Tricks of Trade: Small Little Things to make Practice of Medicine easier

As Featured in Journal "Emergency Medicine". Contributed by readers. Edited by Donald B. Middleton, MD

TETRA BEFORE LIDO
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.

STEALTH APPENDIX
"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.

LIGHT TOUCH
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.

SWEET SUCCESS
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

NO-TEARS EYE DROPS

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.

EXIT SPLINTER

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.

UNDER PRESSURE
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.

POSITIONAL PAIN CLUES
Pain in some illnesses changes with position, Dr. Brady Pregerson of Los Angeles reminds us with some examples. Worse lying down: pericarditis, epiglottitis, Ludwig's angina, asthma, congestive heart failure, gastroesophageal reflux disease. Better lying down: post-spinal tap headache, retropharyngeal abscess. Better lying on the left side: pancreatitis, pregnancy, pyelonephritis on the right, a kidney stone on the left. Better lying on the right side: pyelonephritis on the left, a kidney stone on the right

NOTHING TO SNEEZE AT
To prevent reflex sneezing during a cauterization and packing for epistaxis, Dr. Brian Collins of York, Maine, has his patient rub the nasal bones between a thumb and a forefinger. This technique prevents inadvertent expulsion of the nasal packing and further trauma to the bleeding site. The rubbing may work via the gate theory, by interfering with sensory input from the irritated nasal mucosa. Dr. Collins uses it on himself to stifle his own sneezes whenever the situation dictates.

EYE FEEL SOMETHING...
To remove a corneal foreign body, Dr. Stephen Acosta of Portland, Oregon, recommends eye spuds or a moist cotton-tipped applicator to pop the foreign body off the cornea. The cotton will not scratch if moistened, says Dr. Acosta. Ersatz eye spuds can be made by bending the tip of a 27-gauge needle on an insulin syringe (or a TB syringe if necessary) to a 45- to 90-degree angle with the needle bevel facing away from the eye surface.

PERCUSSION POINTER
The reflex hammer is good for more than just reflexes, writes Dr. Mike Lemanski of Springfield, Massachusetts. Tapping on his finger with the reflex hammer augments the percussion note
from the chest, heart, or abdominal exam, and the soft, round tip leaves his finger feeling fine.

FAMILIAR TWIST
To prevent twisting of the spine during a lumbar puncture, Dr. Jeff Metzger of Durham, North Carolina, puts a pillow or rolled blanket under the patient's knees. With the patient in a decubitus, fetal position, this support keeps the pelvis and shoulders perpendicular to the plane of the table. Perfect alignment leads to a simpler lumbar puncture.

THE GAG IS ON THEM
Some patients with pharyngitis and severe headache are simply too ill to allow a look into the throat. Interference from a heightened gag reflex may be too powerful to overcome by force of will. Before ordering more expensive, complex tests and to get a less time-consuming evaluation, Dr. Stephen Fahey of Kensington, Maryland, puts a dollop of viscous lidocaine on the end of a tongue depressor and asks the patient to flip it so the gel sits on the tongue. The patient slowly "walks" the gel-coated tongue blade as far back on the tongue as possible, coating the tongue itself. The result is an easily depressed tongue and a reduced gag reflex that permits a better visualization of the pharynx and facilitates more specific therapy.

MULTITASKING TEST
Asterixis, also known as the "liver flap," is more than just a bedside assessment of hepatic encephalopathy. It tests for any type of encephalopathy due to a metabolic cause, including renal failure, drug toxicity, and—probably the most useful—elevated pCO2. To remember the causes of asterixis, Dr. Brady Pregerson in Los Angeles, California, uses an ABCD mnemonic: A for ammonia; B for BUN (renal failure); C for pCO2, CVA, CNS infection (malaria, encephalitis), or CNS tumor; and D for drugs (aspirin, antidiabetics, seizure medications, and psychiatric medications).

THE TOPIC OF TOPICAL ANESTHESIA
Everyone wants local anesthetics to work without injecting; in my experience, topical products often fall short. In Overland Park, Kansas, Dr. Dan Harpt claims that dripping several drops of an anesthetic into a wound and waiting a few minutes will provide some decent anesthesia. That effect combined with slow injection during wound infiltration largely eliminates pain, he says. I believe that gauze soaked with anesthetic is even better, especially if left in place for 10 to 15 minutes. Others favor LAC or TAC (lidocaine or tetracaine with adrenalin and cocaine) or lidocaine gels. Trial and error may help you find your favorite.

TEA FOR TOOTH
For a bleeding socket after tooth loss or extraction or even a simple lip or gum laceration, Dr. Michael Jaeger in Tivoli, New York, suggests a teabag moistened with cold water as an astringent compress to quickly stop the bleeding.