October 2007

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

Don’t Come Unglued
To seal off puncture holes from bleeding arteriovenous (AV) dialysis shunts, Dr. Patricia Wong from Lynwood, California, uses acrylic cement. It is imperative that the skin’s surface remain dry or the cement won’t stick. She advises pinching the area around the puncture site and gently lifting it. Applying a little pressure to the AV fistula also helps.

Gauze for a Good Cause
Speaking of acrylic glue, it can be a marvelous time saver. However, when a laceration is near a delicate structure like the eye, extreme care must be taken to avoid leaking any adhesive into it. To prevent this, Dr. Kosta Skandamis in Louisville, Kentucky, tapes a piece of gauze over the area that needs protection. The gauze will absorb any wayward glue. Gravity can also assist the physician in protecting delicate organs or orifices. By carefully positioning the patient, you can assure that any excess glue trails away from sensitive sites.

Going mobile
Given the mobile phone technology at our fingertips, Dr. Gus Garmel from Santa Clara, California, advises that rather than retreating to your office to contact a patient’s primary care provider or required consultant, you should make the call directly from the patient’s room. This will ensure that the patient can listen to your concerns, correct any errors in the history, and share in the decision-making. Sounds like a good call to me.

B52
To sedate agitated patients in the emergency department prior to obtaining intravenous access, Dr. Joe Toscano from San Jose, California, employs a mixture of 5 mg of haloperidol, 2 mg of lorazepam, and 25 mg of diphenhydramine. This concoction, affectionately known as a “B52,” is injected intramuscularly using one syringe. If it’s not immediately effective, the injection can be repeated in 5 to 10 minutes. It is important to always check for medical causes of agitation, such as hypoxia, before administering these drugs. Haloperidol will not suppress respirations but lorazepam may, so care should be taken to avoid repeat doses.

Feeling Drained
To reduce a persistent leak from the needle site after performing paracentesis, Dr. Keith Yablonicky in Los Angeles, California, puts surgical lubricant on one side of a
4-in-3-4-in gauze pad that has been rolled into a ball. The lubricated side is placed over the puncture mark, then covered with a clear surgical dressing to create a tamponade effect. Other sources recommend using a Z-shaped puncture: first put the needle through the skin, then slide the skin over the subcutaneous tissue about one inch before entering the abdominal cavity. For tense ascites, a combination of these two techniques might help.

Get the Picture!
Another tip from Dr. Garmel suggests that if your hospital or office policy allows it, you should e-mail electronically stored radiographs to your patients. He’s found that patients, especially children and those with fractures, love having copies of x-rays in their photo libraries to share with relatives and friends. Patient satisfaction is every bit as important a part of medical care as the return of good health.

Light Show
Before looking in a toddler’s or older infant’s ear canals, Dr. Jennifer Donohue in Lake Oswego, Oregon, points her otoscope up at the ceiling and repeatedly takes the speculum on and off, as if playing with a stacking toy. Most children find the light show entertaining and react with less fear when the time comes to look in their ears. I like showing the child that the speculum isn’t painful by putting it in my own ear canal. Sometimes shining the light into a doll’s or stuffed animal’s ear helps. If all these tactics fail, placing the patient supine on the exam table and holding the head to the side while a parent holds the hands is a quick, safe method to view the tympanic membranes.

Shield Yourself
When draining an abscess, Drs. T.R. Jones and Jody Henson from Temple, Texas, offer the following suggestion. Take two clear face shields, put one on your face, and have an assistant hold the other shield a few inches over the abscess. As you inject or incise the abscess, you not only protect your eyes but also your clothes and the surrounding area from a biohazard splash. The slit in the face shield can also be attached to the hub of the needle for the same effect.