April 2002: Tricks of the Trade

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

HIDDEN JAW FRACTURES

Some simple mandibular fractures may be difficult to pick up on plain facial radiographs. For that reason, Dr. Mark Silverberg of Brooklyn, New York, stresses the need to inspect the floor of the mouth. If hematoma or ecchymosis is present--even in the face of a normal mandibular radiograph--a CT scan is required. Either of those signs is a sure tip-off that there is a fracture waiting to be discovered.

ZIPPER TECH

A foreskin that becomes caught in the zipper of a pair of pants can be pretty tricky to release. Dr. Khin Maung Aye of Yangon, Myanmar, says the best bet is to use both hands to grasp the sides of the zipper above the sliding tab (in unlocked position) and pull them apart as if to separate the two rows of teeth, which will cause the tab to move downward and free the foreskin without too much pain. If the zipper is still resistant, use some EMLA topical anesthetic and try again. No wonder some men prefer button flies.

SAFETY SYMBOL

A dented bicycle helmet makes one of those pictures that are worth a thousand words, according to Kim Gracey, RN, of Forks, Washington. Ms. Gracey notes that the emergency department where she works displays damaged helmets at their booth at a health fair to underscore the importance of wearing helmets. They're "living proof" that helmets work. The department also keeps a supply of undented bicycle helmets on hand to give to children who have no helmets or to offer as replacement helmets to those whose own equipment was damaged in an accident. Seems like a worthwhile project for some civic-minded group.

CHEAP DETECTIVE

Quick and cheap: a winning combination for a substance that can detect the presence of aspirin in urine. Thanks to Dr. Paul Bonucci of Augusta, Georgia, for reminding us of the utility of ferric chloride when you don't want to wait for laboratory results. When Dr. Bonucci is in a hurry to find out aspirin levels--especially in the case of an obtunded patient with an anion gap metabolic acidosis or respiratory alkalosis--he adds one to two drops of 10% ferric chloride to the urine specimen. If the color changes from yellow to purple, salicylate is present and treatment can be quickly aimed in the right direction.

DR. SCISSORHAND

To improve visualization of the vocal cords during intubation, Dr. Michael D. Parsa of El Paso, Texas, employs what he calls the "scissor technique." He places the gloved index and middle fingers of his right hand against the patient's upper incisors, then applies an outward and upward force against the inserted laryngoscope blade with his right thumb. This additional pressure is often all that is needed to allow a good view of the vocal cords.

BARRIER PROTECTION

Prior to looking into a child's throat, Dr. D. Brady Pregerson of Beverly Hills, California, covers his eyes with safety glasses. This action protects him from the stray infectious agent that may be expelled in his direction when a sick child coughs or gags. He makes it easy by keeping the glasses tipped up on top of his head so that they are handy when he needs them. Dr. Pregerson says he can even pull his glasses down into position with his inner arms if he is already sterile. Of course, safety glasses are useful in other situations involving risk of infection, such as suturing and wound cleaning.

PARTING WORDS

Before writing out aftercare instructions or handing over a preprinted instruction sheet, check the patient's signature on the emergency department's consent form. According to Dr. Stephen C. Acosta of Portland, Oregon, if the signature is printed (particularly in all capitals), there is a good chance the patient is illiterate or nearly so. Dr. Acosta advises practitioners to take care to give these patients clear spoken directions for follow-up in addition to the standard-issue printed instructions. Actually, this advice would be wise for all patient encounters.