May 2005

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

TETRA BEFORE LIDO

In Terrell, Texas, Dr. Amaha Hailey uses a few drops of a 3-ml bottle of 0.5% tetracaine solution for topical anesthesia for corneal injury. But rather than discarding the remainder, Dr. Hailey pockets the bottle for later application into open wounds to produce topical anesthesia prior to lidocaine infusion. He claims the tetracaine is usable for a couple of days. Although many claim that topical anesthetics like tetracaine help reduce the sting of lidocaine injection, I have found that one must wait 15 to 20 minutes for the drug to penetrate the tissue and that slow injection of the lidocaine, as an alternative, is almost painless. To each his own, in this case.

 

SALINE BUBBLE

To avoid using lidocaine for a sensitive patient who needs a large-bore intravenous line, Dr. Stephen Acosta of Portland, Oregon, notes that injecting 0.1 ml of sterile saline over a vein will anesthetize it.

 

ERSATZ SKIN HOOKS

To make skin hooks for retracting or aligning delicate tissues, Dr. Chris Dutra of Berkeley, California, pushes the cotton end of a cotton-tipped swab into the hub of a 20- or 22-gauge needle and uses a needle holder to bend the needle to the correct angle. I have always used the wooden end for fear that the cotton tip would slip out. Recently I have seen the needle simply left on the end of a Luer-Lok 3-ml syringe, which has flanges against which to retract that make it really steady.

 

THE RIGHT STUFF

After a nurse or assistant draws up an injectable substance like lidocaine into a syringe, Dr. John Wipfler from Peoria, Illinois, instructs him or her to put the original bottle of injectable beside the syringe, thus avoiding inadvertent injection of the wrong stuff.

 

SLICE OF ADVICE

From Charleston, South Carolina, Dr. Charles Gilman relays a tale about removing a sturdily constructed, thick-banded, and stubbornly stuck-on military class ring. Two manual ring cutters (the first of which broke) and some elbow grease finally resulted in a slice through the ring, but it still was stuck on the finger. Application of clamps on both sides of the ring with attempted traction to open the cut proved futile and ruined one of the clamps. The solution? Dr. Gilman slipped a cast splitter into the cut and opened it to stretch the ring enough to slide it off the finger, to the relief of patient, parents, and doctor alike.

 

STEALTH APPENDIX

"Don't forget about the retrocecal or otherwise unusually placed appendix as a cause of nonclassical abdominal pain," warns Dr. Basil Rodansky of Lincoln Park, Michigan. Pain from acute appendicitis can be lateral or posterior, mimicking other diagnoses. On rare occasions, a long appendix may even result in pain localized to the left lower quadrant. If pain precedes fever and vomiting, appendicitis should enter the differential diagnosis even with an atypical pain site. A computed tomography scan can often clinch the diagnosis.

 

STOPPING THE VEIN DRAIN

When he was a resident, Dr. Michael Harlan of Covington, Louisiana, learned to control vigorously bleeding varicose veins through suturing, an idea that required anesthetic injection and often didn't work to control a large leak. He proposes a different solution: acrylic glue. He first compresses the bleeding vein at each end with his fingers, then applies acrylic glue to the bleeding site. I find a pressure dressing over the top keeps trauma at least temporarily at bay while the hole heals.

 

LIGHT TOUCH

From Paulding, Ohio, Dr. Quang Le reminds us to warm up mirrored instruments or otoscope shields before use to reduce the risk of fogging during the examination. He warms his mirror under hot or warm water and always tests it against his own wrist before using it on the patient. Others warm a mirror on a light bulb, again testing it first before using it.