October 2004

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

VEIN ATTEMPT

Few physical tests accurately predict thrombophlebitis, but the cuff compression test (Lowenberg sign) sent in by Dr. Jerome Lebovitz in Pittsburgh, Pennsylvania, is at least reliable as a way to detect a difference in pain between the two calves. Blood pressure cuffs are wrapped around each leg and inflated simultaneously. Most healthy people tolerate up to 180 mm Hg pressure. In a calf with phlebitis or other tender spot, the cuff will elicit pain at 140 mm Hg or less.
 

A PAIN TO ELIMINATE

To relieve the pain of defecation for patients with anal fissures or inflamed hemorrhoids, Dr. Lane Molpus in Greensboro, North Carolina, recommends a box of 50 flushable, alcohol-free adult wipes saturated with 50 ml of 4% lidocaine solution, usually supplied by the pharmacist. These altered wipes ease pain immediately and improve hygiene, too.
 

RING RESCUE

From Torrington, Connecticut, Dr. Fowler White offers advice on removal of stuck rings. First, rig up something for the patient to hold on to with the hand elevated above the head. If the patient is wearing a watch, remove it, because even a loose wristband may interfere with lymphatic return. After about 10 minutes, lower the hand and lubricate the digit distal to the ring using liquid soap. If you are right-handed, grasp the ring with the left hand and pull while at the same time using your right hand to pull the skin proximal to the ring out from under the ring. Work slowly around while drawing the skin and always use a cloth between skin and finger for a better grip. Although painful, the trauma is trivial. If this usually successful trick fails, only the ring cutter will work.
 

RUNNING STITCH

Lacerations can be quickly repaired with a running stitch. Only two knots are needed, one at the start and one at the end. Dr. David Lemonick from Pittsburgh, Pennsylvania, places external stitches at a right angle to the long wound axis and subcutaneous stitches diagonally. Alternatively, the entire suture material can be buried if one is careful to take the same thickness skin bite each time. Self-absorbing suture material should be used, since removal of a running stitch could create abnormal tension on the wound.
 

CULTURE CAPER

In Summerville, South Carolina, Dr. Colby Grossman uses a technique to perform throat cultures with minimal gagging. The trick is to reverse the gag movement. In order to perform this, begin by turning down the light to relax the patient, whose eyes should be closed. Explain to him or her the process that follows. Gently rub underneath the mandible bilaterally, attempting to relax the musculature and the patient simultaneously. Ask the patient to stick out the tongue and then to pant like a dog. The throat culture is obtained during the panting process. As the soft palate rises during the panting, the normal downward palatal gag movement cannot happen. Dr. Grossman finishes the culture before the patient has a chance to obstruct his view. In a variation of this theme, I pant along with the patient to help with the timing of the swabbing.
 

HARD AS NAILS

To sew a laceration that is next to a fingernail, Dr. Brady Pregerson in Los Angeles, California, first performs a digital block with additional local anesthetic if needed. Then, either with the same needle or an 18- or 21-gauge needle, he drills holes through the nail that are large enough to allow passage of the suture material. Each hole takes 5 to 10 seconds to do. The sutures placed through the nail hold the laceration together firmly.
 

MAGIC WORDS

Hustle and hassle are not inevitable. "Please" at the top of orders and "thank you" at the bottom might get some real action for your patients. Thank you to Dr. Stephen Acosta from Portland, Oregon, and to Dr. Robert Fitzgerald, who taught him this parental advice when he was a medical student in Torrance, California.