August 2006

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

DRILL DOWN

To do a lumbar puncture on a patient who is markedly overweight requires some changes in the usual procedure. Most physicians have the overweight patient sit up and lean over a bedside table to open up the spinal cord. However, even then the standard 3inch needle may not be long enough to reach the spinal canal. To gain an extra inch or so, Dr. Brady Pregerson in Los Angeles, California, attaches a three-way stopcock to the spinal needle and presses the stopcock into the patient’s flesh, pushing the needle deeper into the spinal canal. He claims this technique gives a little extra space so that he can maneuver the collecting tube underneath the trickle of spinal fluid emanating from the stopcock. With the patient in a sitting position and this extension on the needle, your attempts at lumbar punctures in the overweight may be more often successful.

GETTING HOOKED

Soft foreign bodies stuck in the ear canal can be resistant to extraction. From Covington, Tennessee, Dr. Adan Atriham reports that a 14-gauge needle with the bevel bent to a 60- to 70-degree angle makes a sturdy hook that can be embedded into pencil erasers, soft plastic toys, and other items and used to fish out the object with minimal discomfort. With all the objects people stick into their ears, I wonder why no one has manufactured an extractor yet.

DO YOU HEAR WHAT I HEAR?

Treatment of otitis externa requires getting topical drops into the ear canal, which is, unfortunately, often blocked by cerumen or debris. Prior to flushing wax or debris out of the canal, Dr. Lawrence Adler of Beverly Hills, California, instills a few drops of 1% lidocaine with the hope of reducing the pain of irrigation. I would add the caveat that it is necessary to wait at least 20 minutes to achieve any degree of anesthesia.

SWEET NOTHINGS

When Dr. Robert Vezzatti in Falls Church, Virginia, treats a dehydrated child with an oral rehydration solution like Pedialyte, he improves palatability by adding a small amount of unsweetened flavored-drink powder like Kool-Aid or Crystal Light. The flavoring agent must be sugar-free, of course, to avoid altering the beneficial effects of the rehydration solution.

NASAL BALM

Winter dryness and seasonal allergies certainly exacerbate epistaxis. In Random Lake, Wisconsin, Dr. Jay Harms recommends beeswax lip balm (like Burt’s) applied with a cotton swab three times a day for a few days to a week to a bleeding nasal septum. Lots of other products, including other lip balms, A&D ointment, and OTC bacitracin/polymyxin ointment, probably also work well for the problem, but I agree that the beeswax balm is worth a try and can be used as often as needed.

BE A PILL

From Santa Clara, California, Dr. Thomas Crawford suggests that coughing patients who are in transit should be prescribed acetaminophen with hydrocodone or codeine tablets rather than liquids, since the tablets are easier to carry and to take. I wonder whether liquid cough suppressants might have a local soothing property that the tablets cannot provide, but I believe that Dr. Crawford is right about the ease of administration of tablets for travelers.

REQUIRED READING

Dr. Gus Garmel from Los Altos, California, likes to give patients information sheets about their condition as early as possible so they can read about it during their stay in the emergency department, not at the time of their release. In addition to the pure educational value of the sheets, he finds they help patients by giving them something to do. They also save time at the end, when patients tend to have lots of questions about their diagnosis. The sheets are not considered to be discharge or release instructions. If the final diagnosis contradicts the initial assessment (as with a patient who was given a gallstone instruction sheet and turns out not to have gallstones), Dr. Garmel points out that at least they will be more informed if a family member or friend develops the condition.