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 [+]
Paucis Verbis: Approach to rashes
Contact dermatitis from poison oak We see a variety of rashes in the Emergency Department. The first step is to accurately describe the rash. Is this a macule or nodule? Is this a vesicle or bulla? The next step is to quickly "profile" it to see if it fits any classic pattern by patient age, lesion distribution, or presence of hypotension. And finally, if you are still stumped, use an algorithm based on the rash type. These figures are from March 2010's Emergency Medicine Magazine. It's not meant to be a comprehensive article on rashes but it sure does [+]
Trick of the Trade: Crossed straight leg raise test
A 35 year old man presents with low back pain which radiates down his right leg to the level of the knee. Is this sciatica? Low back pain is one of the most common chief complaints that we see in the Emergency Department. In addition to the examination of the back and distal neurovascular function, we also need to test for evidence of a radiculopathy (compression or inflammation of a nerve root typically from a herniated disk). Because most disk herniations occur at the L4-L5 and L5-S1 level, you should test for irritation of the L4-S1 nerve roots. This is [+]
Paucis Verbis: An approach to persistent tachycardia
Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can't send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia? Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best. [+]
Trick of the Trade: Using a funnel for NG tubes
One of the indications for nasogastric (NG) tube placement is to instill fluids or medications. This may be saline or water for NG lavages or charcoal. You can manually push fluids into the NG tube via a 60 cc syringe, but this may take a long time for large volumes. [+]
The future of the ALiEM blog
It has been over 2 years now that my guest bloggers and I write blog posts 5 days a week. The process of writing, maintaining, and collaborating on ideas for the blog has completely changed my career. It has opened new doors, introduced me to new colleagues and friends worldwide, and clarified the direction of my career. Now as I find myself involved with more projects, I need to re-structure my time (unless someone can find me an extra hour a day to work). It was a good run though. Honestly, I’m surprised that I maintained this pace for [+]
TED Video: A lesson from spaghetti sauce on appreciating diversity
One size does not fit all. This is the crux of Malcolm Gladwell’s 18-minute talk. He gave this talk just before his book “Blink” went huge. He makes an eloquent argument for the nature of choice and happiness. There is no one perfect spaghetti sauce that fits everyone. There is no one perfect Pepsi which everyone likes. [+]
Trick of the Trade: Splinting the ear
One of the hardest bandages to apply well is one for auricular hematomas. After drainage, how would you apply a bandage to prevent the re-accumulation of blood in the perichondrial space? Traditionally, one can wedge xeroform gauze or a moistened ribbon (used for I&D’s) in the antihelical fold. Behind the ear, insert several layers of gauze, which have been slit half way to allow for easier molding around the ear. Anterior to the ear, apply several layers of gauze to complete the “ear sandwich”. Finally, secure the sandwich in place with an ACE wrap, which ends up being quite challenging [+]
EM-RAP Educator’s Podcast: How to get promoted in academic EM
Dr. Amal Mattu gives a great 47-minute lecture on “How to Get Promoted in Academic Emergency Medicine”. Catch the podcast from the talk in July’s EM-RAP Educator’s Edition. He pulls many of the lessons from his son’s kindergarten teacher. Getting promoted in academic EM can often be a challenge and a mysterious process. Why is it some are getting promoted faster than others? What can I do to make sure I’m on track for promotion? [+]
Advice for the new EM interns, part II
As a followup to a previous post on “The 10 Commandments in Emergency Medicine”, we would like to pay tribute to our pediatric friends. More than a decade after it was initially published, Timothy Givens (also from Vanderbilt but the pediatric side) published “The 10 commandments of pediatric Emergency Medicine”. Although the original commandments still hold true, the pediatric commandments augment them nicely and are geared towards our littler patients. [+]