May 2002: Tricks of the Trade

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

HYPOGLYCEMIC HEADACHE

The majority of headaches can be ascribed to tension, sinusitis, migraine, or muscular pain, but Dr. Mark H. Selesnick of Pittsfield, New Hampshire, reminds us of another possible etiology. On some occasions, he notes, hypoglycemia can cause headaches. For patients with undiagnosed recurrent headaches, Dr. Selesnick suggests checking for hypoglycemia with a three-hour glucose tolerance test (GTT). If hypoglycemia is detected, then dietary intervention (high-protein, low-carbohydrate) should be tried to see whether the headaches resolve. Two caveats to this advice, however: Most patients with hypoglycemia have other prominent symptoms (hunger, sweating, dizziness) and most references suggest a five-hour GTT as a more accurate tool--with the requirement that the headache develops during the hypoglycemic phase of the test.

TAKING THE WORRY OUT

Dr. Stephen C. Acosta of Portland, Oregon, tries to keep in mind that problems viewed as common and benign by an experienced physician may not seem so to the patient. If you can determine and address a patient's specific concerns, he notes, you can eliminate any unnecessary fears. An 18-year-old who has rectal bleeding, for example, may be reminded of his or her grandmother's fatal colon cancer. Reassuring the patient that the cause is not cancer may have a greater calming effect than explaining the actual diagnosis.

MAKE MINE MINT

To cover up foul odors from drained pus, melena, and the like, Dr. Daniel E. Kates of Scottsdale, Arizona, keeps a supply of pharmaceutical-grade peppermint oil, which is a stock item in his pharmacy. He finds that a small amount goes a long way to pleasantly mask bad aromas and is far preferable to the use of heavily perfumed hospital disinfectants or the especially noxious benzoin spritz. These practices not only "stink," notes Dr. Kates, but can provoke nausea, headache, or even bronchospasm. In his experience, no such reactions have ever been triggered by peppermint oil.

HOW TO TOTE A TOOTH

How do you handle an avulsed tooth? By its crown, stresses Dr. Mark Silverberg of Brooklyn, New York. In fact, no other part of the tooth except the crown should be touched. The part of the tooth that sits beneath the gum line is covered with microscopic periodontal ligaments. Successful reimplantation depends upon the integrity of these tiny fibers, which can be damaged if handled.

GLUE CONTROL

Anyone who has used surgical acrylic glue knows just how messy it can be. To circumvent this problem, Dr. Carsten Zieger of Los Osos, California, has devised an ingenious technique. After breaking the seal of the capsule in the usual manner by squeezing the sides, he inserts an 18-gauge needle through the cotton applicator and withdraws 1 to 2 cc of glue into a 3- to 5-cc syringe. He replaces the needle on the syringe with a 22-gauge angiocath. This allows him to apply the surgical glue to the wound through the angiocath in a controlled manner. There are no smears and nothing gets glued that was not supposed to be glued, comments Dr. Zieger. Now why couldn't the manufacturer have come up with this practical system?

SHOULDERING THE BURDEN

To get the shoulders out of the way so that C7, C8, and T1 can be seen optimally on cervical radiographs, Dr. Robert Becker of Bloomer, Wisconsin, wraps a sheet over each of the patient's shoulders and, standing at the foot of the stretcher, pulls downward. Dr. Becker finds this method more effective in overcoming the strong shoulder girdle muscles than the usual one of pulling caudally on the patient's hands or lower arms.

IMPROVISING AN ANOSCOPE

Dr. Rajeev Pethe of Houston, Texas, reminds us of an old standby trick, one that I have used for more than 30 years. When there is no anoscope handy, try an ordinary red top blood collection tube with the label and stopper removed. The rounded, lubricated bottom is inserted into the anus first, nearly all the way. Once this is done, the anal mucosa can be visualized with the aid of a penlight or otoscope as the tube is slowly withdrawn. Pediatric tubes can be similarly used to detect fissures and other conditions in infants.