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Thread: Tricks of the Trade

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    Arrow Tricks of the Trade

    Tricks of the Trade


    In Terrell, Texas, Dr. Amaha Hailey uses a few drops of a 3-ml bottle of 0.5% tetracaine solution for topical anesthesia for corneal injury. But rather than discarding the remainder, Dr. Hailey pockets the bottle for later application into open wounds to produce topical anesthesia prior to lidocaine infusion. He claims the tetracaine is usable for a couple of days. Although many claim that topical anesthetics like tetracaine help reduce the sting of lidocaine injection, I have found that one must wait 15 to 20 minutes for the drug to penetrate the tissue and that slow injection of the lidocaine, as an alternative, is almost painless. To each his own, in this case.


    To make skin hooks for retracting or aligning delicate tissues, Dr. Chris Dutra of Berkeley, California, pushes the cotton end of a cotton-tipped swab into the hub of a 20- or 22-gauge needle and uses a needle holder to bend the needle to the correct angle. I have always used the wooden end for fear that the cotton tip would slip out. Recently I have seen the needle simply left on the end of a Luer-Lok 3-ml syringe, which has flanges against which to retract that make it really steady.


    After a nurse or assistant draws up an injectable substance like lidocaine into a syringe, Dr. John Wipfler from Peoria, Illinois, instructs him or her to put the original bottle of injectable beside the syringe, thus avoiding inadvertent injection of the wrong stuff.


    From Charleston, South Carolina, Dr. Charles Gilman relays a tale about removing a sturdily constructed, thick-banded, and stubbornly stuck-on military class ring. Two manual ring cutters (the first of which broke) and some elbow grease finally resulted in a slice through the ring, but it still was stuck on the finger. Application of clamps on both sides of the ring with attempted traction to open the cut proved futile and ruined one of the clamps. The solution? Dr. Gilman slipped a cast splitter into the cut and opened it to stretch the ring enough to slide it off the finger, to the relief of patient, parents, and doctor alike.


    "Don't forget about the retrocecal or otherwise unusually placed appendix as a cause of nonclassical abdominal pain," warns Dr. Basil Rodansky of Lincoln Park, Michigan. Pain from acute appendicitis can be lateral or posterior, mimicking other diagnoses. On rare occasions, a long appendix may even result in pain localized to the left lower quadrant. If pain precedes fever and vomiting, appendicitis should enter the differential diagnosis even with an atypical pain site. A computed tomography scan can often clinch the diagnosis.


    When he was a resident, Dr. Michael Harlan of Covington, Louisiana, learned to control vigorously bleeding varicose veins through suturing, an idea that required anesthetic injection and often didn't work to control a large leak. He proposes a different solution: acrylic glue. He first compresses the bleeding vein at each end with his fingers, then applies acrylic glue to the bleeding site. I find a pressure dressing over the top keeps trauma at least temporarily at bay while the hole heals.


    From Paulding, Ohio, Dr. Quang Le reminds us to warm up mirrored instruments or otoscope shields before use to reduce the risk of fogging during the examination. He warms his mirror under hot or warm water and always tests it against his own wrist before using it on the patient. Others warm a mirror on a light bulb, again testing it first before using it.


    Recent studies have supported the idea that sucrose on an infant's pacifier or lips may have some analgesic effect. Dr. Scott McIntosh from Hartford, Connecticut, suggests sucrose as an alternative to more intense anesthesia for infants undergoing minimally painful procedures.

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    Tricks of the Trade - 2


    [HIDE]When administering ophthalmic medication to a sensitive patient like a child, the best technique is to lay the patient on his or her back with the eyes gently closed, then place a drop or two into the inner canthus spaces. Ask the patient to open the eyes while still lying down, and the drops will flow naturally into the eyes without a fuss. Thanks to Dr. Carol Gardner in Lakeland, Florida, for resurrecting this time-honored advice. [/HIDE]


    To reduce skin tenderness during percussion of the costovertebral angle to detect flank pain, Dr. Gus Garmel of Los Altos, California, places his open hand flat against the area, then firmly pounds it with his fist. This indirect percussion improves the chance that any elicited pain is due to an underlying (perhaps renal) rather than a superficial problem. I would add that the flat hand on the skin often worsens blossoming shingles pain, reinforcing the diagnosis of a superficial cause of pain.
    Rather than just incise an offending thrombosed external hemorrhoid to express the clot, Dr. Bruce Becker in Bloomsburg, Pennsylvania, advises the tried-and-true elliptical excision of overlying skin. The ellipse heals via secondary intention, preventing the recurrent thrombosis that can follow a closing simple incision.

    When removing toothpicks or splinters from the skin, Dr. John Wipfler in Peoria, Illinois, anesthetizes the area properly. Then, before he pulls the splinter out, he uses a number-11-blade knife or perhaps the tip of an 18-gauge needle to incise the skin immediately adjacent to the foreign body.

    A 2-mm incision through to the dermis loosens the taut skin, allowing less resistance to extraction. If removal is attempted without this incision, the wooden foreign body may break off, thus making complete removal more difficult. After the procedure, if there is any doubt about whether the entire object was removed, Dr. Wipfler fully educates the patient about the signs and symptoms of a retained foreign body to watch for. Specialist referral is usually indicated in these suspect cases.

    According to Dr. Brady Pregerson of Los Angeles, California, emergency physicians should always ask their patients, "How did you get here?" as part of the history. For patients who drove themselves, he limits the use of drugs that may cause mental impairment to avoid later transportation difficulties.

    [HIDE]In some circumstances, a basic task like taking blood pressure can be nearly impossible. To enhance the Korotkoff sounds, Dr. Jerome Lebovitz in Pittsburgh, Pennsylvania, inflates the cuff to above 180 mm Hg, tells the patient to open and close the fist and then relax, and slowly deflates the cuff. He claims that the sounds are then easily heard. Remember that blood pressure should be measured with the patient at rest for at least five minutes, sitting in a chair with the feet on the ground.[/HIDE]

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