February 2002: Tricks of the Trade

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

AVOIDING STIFF RESISTANCE

To evaluate meningismus in children, Dr. D. Brady Pregerson of Beverly Hills, California, jingles his keys above their heads to make them look up, touches their chests to make them look down, or tickles them behind the ears to make them bend forward. Pushing on the back of a young child's head, observes Dr. Pregerson, does nothing but create false resistance and possible misinterpretation.
 

WHAT'S IN A NAME

I dislike the common practice of calling new patients by their first names without first asking their permission, but many of us trip over last name pronunciations or, worse, don't even try. Dr. Stephen C. Acosta of Portland, Oregon, recommends that you practice saying the common foreign names of those living in your area so that you will be ready to respectfully address patients by their surname. I have also found that almost everyone responds positively to the question, "How do you say your last name?"
 

THE FIDGETY CHILD

To keep a child still for an ENT examination, Dr. Darren L. Cook of Belleair, Florida, asks the parent to stand at the head of the examining table and firmly hold the supine patient's elbows above the head. Dr. Cook then leans over the child's lower body to keep him or her still. This approach allows the parent to be involved and obviates the need for a nurse to help with a fidgety or resistant child.
 

HOT IDEA

Even though it may seem odd to colleagues passing by, the strategy Dr. Cook suggests to keep a patient warm in the incessantly cold emergency department actually does work: Shine an overhead surgical light directly onto the patient's torso. Extra blankets help, too.
 

SNORKEL TO THE RESCUE

While on a trip to Hawaii, the 4-year-old son of Dr. Mark Borden of Davis, California, began to have severe wheezing caused by a viral infection. Dr. Borden had no difficulty in obtaining a metered dose inhaler, but he couldn't find a spacer. What to do? It occurred to him that his spare snorkel could serve the purpose quite well. The inhaler fit perfectly into the end of the tube, allowing the inhaler to clear the wheezing—a great success story!
 

A PICTURE IS WORTH A SHOT

The media-promulgated vaccine anxiety has caused some parents of toddlers to hesitate or even to decisively forgo vaccinations for their children. To help convince reluctant parents to choose vaccinations, Dr. Basil Rodansky of Lincoln Park, Michigan, lets pictures speak louder than his words. He shows parents photographs of the illness to be prevented. Chickenpox is an ideal example, given that many think of it as completely benign. Pictures of severe skin rash, varicella pneumonia, or secondary bacterial invasion may tip the balance in favor of this highly beneficial vaccine.
 

DIGITAL LIDOCAINE: TIMING IS EVERYTHING

Many readers send in tricks that describe how to lessen the pain of a lidocaine injection. For some locations, such as the digits, these tricks really do help. Dr. Daniel E. Kates of Scottsdale, Arizona, has adopted the practice of freezing the interdigital skin with ethyl chloride spray at the exact instant that he inserts the needle to deliver a digital block or to perform an incision and drainage of an abscess. Most of us don't take the time to find the ethyl chloride, but all of us should remember the three basic ingredients for reducing the pain of lidocaine injection: a small-gauge needle, a slow injection, and a means of distracting the patient (or a pinch of the skin proximal to the injection site).
 

DO THE MATH

Tube sizes for pediatric patients are difficult to remember. Accordingly, Dr. Fred Leonard of Tucson, Arizona, offers these useful mnemonics—generally confirmed in the Harriet Lane Handbook. If you know the size of the endotracheal tube (ETT)—which is equivalent to the size of a patient's little finger or to (16 + age in years)/4—you know the rest:
     • ETT X 2 = nasogastric or Foley (French) size
     • ETT X 3 = depth to insert the ETT
     • ETT X 4 = chest tube size
In a pinch, use anything that you think will fit while you calculate the correct size.