May 2006

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

Timing Is Everything

To improve the accuracy of the history when an event such as seizure or loss of consciousness is involved, Dr. Brian Rudick in Philadelphia puts the patient or the family members through a special drill. Looking at his watch, he asks them to replay the event in their minds and tell him when it is over. He records the elapsed time as an estimate of the event’s duration.

Watching Big Brother

From San Diego, Dr. Matthew Perl advises enlisting the help of a calm older sibling when examining a frightened child. He talks to and examines both children, moving from the older to the younger at each stage of the exam. He prefers spending time on the extra exam to wasting time on a struggle with the younger child. In a pinch, even a parent will do.

Nasogastric Probe

Dr. Rondalph Taylor in the Bronx, New York, finds that a nasogastric tube inserted into a posterior naris is a very good way to determine whether an unresponsive patient is organically ill. This maneuver often draws a verbal or motor response from the patient who is manifesting psychiatric illness or “playing dead.” Care should be taken to avoid nasal trauma or advancing the tube too far posteriorly, as gagging may induce troublesome emesis. Debate continues about the best way to sort out malingerers.

Scooby-Doo, I See You

Physicians who work with children need to keep current on youngsters’ favorite animated characters. In Castro Valley, California, Dr. Bernice Rodrigues lets the child stay on the parent’s lap as long as possible and creates a helpful distraction by looking for Barney in the ear or Sponge Bob in the throat. I knew there was a reason for me to watch TV.

Turbo Wash

To save the time and effort of filling a syringe for wound irrigation, Dr. Jesse Wells in Oakland, California, places the irrigation solution bag inside a pneumatic pressure infuser with an IV set attached to the bag and a three-way stopcock adjusted to allow the wound to be irrigated. But whenever feasible, he resorts to his favorite time-saver—sitting the patient by the sink and rinsing the anesthetized wound out for a good three to five minutes under the faucet.

Foreign Body Punch

To detect a nonvisible foreign body lodged in the skin, Dr. Kwei Quartey from Montebello, California, turns off the room lights and transilluminates the skin across the suspect area. Then, rather than launching a digging expedition, Dr. Quartey performs a punch biopsy—making sure that it is wide and deep enough to surround the foreign body—and closes the skin with a couple of sutures.

Magnet Magic

Following up on Dr. Gary Glassman’s tale of two magnetic earring backs stuck in place across the nasal septum (see emergency medicine, November 2005, page 6), Dr. Safia Rubaii in Tuba City, Arizona, reports that two pacemaker magnets held opposite each other outside the nostrils helped to temporarily magnetize a metal nasal speculum, allowing uneventful serial extraction of the earring parts. I wonder what the ICD-9 code is for that procedure?

A Technique of Note

Partly for the fun of it, Dr. Philip Bonanni from Rochester, New York, improves on the traditional technique for visualizing the posterior pharynx by instructing his patients to sing “Ahhh!” like an opera diva for as long as possible. A properly sustained, open-mouthed “Ah” allows for thorough observation without a tongue depressor.

Jelly Up

To insert an ear wick into a canal swollen by otitis externa, Dr. Ronald Raelson of Chesterton, Indiana, coats the wick with 2% lidocaine jelly. The jelly reduces friction and may also anesthetize the canal somewhat.

Trick of the Trach

When Dr. Ramsay Hasan in Kapolei, Hawaii, changes a tracheostomy tube, he puts a feeding tube down through the old trach tube to serve as a “guide wire” over which the new trach tube can be placed. Feeding tubes are cheap and easy to find and use for this purpose.