September 2001: Tricks of the Trade

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

THE MOORE MANEUVER

To readily reduce a shoulder dislocation, Richard B. Moore, RPAC, of Stamford, New York, first administers intravenous midazolam to provide adequate conscious sedation. He then places a sheet around the patient's torso so that an attendant can apply countertraction. In the case of a right shoulder dislocation, he flexes the patient's forearm to 45° and then places his left knee in the patient's right antecubital space (for a left shoulder dislocation, the right knee is placed in the patient's left antecubital space), places the appropriate hand on the patient's dislocated shoulder and on the wrist, and then exerts downward and outward pressure on the arm with his own body weight. At the same time, he abducts and externally rotates the arm to easily move the humeral head back into place. To perform these maneuvers, Mr. Moore actually stands up on a stretcher--making certain that the wheels are locked--at the patient's affected side. He says he usually does not feel any pop during the procedure, because the reduction is so well controlled that the final movement is not sudden.

ALL TOGETHER NOW

For the family that has been through a traumatic event together, such as a car accident, Dr. Ken Berniker of Vallejo, California, likes to perform a "group exam." He asks all present to simultaneously wiggle their fingers, move their wrists, and raise their arms, among other motions. Anyone professing any discomfort gets the individual attention necessary to make an accurate diagnosis. The whole process saves time and often produces some chuckles--particularly from the children. Dr. Berniker finds that in addition to providing a quick assessment of damage, the group examination breaks the ice without breaking the bond.

HIGH MARKS TO HIGH FIVE

When he evaluates a pediatric patient, Dr. D. Brady Pregerson of Beverly Hills, California, employs this technique to put the patient at ease and get a quick assessment of the child's condition at the same time. He says, "Give me five," and puts out his palm. This is an excellent way to gauge a child's alertness, mood, and motor responses. It generally elicits a smile as well, something all doctors like to see. Equally important, says Dr. Pregerson, it makes him smile, too.

RULE OVERTURNED

Dr. Pregerson also told EM why he disagrees with the conventional wisdom on preventing the headache that sometimes occurs after lumbar puncture. Most physicians instruct the patient to lie supine, but this position really does not make good sense. Just think of how gravity works, Dr. Pregerson points out, and you will see that the prone position is much more sensible. In fact, according to some reports, the incidence of headache among patients who assume that position is 10 times lower: 0.5% among prone patients versus 5% among supine patients.

GLUE WITHOUT A GLITCH

Applying acrylic glue to a laceration requires some expertise--particularly for wounds that are near the eye. For such a procedure, Dr. Stephen Farnes of Dallas, Texas, offers some expert advice. Topping his list of "acrylic aids" are a tuberculin syringe, an assistant, and antibiotic ointment. After crushing the glue vial, Dr. Farnes pierces the outer plastic shell of the tube with a needle and draws the glue into the tuberculin syringe. During the next 30 seconds, an assistant drips the glue onto the wound as Dr. Farnes uses both hands to hold it closed. To avoid the dreaded complication of gluing an eye shut, before beginning the procedure he forms a barrier between laceration and eyelid, using a small amount of antibiotic ointment.

JELLY DOES THE TRICK

When a young child has a laceration that must be anesthetized quickly, Dr. Vikki McKane of Albany, New York, applies lidocaine jelly to the wound. She first opens the wound gently, then spreads 1% lidocaine jelly inside, even before irrigating the cut. She claims that the wound is quickly numbed, thereby permitting easier exploration, cleaning, and subsequent injection of local anesthetic. I have found that at least 10 to 20 minutes of exposure is required--even with 5% lidocaine jelly. Still, in many instances this technique may be worth a try.