June 2006

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

AUSCULTATE THIS

It can be remarkably difficult to get a patient to take a deep breath, in and out, mouth open, without accompanying vocalizations. From Burlington, Vermont, Dr. Amy Siegel reminds us of an old method to get that deep inspiration and expiration: Tell the patient to cough. The inhalation is usually clear and full, and the cough can often reveal wheezing that would not be audible otherwise.

MORE CHEST TECH

To eliminate upper airway noise during lung auscultation, Dr. Philip Bonanni in Rochester, New York, tells his patient to bite down on a tongue depressor held sideways, not flat, between the front teeth. The depressor keeps the mouth open, making it likely that any noises heard are truly from the lungs.

USE THEIR IMAGINATION

Hoping that subtle hints may help smokers quit, Dr. Basil Rodansky of Lincoln Park, Michigan, uses militaristic terms when he advises patients to stop their health-damaging habits. He speaks of “victory” over the “enemy”—cigarettes—and helps his patients to develop “strategies” to end the truly life-threatening “conflict.” I often suggest to overeaters that too much food is a “slow poison” that they must avoid. Perhaps somewhere there is some evidence that how we speak to patients about habits matters. In the meantime, thematic word choices may work to our advantage and theirs.

OFF WITH ITS HEAD

If a nail gun injects a nail though a hand or foot, the case-hardened head must be cut off prior to pulling the shaft through the wound. Dr. Ronald Raelson in Chesterton, Indiana, finds a ring cutter the best tool for this job.

NOT SKINNING THE SKIN

To hold a dressing in place on an elderly patient with thin, friable skin, Dr. Brady Pregerson in Los Angeles favors burn net over tape. Burn net is less likely to tear the skin when it is removed.

BRIGHT IDEA

To facilitate placement of an intravenous line in an infant, Ms. Kim Casagni, APRN, of Litchfield, Connecticut, has an assistant hold the baby’s arm still while shining an otoscope or other focused bright light upward through the palm or wrist to outline the veins. She cautions that some otoscopes get hot, so I would suggest that a speculum may help reduce the risk of a burn.

TROUBLED WATER

The most commonly accepted method for confirming placement of a nasogastric tube is to blow air into the tube and listen for borborygmi over the gastric area. Another method espoused by Dr. Ariel Marks in San Carlos, California, is to place the end of the tube coming out of the patient’s nose into a cup of water and observe the surface of the water. If there is rise and fall of the surface with respiratory effort, the tube is in the lungs. If not, it is appropriately placed in the stomach.

EXCUSES, EXCUSES

At the end of his initial assessment—especially at night—Dr. Gus Garmel from Los Altos, California, routinely asks his patients if they will be needing an excuse note for work or a verification of their visit or treatment. He finds that this helps relieve their stress, since they need not remember to ask for the paperwork, and that they perceive it as a gesture of kindness and empathy. From an efficiency standpoint, this is the best time to deal with the documentation issue, says Dr. Garmel, rather than going back to the patient to address it later or putting nurses in the position of having to search for him to get it done at discharge time.

VAL-SOLVE-IT

To avoid puncturing the lung when placing a line in the subclavian vein, Dr. Adan R. Atriham in Covington, Tennessee, asks the alert patient to perform a Valsalva maneuver, which increases the size of the vein. His favorite method of getting the patient to perform the maneuver is to have an assistant gently push on the patient’s abdomen while telling the patient to push back with the abdominal muscles. I sometimes ask the patient to pretend to initiate a sit-up. While this maneuver is extremely useful to expand the subclavian vein, one must be ready to insert the line quickly because most patients are unable to hold their breath for a prolonged period of time.