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June 2002: Tricks of the Trade
Contributed by readers. Edited by Donald B. Middleton,
MD
Smooth Set-up for Adenosine
To push adenosine rapidly, you might want to try this technique.
Dr. Kumara V. Nibhanipudi of New York City sets up a system incorporating
two three-way stopcocks and two syringes—one containing adenosine
and the other containing normal saline (see photo). One prong of
the first stopcock is attached to the end of intravenous line tubing
and the other prong is attached to the hub of the catheter. The
prong of the second stopcock is inserted in the 90° port of the
first stopcock. The adenosine and saline syringes are inserted in
the other two ports of the second stopcock. This set-up allows a
rapid push of the adenosine, followed by clearance with saline and
administration of intravenous fluids as needed.
Flush Like a Butterfly
The trick is an old standby but it does work to clean out ear wax,
as Karen Criminger, FNP, of Blowing Rock, North Carolina, reminds
us. Cut the needle and distal portion of tubing off a #22 or #23
butterfly needle. Then attach the butterfly to a syringe and irrigate
the canal. The advantages of this technique are threefold: The tubing
is flexible, so it can fit into the narrowest external ear canal;
the syringe provides just enough pressure; and the tubing can be
maneuvered behind most ear wax blockades to create a flushing force
that extrudes the wax. But it does have the disadvantage of not
allowing visualization of the canal. Rarely, too, it can puncture
the eardrum, either with the tubing itself or with the jet of water
pressure.
Peritonsillar Precaution
When she has to aspirate a peritonsillar abscess, Claudia Radist,
RPA-C, of New York City, relies on an 18-gauge needle. To avoid
inserting the needle too far, she cuts half an inch off the tip
of the needle cap and places it back on the needle to act as a stop
guard. I would add that other measures that help this procedure
go smoothly include the liberal use of an anesthetic and a headrest
or similar support against which to rest the back of the patientšs
head.
Fluorescein First
To adequately evaluate patients presenting with eye complaints,
you may need to perform two actions: measure intraocular pressure
and use fluorescein to check for corneal abrasion. Accordingly,
Dr. John Leisey of Beavercreek, Ohio, warns that the tonometry measurement
should follow—not precede—the fluorescein examination.
Too many falsely abnormal fluorescein evaluations have occurred
after the tonometer has touched the cornea.
Turning to the Tourniquet
Prior to exploring and suturing a distal extremity laceration,
Dr. Leisey briefly applies a proximal tourniquet to control bleeding
during the repair. A blood pressure cuff inflated to above systolic
pressure works well for major lacerations. For lacerations on the
fingers, a piece of rubber tubing or Penrose drain does the trick.
Tea for Two (Feet)
Dr. Gus Garmel of Los Altos, California, submits another item for
the list of teašs helpful health effects: He recommends several
tea bags in a warm foot bath for patients who complain of "smelly
feet," explaining that tea's tannic acid content helps to reduce
or eliminate odor.
Dr. Middleton is vice president for family medicine education, UPMC
St. Margaret Hospital, and professor of family medicine at the University
of Pittsburgh. He is also a member of the Emergency Medicine editorial
board.
Emerg Med 34(6):2002
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