July 2002: Tricks of the Trade

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

 
STICK THAT SPLINTER

To remove a splinter that has become lodged entirely under a fingernail with no portion of it protruding, Dr. Khin Maung Aye of Yangon, Myanmar, inserts the tip of a sterile 23- or 25-gauge hypodermic needle directly into the end of the splinter, with the needle roughly parallel to the nail plane. Then he lowers the hub of the needle, which thrusts the needle's tip toward the nail edge, dragging the splinter along with it. As he completes this motion, the splinter comes out along with the needle. Dr. Aye describes his technique as "simple, painless, and usually successful," and always tries it before resorting to a surgical procedure.

 
PHOTOGRAPHIC MEMORY

In Brooklyn, New York, Dr. Mark Silverberg checks for a subtle change in a patient's facial appearance in two different ways. He asks a family member if any change, like a droop or swelling, has been noticeable, and he examines a recent identification photo, like that on a driver's license. I have found the photo idea particularly useful in diagnosing changes such as the pigmentation that occurs with Addison's disease.

 
THE FOURTH 'I'

To the "Remember the Three 'I's" trick (EMERGENCY MEDICINE, August 2001) for the diagnosis of illnesses underlying diabetic ketoacidosis (DKA), Dr. Nicole DeIorio in Portland, Oregon, adds a fourth "i": infant. She reminds us that women of childbearing age with DKA (or for that matter, any other unexplained new illness) should be checked for pregnancy. In case you have forgotten the other three 'I's, they are infection, infarction, and insulinopenia.

 
TOO COLD FOR COMFORT

Commenting on another trick from that same EMERGENCY MEDICINE issue, Dr. Vijay Chowdhary of Romney, West Virginia, advises that immersing an acutely injured ankle in a bucket of cold water to allow acclimation before adding ice ("Easing the Chill") might prove too painful for the patient to tolerate. In my own experience with an injured leg, icewater was invaluable both for pain relief and control of the swelling. Nevertheless, I agree with Dr. Chowdhary that this technique is not for everyone. Most sources recommend icing for no longer than 15 minutes at a time.

 
THE RIGHT DOSE OF GLUE

Someone needs to invent a better delivery system for acrylic glues. To avoid unintended runover, Dr. Rodney Cowans and Ms. Mary Paul, RN, in Arlington, Virginia, crush the acrylic glue tube and squeeze the glue into its storage packet. Then they siphon up the glue with a pipette from a glucometer tray. (I suspect hematocrit tubes would also work.) This facilitates squeezing a small amount onto the opposed edges of the laceration to create a perfect, clean bond. Sounds like a technique worth trying to avoid the all-too-common glue mess.

 
RECTAL RELIEF

When faced with a herniated L5-S1 disk that has caused anal dysfunction with severe, painful myospasm, Dr. Basil Rodansky in Lincoln Park, Michigan, thoroughly chills and lubricates a rectal tube and inserts it through the anal sphincter to relieve the spasm and reduce rectal distension by allowing for the release of flatus. Dr. Rodansky warns that the tube may need to be removed to permit defecation, then subsequently reinserted until definitive treatment with surgery or spontaneous improvement occurs.

 
TUBE B OR NOT TUBE B?

To deal with postprandial formula or gastric juice leak from a gastrostomy tube stoma, Dr. Gerard Landais and Ms. Joyce Young, RN, from Dix Hills, New York, recommend switching to a smaller gastrostomy tube. Just be sure to wait 15 to 20 minutes after removing the original tube to allow the stoma to shrink before placing the smaller tube.

 
VITAMIN E FOR DYSURIA?

Vitamin E has been proposed as a cure for innumerable problems. Now, Dr. Martha Saavedra of Silver Springs, Maryland, tells us that 400 IU of vitamin E from a punctured capsule can help to correct dysuria when applied around the urethral opening. Because vitamin E cream does have soothing properties, it is plausible that this unusual advice may benefit some patients.