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September 2002: Tricks of the Trade
Contributed by readers. Edited by Donald B. Middleton,
MD
RAPID SNIFF TEST
To screen for possible respiratory failure, especially in myasthenia
gravis or Guillain-Barré syndrome, Dr. Brady Pregerson in Beverly
Hills, California, asks the patient to sniff loudly. The ability
to sniff signifies adequate respiratory reserve, according to Dr.
Pregerson. If the sniff is weak, however, pulmonary function tests
should be obtained.
BICARBONATE BACKUP
Fortunately, as treatment of fever in children and arthritis in
adults has shifted away from aspirin, aspirin overdose has become
less common. When it does happen, the urine must be alkalinized
to aid excretion of salicylate, which is usually done by administering
intravenous bicarbonate. From Brooklyn, New York, Dr. Mark Silverberg
properly points out that potassium should also be given to those
who don't respond to bicarbonate alone. They may need supplemental
potassium to reduce the renal tubule's exchange of potassium for
hydrogen, which can cause the urine to remain acidic despite the
bicarbonate infusion.
SUTURE YOURSELF
In Los Angeles, California, Dr. Michael Leinwand touts a one-person
suture technique to both sew and cut. Typically, if an assistant
is not available, the physician opts to exchange the needle driver
for the scissors after each stitch. In Dr. Leinwand's variation,
the needle driver and scissors are held together in the same hand
to improve the efficiency of wound closures. This technique is especially
useful for suturing simple skin lacerations and closing surgical
skin wounds, because these procedures do not require long instruments
that would not be so easily contained in one hand.
To try it, place the scissors in the palm
of your dominant hand with the tips pointing in the ulnar direction.
Put your long finger through one of the rings and leave the other
ring free in your palm, next to your thumb. Hold the needle driver
in the same hand in the usual manner with thumb and ring fingers
in its rings (see photo, below left). Tucked neatly into the palm
of the hand, the scissors do not interfere with suture placement.
A placed stitch is instrument-tied in the usual fashion. The two
ends of the suture are then held up by the nondominant hand and
cut with the scissors by the action of the dominant hand's thumb
against the long finger. Supinate the hand, remove the thumb from
the needle driver ring, and use it to open and close the scissors
without placing it in the ring of the scissors (see photo, below
right). The thumb is then placed back into the ring of the needle
driver, and the process is repeated. This technique is very easy
to learn, is quite comfortable to perform, saves time, and does
not impede delivery of well-placed sutures.
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SATURATION OVER PRESSURE
To estimate O2 saturation of hemoglobin from arterial O2 values,
Dr. Fred Leonard from Tucson, Arizona, suggests the formula "40,
50, 60, 70, 80, 90" expressed as below:
40, 50, 60 PaO2
70, 80, 90 SaO2
So if the PaO2 is 50%, the SaO2 is 80%. In the absence of a diffusion
block, this formula should prove useful.
SIMPLE SOLUTIONS
It seems that everyone has their own favorite ear cleaning solution.
Dr. Michael Jaeger in Tivoli, New York, likes a 50% solution of
hydrogen peroxide in water. I like baking soda, one teaspoonful
per ounce of water. These home remedies spare us the expense of
ear wax dissolving products. Any other ideas?
Dr. Middleton is vice president for family medicine
education, UPMC St. Margaret Hospital, and professor of family medicine
at the University of Pittsburgh. He is also a member of the EMERGENCY
MEDICINE editorial board.
Emerg Med 34(9):2002
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