January 2005

Contributed by readers • Edited by Donald B. Middleton, MD
 

INVERT THAT OTOSCOPE

You have often seen it done, and now Dr. Bernard Bronczyk of Columbus, Ohio, would like to officially recommend that we all turn our otoscopes upside down to get a safer look into our patients' ears. Dr. Bronczyk grips the otoscope by the center and extends his fifth finger to touch the patient's head as a stabilizer to keep a safe distance should the patient suddenly move. The fulcrum is now the center of the handle, with less force on the speculum. I would remind everyone to warn patients that you are going to touch them, to avoid a sudden jerk away, and to carefully watch seated patients after the exam, since they do occasionally faint.

HAIR IS EVERYWHERE

To hold hair out of the way while she repairs an anterior scalp laceration or removes a forehead growth, Dr. Jennifer Donohue in Portland, Oregon, cuts a 2- to 3-inch wide strip of large tube-gauze (stockinette would also do) to use as a headband. She finds it suffices to keep back the hair, and certainly it is a lot easier to remove than tape.

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.

NOTHING TO CRY ABOUT

Some intranasal foreign bodies defy traditional removal techniques. When Dr. John Shields of Clarksville, Tennessee, was faced with a pair of toddlers thus afflicted (one with a crayon, the other with a french fry), he recalled that on occasion he asks the mother to give a quick breath into the child's mouth to expel a foreign object from the nostril. Rather than follow that course, he realized the crying fits his nasal probing had induced in these two children might work to his and their advantage. Waiting for an expiratory phase in the crying, he quickly occluded both the mouth and unplugged nostril of each child so the expired air was forced through the obstructed nostril—and out popped the lodged object, in both cases. Takes a good sense of timing, but whatever works.

TRACKING DRUG THERAPY

To remember how many days a hospitalized patient has been treated with antibiotics, Dr. Joan Presby of Beverly Hills, California, reminds us to write down the number of days each drug has been given beside the drug name in each day's progress note: "ceftriaxone #6." To remind myself of the intended length of treatment, I also write the number of days the antibiotic treatment is planned like a fraction beside the antibiotic name: "metronidazole, day #3/7." The notation gives other consultants, residents or partners rapid notification of the treatment plan.

PRETTY CORNY

To relieve the discomfort of painful corns, Dr. Ramanatha Srinivasan from Nanuet, New York, injects 1 to 2 ml of 1% procaine into the corn. He claims that the injection induces permanent anesthesia and, on occasion, resolution of the corn.

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.