• Contact Lens Yellow

Tricks of the Trade: Finding the wandering contact lens

By |Categories: Ophthalmology, Tricks of the Trade|

Contact lens wearers are familiar with the phenomenon of the wandering lens. What should you do if you can’t visualize the contact lens of a patient, who presents with a “lost contact lens” in the eye? You have the patient look in all directions and you evert the eyelid, but still no contact lens can be found. The patient swears that it’s there because of the painful foreign-body sensation. […]

  • CT SAH

Paucis Verbis card: Subarachnoid hemorrhage high-risk characteristics

By |Categories: ALiEM Cards, Neurology|

In Wednesday’s post about the Colorado Compendium, Graham mentioned a new 2010 BMJ article on the high-risk signs suggestive of subarachnoid hemorrhage by the gurus in clinical prediction rules in Canada. We excessively work-up patients for a subarachnoid hemorrhage with a nonspecific headache and no neurologic deficitis. This is because it’s difficult to predict who is high, medium, and low risk for such a bleed. So we throw a wider net so that we don’t miss such a devastating diagnosis. This usually means a CT and LP for many patients with a headache. […]

Paucis Verbis card: Cervical spine imaging rules

By |Categories: ALiEM Cards, Orthopedic, Trauma|

There is constant debate on whether to image the cervical spine of blunt trauma patients. Fortunately, there are two clinical decision tools available to help you with your evidence-based practice. The NEXUS and Canadian C-spine Rules (CCR) are both validated studies which both quote a high sensitivity (over 99%) in detecting clinically significant cervical spine fractures. Both studies primarily used plain films in evaluating their patients. Sensitivity (%) Specificity (%) NEXUS 99.6 12.6 CCR 99.4 45.1 […]

  • Self reflection

Trick of the Trade: Self-Reflection

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

 After a shift, we often review the day’s case with our learners. We sometimes ask them to self-reflect. I often used Demian’s ‘Plus/Delta’ approach and ask ‘What did you like /what would you change?’ This approach works well mostly. But, when the answer is ‘I don’t think I would change anything’, it is hard to target teaching and feedback to the learner’s need. […]

  • Dysphagia

Paucis Verbis card: Dysphagia

By |Categories: ALiEM Cards, Gastrointestinal|

Dyphagia is a disorder of swallowing. It actually occurs in up to 10% of adults older than 50 years old. How can you determine the most likely causes for dysphagia? The secret is to obtain a thorough history and using the algorithm below, which I find really helpful from a review article in American Family Physician. […]

  • skull anatomy

Trick of the Trade: Laryngospasm notch maneuver

By |Categories: Pediatrics, Tricks of the Trade|

 What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED? Answer = 0.3% A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it. You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?   […]

  • Finger Laceration

Trick of the Trade: Hemostasis of bleeding finger laceration using a glove

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

Lacerations of the finger can bleed quite profusely because of digital vascularity. This obscures the provider’s ability to perform a careful exam and can make suturing quite difficult. Simple direct pressure over the laceration often controls the bleeding. What if this doesn’t work? […]

Paucis Verbis: Identifying toxidromes by vital signs

By |Categories: ALiEM Cards, Tox & Medications|

A middle-age woman presents to the Emergency Department with altered mental status after having ingested a drug. Is it an opioid? Is it an antihistamine? The key is to pay close attention to the vital signs. They are often the clue to the mystery. I found this great table from EM Clinics of North America by Dr. Timothy Erickson from 2007. I can’t imagine how long it took for him to create all these mnemonics. I’ll never remember these mnemonics, but they’re fun to read nonetheless. […]

  • cpr

New 2010 ACLS guidelines from the AHA, ERC, and ILCOR

By |Categories: Cardiovascular, Guideline Review|

Last month the AHA, ERC, and ILCOR released the 2010 Resuscitation Guidelines. They build on the 2005 and previous guidelines and continue the trend towards more, higher quality, uninterrupted CPR. The complete summary and recommendations are published in Circulation and are available for free. Here is my summary for you! […]

  • Paronchia splint

Trick of the Trade: Toe paronychia splinting

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

Ingrown toenails, or paronychias, are usually exquisitely painful and a bit gnarly when they present to you in the Emergency Department. Dr. Stella Yiu described toenail splinting techniques using steristrips or dental floss. The purpose of splinting is to prevent the toenail from growing back into the lateral nail fold. This assumes a relatively mild-to-moderate case. Often simple elevation of the nail out of the lateral nail fold (under digital block anesthesia) is all that is needed to treat a paronychia. Pus is often released with this maneuver. What do you do for more severe cases when you have to [...]