January 2007

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

Family Affair

Rules about family members joining a patient in the emergency department vary from hospital to hospital. However, when faced with an intoxicated or delirious patient, Dr. Gus Garmel in Santa Clara, California, encourages a family member to stay in the emergency department with the patient. The obvious advantage is that someone recognizable is there to observe the patient and perhaps help control behavior. As a secondary benefit, Dr. Garmel doesn't have to search for a family member to take the patient home when the intoxication wears off. Anybody got a cot?

don't panic

To treat hyperventilation during panic attacks, Dr. Rajeev Pethe in Spring, Texas, applies a nonrebreathing face mask connected to an oxygen source, but with the oxygen turned off to reduce flow. Carbon dioxide builds up in the mask, thus limiting the effects of hyperventilation.

keep your focus

From Nashville, Tennessee, Dr. Sam Pearson reminds us that a myopic patient who has forgotten, lost, or damaged her glasses can still be tested for visual acuity. The answer is the pinhole occluder, which reduces the diversity of angles through which light rays enter the eye, allowing the image to focus on the retina. In the absence of an official pinhole occluder, Dr. Pearson punches a paper-clip-sized hole in a Styrofoam cup, which brings the focal point out to the proper distance from the eye for testing.

hard to swallow

To get a reluctant patient to swallow a pill, Dr. Daniel Kranitz in Chagrin Falls, Ohio, has the patient chew—but not swallow—some food, such as a cracker. Prior to swallowing, he has the patient stick out his tongue with the food bolus on it, puts the pill in the bolus, and tells the patient to swallow without further chewing. This advice reminds me of the trick often used in attempting to medicate pets. Sometimes it works, and sometimes the food goes down and the pill pops out.

flipping your lid

Many practitioners use a cotton-tipped swab stick and a fingertip grasp to evert the eyelid. In Honolulu, Hawaii, Dr. David Yew's first choice is an eyelid retractor, but if one is not available, he uses the round end of a paper clip, which works particularly well for smaller eyelids. My one caution is that many metal paper clips have sharp ends or edges, so they must be used with care around the eyes. Plastic-coated paper clips might be safer.

soft touch

To detect abdominal tenderness in a child, Dr. Thomas Crawford from Santa Clara, California, uses a two-handed technique. After listening for bowel sounds, he alternates pressure from the stethoscope on one area of the abdomen with pressure from his other hand on a different region all the while watching for a reaction from te child. He says the eyes of the child are most revealing. Perhaps he is able to detect pupil enlargement or a facial grimace alerting him to the abdominal area of concern.

floor me

To single-handedly manage a patient requiring an ankle splint, Dr. Barry Hahn in Staten Island, New York, places the patient in a chair or wheelchair, applies the splint, and then lightly rests the foot on the floor with the ankle at 90°. He tells the patient to maintain this position while the splint sets, and in the meantime he writes out any necessary prescriptions or instructions. The hardened splint is nicely molded to the natural curves of the patient's ankle and foot, says Dr. Hahn—and the discharge process is expedited.

chest pain clues

Chest pain in young women is only rarely cardiac in nature. Coronary artery disease is particularly rare, but Dr. Basil Rodansky of Lincoln Park, Michigan, reminds everyone not to forget about the spector of pericarditis, especially if the pain is persistent and changes in position, such as moving from lying down to sitting, reduce the pain. Of course, the most dreadful cause of pericarditis is cancer, and in young women, Hodgkin's is the usual problem.