August 2002: Tricks of the Trade

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

 
OUCHLESS TAGS

To remove small unwanted or irritating skin tags, Dr. Bruce Becker from Bloomsburg, Pennsylvania, touts the merits of a quick clip of the slender stalk without the need for local anesthetic. The tag is lifted slightly with forceps, then quickly snipped with scissors at the base, a generally painless and well tolerated maneuver. If necessary, a dot bandage usually is enough to control bleeding. I usually clean the base of the tag with Betadine prior to the trim to reduce the risk of infection.

 
PATELLAR FRACTURE LOOKALIKE

In the setting of acute patellar trauma and pain, warns Dr. Becker, a bipartate patella can mimic a fracture. The distinguishing features are the vertical nature and smooth sclerotic margins of the two-pieced patella. This normal variant is also usually bilateral, so an x-ray of the other knee often settles any debate.

 
DIGITAL BLOCK TECHNIQUE

From Beverly Hills, California, Dr. Brady Pregerson reports that a digital block is best accomplished via a dorsal approach in the web space, with a small injection into one of the dorsal nerves before advancing the needle to the volar surface to anesthetize the ipsilateral volar nerve. Because four nerves must be anesthetized, at the 2-, 4-, 8-, and 10-o'clock positions, I like to make one injection at 2 o'clock and, without withdrawing the needle, go to 4 o'clock along the side of the finger or toe, then redirect the needle across the top of the digit to the other side's 10 o'clock position. The second needle insertion into the other side of the digit's dorsal surface is then less painful. As Dr. Pregerson points out, injecting while withdrawing the needle is a bad idea that may result in squirting your own eyes or skin if the tip escapes from the patient's skin.

 
POISON CONTROL CHRONICLE

A poison control center is a tremendous asset to any emergency department. To save time with the next poison victim, Ms. Kim Gracey, RN, in Forks, Washington, files all the printouts generated by her department's queries to their poison control center, alphabetized and indexed, in a reference notebook. This gives the team a basis for action that can be initiated while they await the very latest information from poison control for each case. The entire book is reviewed and updated periodically and new protocols specific to medications are added as they are received. Of course, a copy of the relevant management protocol is placed in each patient's chart.

 
MR. FIX-IT

To replace that often missing earpiece on a stethoscope, Dr. Basil Rodansky from Lincoln Park, Michigan, wraps a wisp of cotton from a cotton ball around the tip of the metal tube and covers it with three to four layers of tape, being careful not to cover the opening. Others have suggested that the rubber stopper from a blood collection tube with the center cut out works extremely well. In any case, with the metal tip covered, at the very least the other earpiece still functions well acoustically.

 
WALL WITH A VIEW

To better illuminate an underexposed chest x-ray, Dr. Rodansky holds it against a white wall, turns out the overhead lights and shines a flashlight or procedure lamp on the film. He finds that the light reflected off the wall improves the radiograph's clarity, making it easier to read and avoiding the need for repeat films.

 
ONE-TWO PUNCH

To treat a difficult case of acute labyrinthitis, Dr. Carl Werne in New York City prefers a combination of droperidol and fentanyl, available commercially as a mixture containing 1.25 mg and 25 mcg, respectively, in 1/2 ml, or double those amounts in 1 ml. Although less potent medication is available for this illness, the severely compromised individual may do well with droperidol and fentanyl as initial therapy.

 
DIETARY REINFORCEMENT

From Yangon, Myanmar, Dr. Khin Maung Aye suggests that we can reinforce the importance of a correct diet in diabetes mellitus, hypertension, and other conditions by providing patients with dinner plates imprinted with menus or pictures of appropriate meals. If that's too tall an order, place mats might be an alternative worth looking into.