June 2004

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

NOT GETTING THE POINT

To reduce the incidence of headache after lumbar puncture, Dr. Mitchel Schwindt from Savage, Minnesota, does his lumbar punctures with a blunt-tipped, small-caliber (22 gauge) needle such as a Whiticare needle. Rather than cutting the meninges, this needle divides the fibers. Since the blunt tip does not easily penetrate the skin, Dr. Schwindt anesthetizes, cleanses, and drapes the lumbar region, then punctures the proper site with a 20-gauge, standard-bevel needle. He inserts this needle toward the L4-L5 interspace, then withdraws it and inserts the blunt-tipped needle into the puncture site. Sounds like some enterprising soul needs to do a post-lumbar puncture headache study on this trick.
 

BLOOD PRESSURE PRECISION (REVISITED)

From Boston, H. Robert Yeager, RN, properly points out a misstatement in the June 2003 trick about blood pressure measurement technique entitled "Cuff Capacity," which stated that "the center of the cuff" should be over the brachial artery. In fact, the center of the cuff's bladder should be positioned over the brachial artery. Most blood pressure cuffs have some sort of centering mark over the bladder to facilitate correct positioning, but with hypertension prevalence so high, we should all take care to measure blood pressure as accurately as possible. Our thanks to Nurse Yeager.
 

EYE STAIN

To avoid missing superficial corneal abrasions after application of fluorescein dye to the eye, Dr. Brady Pregerson in Los Angeles has the patient wash out the eye in the bathroom and then re-examines it. (Another way to get a dilute solution to view more superficial lesions is to run water over the fluorescein strip prior to putting a drop into the eye.) He also cautions that when examining both eyes, the one less likely to be infected should receive the dye first so that the fluorescein strip does not act as an agent of disease transfer.
 

SUCTION SOLUTION

To drain an abscess, Dr. Paul Rodon of Atlanta, Georgia, enlists the assistance of a low-pressure suction apparatus. The pus is easily extracted from most dermatologic abscesses and the wound is thus more thoroughly cleaned. Be on the lookout for nerves or vessels, Dr. Rodon warns.
 

TRAVELER'S FRIENDS

When a patient is planning to visit an area where traveler's diarrhea is common, Dr. Basil Rodansky of Lincoln Park, Michigan, advises taking acidophilus bacillus caplets two to three times a day throughout the trip to reduce the risk. Dr. Rodansky claims both clinical and personal experience (he always follows his own advice on this). Some expert sources support this measure, he says, in addition to the dietary and other precautions required to avoid waterborne agents of diarrhea. The advice seems suitable, considering the difficulties of antibiotic administration.
 

NO BELLY LAUGH

To get past the ticklish belly for a good abdominal examination, Dr. Anthony Russo in Hayden, Idaho, reminds his patient that one can't tickle oneself, then has the patient place his or her hand on top of Dr. Russo's palpating hand to move with him around the abdomen. He claims the power of suggestion reduces the patient's guarding against a deep but ticklish examination.
 

CHANGING THE REGIMEN

When Ms. Jane Gunter, PA-C, of Russell Springs, Kentucky, changes a coumadin dose, she prints a new label with strength, date, and directions to put on the old bottle. Her effort may sound time-consuming, but the reduction in patient phone calls seeking further clarification of simple verbal instructions more than makes up for the time needed to print or write labels. Of course, patient safety is enhanced by the update.
 

OPHTHALMOSCOPE DOUBLE DUTY

When evaluating a patient for possible collagen vascular disease, Dr. Timothy Bonine of Sandpoint, Idaho, uses an ophthalmoscope to look at the skin of the nail beds. A drop of microscope immersion oil cuts glare, and the red-free green lamp allows better visualization of the capillary bed. Normal capillary vessels appear as thin, hairpin shapes, while vessels affected by collagen vascular disease will have a thickened appearance with areas of dropout. This easily accomplished trick seems worth a try in making what is often a difficult diagnosis.