October 2002: Tricks of the Trade

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

 
OPHTHALMIC SOLUTION

From Yuma, Arizona, Dr. Rodolfo Gonzales has a unique remedy for dry mouth in patients with sicca or Sjögren's syndrome. Instead of saliva substitutes or sugar-free gum with their short-lived effects, Dr. Gonzales advises oral use of 2% pilocarpine eye drops (four drops, swish and swallow, three times a day). He says pilocarpine tablets cost too much and produce excessive systemic side effects. When using a drug for a non-approved treatment, strict documentation of informed consent and close observation for untoward effects are mandatory, of course.

 
HIP TO THE FRACTURE

To avoid missing a hidden hip fracture in a patient who has been treated for a humeral or other bone fracture, Dr. Gonzales warns that we should watch the patient walk before discharge from the emergency department or office. A limp may turn out to be a fracture that can be seen in a magnetic resonance image but was not visible on x-ray films.

CAPSULE CAPER

From Philadelphia, Dr. Arthur Newmark suggests keeping empty gelatin capsules on hand to help the patient who cannot swallow pills, is upset by bad-tasting medicine like prednisone or methylphenidate, or is worried about esophageal irritation. Irregularly shaped or oversized pills usually can be crushed or broken into parts to fit into available capsules. The slippery capsules are easier to swallow and less likely to hang up in the esophagus—or at least won't subject it to medication erosion if they do get stuck.

 
FETAL ERROR

From Brooklyn, New York, Dr. Mark Silverberg warns about the interpretation of pediatric blood gases. Some blood gas machines must be switched to the "pediatric" setting to avoid misinterpretations of fetal hemoglobin as erroneously elevated carboxy-hemoglobin (CO-Hgb). If the test report indicates high CO-Hgb when carbon monoxide poisoning is not part of the differential, remember to question the lab about this switch.

 
IT'S A GAS

Every medical student knows to look for the stomach bubble under the diaphragm to help identify the left costophrenic angle and left heart shadow on a chest x-ray. From Tulsa, Oklahoma, Dr. John Broughton suggests a method to enhance the bubble: ask the patient to drink a carbonated beverage before the radiograph is taken. I wonder if simply swallowing a few gulps of air might not be equally effective, though certainly not as tasty.

 
LEAVE NO DOUBT

Give an old-fashioned calling card printed with only your name and professional degree to each patient you see, advises Dr. Stephen Acosta in Portland, Oregon. That way everyone always knows exactly who and what you are. He even gives children his cards, sometimes even sticking one between an infant's toes for a bit of lightheartedness.

 
HEADS UP

The typical medical supply blanket is easy to clean but not substantial enough to warm a flea, even after heating—and it's amazing how many patients get chilly in both office and emergency department settings. So Dr. Edward Panacek in Sacramento, California, likes to use an extra blanket as a wrap around the top of the patient's head, wisely recognizing that much of the body's heat is lost through the scalp. This solution—or even just a warm hand laid on top of the head—also works for children who have caught a chill on a winter day.

 
SLICK SYSTEM

If you do a great number of procedures with set-ups from different personnel, Dr. Kent Carey in Tucson, Arizona, suggests that you type and laminate cards with your special instructions for each procedure to allow staff to know exactly what you need. For example, to do a lumbar puncture, his card lists the following requirements: "lumbar puncture tray, liquid Betadine, liquid alcohol (to remove Betadine), sterile 4x4s, 22- gauge 3.5-inch LP needle, page me when set up, return card to Dr. Carey." Assuming one can keep track of the cards, this system sounds efficient and simple.