May 2004

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

PINCH AN INCH

To distinguish a low pain threshold from true abdominal pain due to processes such as peritonitis, Dr. Bruce Adams from Ft. Sam Houston, Texas, pinches an inch of abdominal skin over a site such as McBurney's point and lifts it off the peritoneum. This pinching should not hurt, since the peritoneum is separate from the skin. He lets the skin recoil back against the peritoneum, which (like rebound from palpation) should hurt if peritonitis is present. Patients who complain about the initial skin pinch have low pain thresholds while those who complain only about the recoil probably have peritonitis.
 

V FOR VICTORY

The art of venipuncture is well known to phlebotomists but less so to today's young physicians. To reduce the chances of a vein rolling out of the way when attempting to place a heparin lock in the back of the hand, look for a convergence of two veins and insert the needle directly in the apex of the inverted V. Veins are anchored at these sites, and thus are more easily penetrated. Thanks to Dr. Dilip Unnikrishnan in Yonkers, New York, for the reminder.
 

WICKED SOLUTION

If you have no otic wicks available to treat otitis externa, getting antibiotic into the ear canal can be nearly impossible. For a good substitute, Dr. William Kranichfeld and Dr. Lisa Dewitt from Hialeah, Florida, suggest peeling the end off a cotton swab and twisting it tight to create a firm wick. Some ENT physicians make their own by tearing off a small bit from a cotton ball and twisting it around a wire, which they remove once the cotton is tight.
 

PORTABLE PERSPECTIVE

In Columbus, Ohio, Dr. B. A. Bronczyk carries a small hand mirror with him for assessing areas that are hard to view if the patient is seated or compromised in mobility. No more getting on the knees to see the backs of the calves or look for a heel ulcer. Dr. Bronczyk also suggests a small flashlight to improve the illumination. A hand mirror in every examining room makes good sense.
 

OUT OF THE LOOP

The nose of a child can hold all sorts of interesting objects. To get them out, Dr. Anthony Russo of Hayden, Idaho, bends the loop of a small white plastic ear curette to a 45º angle, flattens the long axis of the loop, and inserts it past the object while an assistant holds the child's head still. A slight upward twist and a pull usually gets the job done. I would not be surprised if someone were already marketing a nose loop.
 

SOFT SPLINT

In Patchogue, New York, Dr. M. G. Jacoby supports multiple layers of tube gauze as the splint of choice to treat a fractured finger. The thick gauze layers reduce movement but are more comfortable than traditional splints or strapping to an adjacent finger.
 

STUCK RING STRATEGY

Removing rings from swollen fingers is a common and often frustrating procedure that, if unsuccessful, can result in having to destroy a piece of jewelry. Unsuccessful attempts at removal often increase the associated swelling and result in even more discomfort. Over the years, Dr. Raymond Roberge from Pittsburgh, Pennsylvania, has found it helpful to establish a digital nerve block with short-acting, 1% plain lidocaine to eliminate the discomfort of manual attempts at ring removal. In addition, digital nerve block facilitates the use of other strategies that might otherwise cause the patient discomfort, such as immersing the finger in ice water to induce tissue shrinkage. Dr. Roberge claims the digital block is well tolerated and easily accomplished. After the procedure he makes certain to recheck the patient for strength, range of motion, and sensation.
 

EASING EYE IRRIGATION

Eye irrigation is often an uncomfortable, even painful experience. The anesthetic placed in the eye to numb it is often washed away in a matter of seconds. To prevent this problem, Dr. Michael Solis of Visalia, California, puts 1 ml of 0.5% tetracaine in every 100 ml of irrigation fluid. The constant infusion of anesthetic makes the irrigation tolerable to most patients.