November 2001: Tricks of the Trade

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

PIECE OF CAKE

Adding to previous suggestions for ways to get children to generate a good respiratory effort--such as blowing out a penlight or activating a pinwheel--comes this contribution from Craig J. Huang, MD, of Norfolk, Virginia. Many children, Dr. Huang points out, will happily blow out the candles of a birthday cake, even if it is imaginary. A really big breath is elicited with instructions to blow out ALL the cake's candles.

MAN OF VISION

To get a child to open his or her eyes, C. Philip Carter, MD, of Clinton, Tennessee, asks the child to look into the light of the ophthalmoscope to try to see the doctor's eye. That instruction generally proves to be both intriguing and distracting. Most children respond by staying calm and keeping their eyes open. After a decent examination, they invariably report having seen the doctor's eye.

INFLIGHT COMFORT

For his cigarette-smoking patients who are about to take long airplane trips, Basil Rodansky, MD, of Lincoln Park, Michigan, adds one more item to his checklist (in addition to advising rest, good hydration, and moving about the cabin at frequent intervals). He prescribes nicotine patches for his patients to wear during the flight to reduce cigarette cravings. He also takes the time, he adds, to bring up the subject of the health implications of the habit and once again suggest quitting.

ALTERNATE ROUTE

It is no small task to treat a wound after a nail or other sharp object has punctured the sole of a shoe and pierced the plantar aspect of the foot. The literature suggests core sampling, exploration, or irrigation--all of which are fairly difficult to perform. Irrigation, in particular, poses its own set of problems because there is only one entrance and no exit.

Robert C. Becker, MD, of Merrill, Wisconsin, however, offers this approach. After cleaning around the wound, he infiltrates a site adjacent to the puncture with lidocaine. He inserts a large-bore needle (18 gauge will do) attached to a large saline-filled syringe through this site at an angle, aiming toward the bottom of the puncture tract. A little guessing about the depth of the wound is required. According to Dr. Becker, vigorous infiltration with the saline can often dislodge foreign material from the puncture site, such as bits of rubber or dirt. I would be concerned about too much irrigating fluid distorting the anatomy or worsening the pain, but this technique certainly sounds less irritating than core sampling or exploration. And, of course, instruct the patient to return for a follow-up visit, just to make sure there is no infection.

PUNCTURE PUNCH

To quickly débride a puncture wound of the foot after a patient has stepped on a nail, Ahmad Hakemi, MD, of Mount Pleasant, Wisconsin, suggests the following procedure. A thorough cleansing comes first, then an injection of local anesthesia. The next step is a punch biopsy with a large-bore needle following the nail track. This serves to remove the tissue around the puncture wound, which may contain fiber particles or other debris. I personally have not found that routine deep exploration helps much, but if infection threatens, débridement is best. Although Dr. Hakemi recommends against the use of prophylactic antibiotics, they are usually indicated in the face of potential infection.

NEW TWIST ON A SPLINT

To immobilize a wrist or metacarpal bone after a fracture or severe soft tissue trauma, Dr. Tom Bloom of Iowa City, Iowa, constructs a splint that is less restrictive than the regular sugar tong splint. He puts two 45º folds into the splint before wrapping it with an elastic bandage or taping it together (see illustration). The curved portion goes around the ulnar surface of the forearm, while the open ends are on top of and under the metacarpals. The elbow can then move freely, and the discomfort of wearing a splint is significantly reduced.