary by Dr. Rick Haber. This installment of the Paucis Verbis (In a Few Words) e-card series reviews ABG Interpretation. The recent addition of an ABG machine in our ED has made a tremendous difference in our ability to care for undifferentiated patients. This is a refresher in making heads and tails of mixed acid-base disorders. Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Haber R. A practical approach to acid-base disorders. West J Med. 1991;155(2):146-151. [PubMed]
Tricks of the trade: Anesthetizing the nasopharyngeal tract
Nasogastric tube placement is one of the most uncomfortable procedures in the Emergency Department. Why can’t we find a painless way to do this? Now that I am doing more fiberoptic nasopharyngoscopes, this issue is coming up more and more frequently. I’ve been using NP scopes mainly to check for laryngeal edema in the setting of angioedema. These recent photos visualize a normal epiglottis and normal laryngeal anatomy, respectively. [+]
Great teaching video: Corneal FB removal
Patients often come into the ED for eye pain. One of my favorite procedures is removal of a small foreign body embedded in the cornea. There is a great instructional video on removing such foreign bodies and the use of a ophthalmic burr on removing rust rings. The video recommends using either a 30-gauge or 18-gauge needle. I prefer the less innocuous-looking 29-gauge insulin/TB needle. Can you imagine someone coming towards your eye with a large 18-gauge needle?! [+]
Paucis Verbis card: Angioedema
Recently, a patient presented with angioedema after starting taking an ACE-inhibitor. There was upper lip swelling, similar appearing to the case above. He also experience a hoarse voice. Before the advent of fiberoptic nasopharyngoscopy, it was assumed that there may be laryngeal edema. Fortunately, using technology, we were able to visualize a normal epiglottis and a grossly normal laryngeal anatomy. Should patient with angioedema be admitted? The 1999 study on admission guidelines, of course, should be weighed with physician judgment and the patient's social issues. The study was retrospective and the results should be weighed carefully. For me, generally I [+]
Director of Growth, Strategic Alliance Initiative, Center for Innovation and Digital Health
Massachusetts General Hospital;
Chief Scientific Officer, Conductscience.com
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