August 2001: Tricks of the Trade

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

REMEMBER THE THREE I'S

For physicians who are confronted with a patient in diabetic ketoacidosis (DKA), Dr. Mark Silverberg of Brooklyn, New York, suggests a mnemonic aid he calls the Three I's to remember the underlying causes of the disorder: infarction, infection, and insulinopenia. All patients in DKA should undergo electrocardiography and the appropriate tests that will detect or rule out myocardial infarction. Clinicians must also perform sepsis evaluation, especially for detecting urosepsis or gangrenous diabetic ulcer, and they should ensure that such patients are complying with their insulin regimen. Although not all-inclusive, this list does provide a great start.

EASING THE CHILL

The usual recommended treatment for acute ankle sprain is the application of ice during the first 24 to 48 hours, which can be a "chilling" experience for patients. Many of them are reluctant to dunk their feet into freezing water. To enhance a patient's compliance with treatment, Ms. Patricia Barreto, PA-C, of Visalia, California, recommends that the injured ankle be placed initially into a bucket or bowl of cold water. After the foot has become acclimated to the cold temperature, ice can be added, allowing for more prolonged tolerance and greater surface area coverage.

KITCHEN SCIENCE

Insect bites and stings often cause painful itching, and topical diphenhydramine works well to stop the itch. But for children, a commercial product containing the drug could be toxic when they touch the medicated wound and then put their fingers in their mouth. To avoid that risk, Dr. Gopi Rana-Mukkavilli of New York City makes a paste of baking soda and lemon juice and applies it to the insect bite. I wonder if anyone has done a double-blinded study on this technique. It certainly seems an innocuous way to alleviate pain and itch.

STICKY FINGERS

Dr. Marcus A. Crouther of Texarkana, Texas, offers a neat method for opposing the edges of a wound so that it can be closed with acrylic glue. Many patients--especially children--will not tolerate a forceps pinch, but you also do not want to glue your own fingers or a piece of latex glove to a patient's skin. And perspiration from the skin may weaken your grip as you try to close the wound. The answer? Apply tincture of benzoin to the fingertips of your gloved hand and allow it to dry. Now the edges of the wound can be pushed easily together with the gloved hand. Yet another advantage of this technique is that it does not leave benzoin on the patient's skin. The physician has only to remove the latex glove and discard it, making clean-up quick and easy.

ASPHALT BUSTER

Hot asphalt burns are especially unpleasant. For areas of the skin that have third-degree burns a sterile débridement procedure must be performed, with the patient under anesthesia. But for the removal of hot tar and asphalt from first- and second-degree burns, Dr. Konrad Widmer of St. Louis has a simple recipe. He recommends that solid shortening be applied, which becomes very soft at body temperature. Paired with facial tissues (several boxes may be needed), this approach allows easy removal of sticky road surfacing materials. Such routine measures as vaccination against tetanus and the application of topical protective antibacterial ointments are also required, as is admission to a burn unit when the injury is severe. As a postscript, Dr. Widmer adds this caveat: Don't even think of using industrial solvents to remove asphalt or tar from burned skin!

DIZZY IDEA

To rapidly elevate the legs of a patient having an episode of vasovagal syncope, Dr. Basil Rodansky of Lincoln Park, Michigan, does not waste time looking for a pillow. Instead, he simply places the fainted patient's feet up onto his own or an assistant's shoulders. If the patient happens to be on the floor, Dr. Rodansky or his assistant kneels to accomplish the same effect. The raised lower limbs quickly drain to promote the return of blood to the brain. This solution, observes Dr. Rodansky, comes in handy when performing minor surgical procedures on patients who are in a supine position. It also works well out in the field when nothing suitable is available to prop up a patient's legs.