July 2006

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

GET THE PICTURE?

From Portland, Oregon, Dr. Nicole DeIorio reminds us all to use the resources of modern technology to help us assess how our patients are doing. An infant was brought to her emergency department with a rash over the eyelid that had evolved rapidly, according to the parents, but it did not change much in the emergency department. Dr. DeIorio had them take a photo of the affected area with the camera built into their cell phone to help them monitor the rash. Subsequently, when it did appear to spread, the parents took another picture and sent it in to the emergency department over the camera-phone so that Dr. DeIorio could take appropriate steps to get the rash under control.

PAIN GAUGE

These days everyone needs to judge how much pain a patient is really feeling, usually graded on a 1-to-10 scale. From Vestavia Hills, Alabama, Dr. Adam Nortick sends in his assessment method—the FAKES scale (F = facial expression, A = appearance of dress along with body posture, K = kinesis, or how a patient lies on the examining table, E = how the patient enters the department, S = sounds a patient makes spontaneously). We have all encountered the patient who complains of intolerable pain but looks to be in no distress, and on the flip side, the patient who denies that the pain is severe despite the fact that it clearly is challenging. Dr. Nortick advises that we take a few seconds to observe our patients and to quantify our observations to get a more complete picture of pain severity.
Point values for the five attributes are as follows:
Face: calm, 0; clenched, 1; grimacing, 2
Appearance: normal, 0; frayed, 1; disheveled, 2
Kinesis: still, 0; fidgety, 1; writhing, 2
Entry: routine, 0; slow, 1; assisted, 2
Sounds: quiet, 0; sighs, 1; screams, 2
The higher the score, the worse the pain.

ACRYLIC CLOSURE

To improve distribution of acrylic glue when closing a laceration, Dr. Tammy Foster from Burlingame, California, prefers to achieve hemostasis with lidocaine with epinephrine or lidocaine-epinephrine-tetracaine, then draw the glue into a 3-ml syringe with a half-inch 25-gauge needle. Working quickly to avoid clogging the needle with glue, she directs it deep into the wound to achieve superior closure. Having an extra needle on hand in case of blockage may be wise.

DIGITAL CONTROL

As a variation on the finger cot tourniquet, Dr. Mark Spadaro of East Meadow, New York, covers a finger wound with a first-aid strip, then puts a whole latex glove on that hand, cuts a hole in the tip of the latex finger covering the wound, and rolls just that finger back to the digit’s base to act as a tourniquet.

STRAIGHT TO THE POINT

Dr. Brady Pregerson from Los Angeles reminds us that when suturing a laceration, a good method to avoid a translational error that can end in a dog ear is to use the thumb and index finger of your nondominant hand to apply traction in-line with the laceration, so that the wound is extended. Holding the traction as you insert the needle through both sides of the wound helps everything to line up perfectly. When using interrupted sutures, some practitioners like to put the first stitch in the middle of the wound to keep the edges neatly aligned.

NOT HANDLING IT

During procedures, one often has to adjust the light source. To avoid contaminating the lamp, Dr. Chris Dutra of Berkeley, California, remembers to put a glove (sterile or nonsterile, depending on the procedure) over its handle so he can adjust it as needed.

PLAN B FOR PARONYCHIA

Dr. Robert Molino in Mill Valley, California, reports that ethyl chloride spray is often in short supply or missing. He uses ice water anesthesia as an excellent substitute in preparing for incision and drainage of a paronychia. A small cup of ice water with a little povidone-iodine serves to chill the digit prior to the incision. Sounds like a cool idea.