March 2003

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

TIMELY BLOCK

For a painful finger injury that requires an x-ray, Dr. Stephen Acosta in Portland, Oregon, provides a digital block with a long-acting anesthetic prior to the radiologic procedure. By the time the patient returns, the finger will be numbed. Pain is reduced during the radiologic examination and thereafter regardless of whether a fracture or laceration is present. Always remember to inform technicians and staff that the finger is blocked to avoid further injury.
 

SINUS SCAN

From Yuma, Arizona, Dr. Rodolfo Gonzales recommends a limited computed tomography scan of the sinuses for patients with purulent nasal discharge who could have sinusitis. This prevents needless antibiotic use in cases of simple rhinitis, and with antibiotic resistance on the rise, it is good practice.
 

SOUND CHECK

To detect a femoral fracture in the field, Gary Keel, PA-C, in Granbury, Texas, enlists the ability of hard tissue to conduct sound better than soft tissue. He places his stethoscope on the symphysis pubis, then taps on each patella. The percussion note on the side of the intact femur sounds like a click, while that on the side of a broken femur could be described as a thud. This added bit of diagnostic information may help to identify the leg in need of radiologic evaluation and at least warrants a splint for the side with the thud. Practice on a healthy, uninjured leg to become familiar with the normal sound, suggests Mr. Keel.
 

ADENOSINE ALTERNATIVE

From Cincinnati, Ohio, Dr. Tamela Zimmerman sends in an alternative method for an adenosine injection that eliminates the stopcock we advised using in a previously published "Trick" (see Emergency Medicine, June 2002, p. 8). She simply inserts two needled syringes, one with adenosine and one with saline, into the line port or the hub of a heparin lock. After rapidly injecting the adenosine, she pushes the saline. I have used this method often, but once when I pushed the adenosine, the saline syringe hub backed up, indicating I was injecting it there rather than into the patient. A little extra care is in order if the stopcock is not used, but the simplicity of Dr. Zimmerman's method is advantageous.
 

UPLIFTING SUTURE TECHNIQUE

Often, stitches may become buried in the skin and thus difficult to extract, especially from wounds in patients who are a bit overdue for their return appointments. Dr. Michael Hood in White Pine, Tennessee, finds it helps to use a running simple or mattress stitch with a long end remaining after the first needle insertion. This end is placed underneath each successive stitch on alternate sides of the wound and left free after the wound is closed. The patient is instructed to inform the person removing the sutures that this loose end can be pulled up on to raise each stitch off the skin, simplifying removal. I suspect this idea works best with small sutures that are tightly spaced, such as those on a digit or the face.
 

HOT POTATO

An old, but still good, trick is the hot potato in a wet towel or washcloth used as a hot compress for abscess or hordeolum treatment. In New York City, Claudia Radist, RPA-C, simply tells her patient to microwave the potato to a warm temperature that feels good to the back of the hand. The potato acts as a heat source inside the moist washcloth, staying hot much longer than the moist washcloth alone.
 

STEADY CLIP

To meet the challenge of a foreign body lodged in a toddler's nose, Dr. Brady Pregerson in Los Angeles prefers that tried-and-true medical tool, the paper clip. He straightens the clip with a needle driver, then bends a small triangle in one end to hide the sharp tip. Next he tilts the triangle to a 115° angle from the shaft of the clip so it can be used like a hook. After spraying the child's nose with a vasoconstrictor such as phenylephrine, he passes the paper clip behind the foreign body and pulls. Given enough helping hands to steady the child's head, Dr. Pregerson claims 100% success with this approach.