May 2007

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

The Eyes Have It

In London, England, Dr. Philip Banerjee removes a superficial foreign body from the cornea using a moistened cotton swab. After anesthetizing the cornea, he has the patient look down. Holding the swab close to, but above, the cornea, he then instructs the patient to look up quickly, gently passing the moistened swab over the cornea as it elevates. Most foreign objects adhere to the cotton, and so are rapidly dislodged. Dr. Banerjee states that this technique is widely employed and well tolerated.

Helpful Mnemonic

To avoid critical omissions, Dr. Marson Ma, Jr., in Detroit, Michigan, uses the mnemonic “ABC-DOT,” meaning:
A - Airway (or allergy)
B - Breathing
C - Circulation (or cervical collar)
D - Dextrostix (or dextrose)
O - Oxygen
T - Type and cross (or trauma, tubes, or Td)
This mnemonic seems useful enough but should not take the place of an electronic record reminder.

Cottony Throat

When Dr. Tony Bekkerman of Highland Park, Illinois, suspects streptococcal pharyngitis, he places a throat swab on top of a tongue blade and, holding both in one hand, depresses the tongue and swabs the tonsils and pharynx at the same time. Although this technique takes a bit of practice to perform well, it is rewarding not to have to gag the patient (especially a young child) twice. The cotton swab can be cultured, used for a rapid strep test, or discarded as the exam warrants.

Lidocaine Blush

Using real-time ultrasound guidance to place central lines may be hampered by difficulty visualizing the needle, because metal is hard to see on ultrasound. In Los Angeles, California, Dr. Brady Pregerson, in addition to using a “poking” type motion, employs a more vertical approach to the vein than is traditional and uses a transverse plane of imaging. He recommends pre-filling a syringe with lidocaine and occasionally injecting a small amount as you approach the vein. The injection will cause a white “blush” at the needle tip, confirming your position.

Timely Tubing

Speaking of lidocaine, viscous lidocaine needs contact time to anesthetize a mucus membrane. Putting it on a nasogastric tube or Foley catheter just before insertion is unlikely to offer anesthetic benefit. In Glen Cove, New York, Dr. Rachel Waldron pretreats the nostrils or urethra with viscous lidocaine. A bit of gel injected from a syringe into each nostril, snorted to the back of the mouth and swallowed, or inserted into the urethra through an angiocath, followed by a delay of 10 to 15 minutes, reduces the pain from these procedures.

Allergy Alert

Here’s another trick from Dr. Waldron: To avoid ordering medications to which the patient is allergic, she writes these drugs in large letters at the top of each order sheet. I suspect the same exercise would work for contrast dye allergy also.

MIX IT UP

From Lincoln Park, Michigan, Dr. Rodansky provides another trick. To reduce the likelihood of diarrhea and other gastrointestinal upsets associated with colchicines prescribed for gout, he advises patients to crush their colchicine tablets and mix them with at least one tablespoon of applesauce or mashed potatoes to hide the taste. Not being a pharmacologist, I trust this is a plausible strategy to reduce side effects, but I worry about the speed of relief for gout symptoms. Anyone care to comment?

A Child’s Permission

A few seconds spent examining a child’s stuffed animal, doll, or even her shoe is often rewarded by increased cooperation from the patient when her turn comes. Dr. Gus Garmel from San Francisco, California, carries this idea one step further: He asks the child if he can have permission to examine the parent first. A quick otoscopic evaluation of the parent’s ear often makes the child’s check simpler.