August 2005

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

Anion Gap Analysis

Most physicians remember the MUDPILES mnemonic for the differential diagnosis of an elevated anion gap (Na⁺ - Cl^- + HCO^3-): methanol, uremia, diabetic ketoacidosis, paraldehyde, iron/INH, lactic acidosis, ethylene glycol, salicylate. But what if the anion gap is too low? Dr. Bruce Adams of Fort Sam Houston, Texas, suggests BLIMP CLAMP, for bromide, lithium, iodine, multiple myeloma (high IgG proteins), potassium excess, calcium excess, low albumin, magnesium excess, polymyxin B.

Vent-Friendly Forceps

To put a nasogastric tube into a sedated or unconscious patient on a ventilator, Dr. Patrick Martin of Hamlin, New York, recommends the McGill forceps. With a laryngoscope he checks landmarks and, remembering that the esophagus is posterior to the larynx, he advances the nasogastric tube with the forceps. A deflated stomach certainly aids respiration.

Tap Dancing

One of my old residents, Dr. Larry Novik in Fairfield, Connecticut, uses the technique of distraction like a master. To get children or skittish adults to cooperate during throat cultures, he tells them to tap fingers 2 through 5, quickly, on a stand beside the examination table. Then he places a bet, claiming that he can culture the throat faster than the patient can tap this sequence five times. He gets the tongue depressor on the tongue and the swab near the mouth and says something like, "Okay! Start!" As he is actually starting to swab the pharynx, he can usually finish before the patient finishes tapping. One should recall, however, the recommendation that the swab should touch the pharynx for at least 10 seconds, so I might alter his advice to make the count 10 sets of taps.

Poking the Pus Pocket

When faced with a paronychia, Dr. Thomas Crawford in Santa Clara, California, has the finger soaked in warm water for 10 to 15 minutes to soften the cuticle and skin around the nail plate. With the tip of an 11 blade held parallel to the nail, he gently elevates the cuticle off the nail plate, extends the area of elevation laterally and deeper, and is usually rewarded by the flow of pus. Dr. Crawford believes patients feel little pain with this approach.

No Hands Please

When he is worried that a neck trauma patient may have a cervical fracture despite plain films that are "normal" or difficult to interpret, Dr. Donald Correll in Jackson, Tennessee, looks for the "head in hand" sign. After removal of the cervical collar, the patient is instructed to move the head and neck slowly. If the patient used the hands to support the head or neck while moving, Dr. Correll reapplies the collar and orders a cervical spine CT scan. I am uncertain what the sensitivity or specificity of this sign is, but I am sure that all precautions to avoid missing a cervical fracture are warranted.

Parents Get A Grip

From Panama City Beach, Florida, Dr. Jimmie McCready suggests that the best way for parents to help hold youngsters still is to have a parent lie down on the table and have the child lie on top of him or her face up, allowing for easier blood drawing or intravenous line insertion. Parents thus deployed cannot faint, their anxiety is mitigated by a sense of being part of the process, and they really do help hold the child.

A Man Remeasured

Commenting on a "Trick" entitled "Measure of a Man" (EMERGENCY MEDICINE, Dec. 2004, p. 8), Brian Weiss, a medical writer from Pasadena, California, properly points out that a photocopy of a ruler may be inaccurate because the copier can magnify or reduce the ruler's true size. Such discrepancies may or may not matter in a given situation, but if you are concerned, you might instead get a paper tape and cut off and mark an 8- or 9-cm segment to attach to your identification badge.

Cutting to the Chase

When a patient's story begins to ramble, Dr. Brady Pregerson in Los Angeles starts his physical exam with the feet first. While listening to the story, after examining the pulses and joints, he checks for a Babinski response. This last maneuver is irritating enough to most patients to make them interrupt themselves to ask what is going on. After he replies with an explanation, Dr. Pregerson gets the opportunity to ask a more direct question that will elicit the necessary history.