Trick of the Trade: Temperomandibular (TMJ) dislocation
Mandible, or TMJ, dislocations occur when the patient excessively opens the mouth, such as in a yawn. They are typically bilateral and are difficult to relocate because of masseter and medial pterygoid muscle spasm. You can relocate the condyles back into the TMJ space with gentle but firm intraoral pressure inferiorly and posteriorly. Often it requires some sedation to help relax the muscles of mastication. [+]
Article review: Teaching learners about ‘difficult’ patients
Your capable resident comes to you, looking frustrated. He says, ‘What a difficult patient. I think you need to get involved.’ This article provides a framework for teachers to allow learners to appreciate these encounters in the Family Medicine. Their points are highly relevant to Emergency Medicine. Strategies include: [+]
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Paucis Verbis: Asthma classification
Emergency physicians have the opportunity to educate patients and prescribe chronic inhaled corticosteroids to patients who should be on these medications chronically. Patients may be more receptive to education and advice given immediately after an asthma exacerbation, managed in the ED. Using the National Institute of Health/ National Asthma Education and Prevention Program classification system, physicians can quickly determine if the patient is a candidate for inhaled corticosteroids and initiate therapy accordingly. PV Card: Asthma Classification system In short, patients can be classified into one of 4 classes: intermittent, mild persistent, moderate persistent, and severe persistent asthma. Patients in these [+]
Trick of the trade: Nebulized … orange juice?
In my theme of detoxifying malodorous smells in the ED, I recently learned of a new way of masking odors. Imagine the stress on your olfactory nerves from the combined effects of urinary and fecal incontinence from a nursing home patient. An ingenious nurse proposed nebulizing actual coffee within the room. Unfortunately, our ED was out of coffee at the moment. [+]
Paucis Verbis: Dental infections
To follow up with the wildly popular Paucis Verbis card made by Dr. Hans Rosenberg (University of Ottawa), here is his card on Dental Infections. This card summarizes common dental infection complaints (like the periapical abscess seen to the right) that we see in the Emergency Department. PV Card: Dental Infections Adapted from [1] Go to ALiEM (PV) Cards for more resources. Reference Nguyen D, Martin J. Common dental infections in the primary care setting. Am Fam Physician. 2008;77(6):797-802. [PubMed]
Trick of the Trade: Corneal reflex test
The corneal reflex test (blink test) examines the reflex pathway involving cranial nerves V and VII. Classically the provider lightly touches a wisp of cotton on the patient’s cornea. This foreign body sensation should cause the patient to reflexively blink. This maneuver always makes me a little worried about causing a corneal abrasion, especially if you are examining a very somnolent patient. You are wondering — Is there no blinking because you’re not touching the cornea hard enough? You apply harder pressure but still no blink. You repeat the test and now the patient finally blinks. That’s 3 times you’ve [+]
First annual Medical Apps Awards: Vote now
The polls for the first annual Medical Apps Awards is now open. Voting closes April 21, 2011 @ 12:00 AM EST. General instructions (you can win various prizes) Go directly to the polls There are 3 categories that you can vote on: 1. Best Medical App for Healthcare Professionals MediBabble - a medical translation tool Doximity - a professional networking tool Medscape - comprehensive guide to drugs, interactions, diseases, & procedures Epocrates - comprehensive guide to drugs, interactions, identifying pills, & calculators DrChrono - the first EMR for the ipad 2. Best Medical App for Patients iHealth BPM w/ [+]
Article review: What’s wrong with self-guided learning?
There is a constant tug-of-war between self-guided learning and supervised learning. With the advances in technology for medical education such as asynchronous learning modules, simulation, there has been a movement away from traditional, instructor-led teaching and towards more independent, self-guided learning. There is less supervision of learning. But left unsupervised, are learners learning the right things and doing so optimally? The authors, in this review, say yes and no. [+]
Paucis Verbis: Dental trauma
How cool is this -- I have talented emergency physicians contributing Paucis Verbis card content! This week features excellent pearls on Dental Trauma by Dr. Hans Rosenberg (University of Ottawa). Here's his recent article in Annals of EM on reimplantation of avulsed teeth.1 PV Card: Dental Trauma Go to ALiEM (PV) Cards for more resources. Reference Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375-377. [PubMed]
Trick of the Trade: Oblique CXR to look for pneumothorax
Supine chest xrays have an extremely low sensitivity (12-24%) in detecting pneumothoraces. Because a pneumothorax layers anteriorly on an AP CXR film, the xray beam is perpendicular rather than tangential to the pneumothorax edge. This makes visualizing a small to moderate sized pneumothorax extremely difficult. So you are left to look for indirect signs such as a deep sulcus at the costophrenic angle or subcutaneous air. I’m often surprised at how large of a pneumothorax can be missed on CXR based on CT imaging. The image to the right shows a large left-sided pneumothorax on CT. What if you [+]