November 2002: Tricks of the Trade

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

 
COAXING FLUID FROM A JOINT

From Tucson, Arizona, Dr. Kent Carey reminds us of an old technique used to enhance the success of joint aspirations. When little fluid is present, he wraps the joint in an elastic bandage in a figure-eight, leaving a small window of bare skin over the intended site of the tap. Fluid is thus forced from other areas of the joint to the window to simplify the aspiration. A wadded washcloth under the elastic wrap on the side opposite the intended tap site helps even more. This technique works best on ankles, knees, and elbows but should be good for shoulders as well.

 
CHILD'S PLAY

To get a child to cooperate with an ophthalmologic examination, Dr. C. Philip Carter in Powell, Tennessee, approaches the child calmly, asking him or her to stare into the ophthalmoscope's light and try to find his eye. This searching task provides enough of a distraction to allow Dr. Carter to get a good view. Almost every child reports being able to see his eye, says Dr. Carter.

 
FEELING LOW AT HIGH ALTITUDE

A case sent in from Morristown, Tennessee, by Dr. John Horner illustrates the dangers of supposition. A couple vacationing at a resort in the Rocky Mountains developed severe headache, nausea, weakness, malaise, and dyspnea. After an unrevealing evaluation in the emergency department, a diagnosis of altitude sickness was made. Unfortunately, the true culprit was carbon monoxide poisoning, due to defective ventilation. The couple did not fare well. Dr. Horner's tips are that symptoms in multiple persons in the same quarters, worsening over time, should prompt a search for carbon monoxide poisoning. A cherry-red hue to venous blood would heighten that suspicion. He also recalls an old bedside diagnostic test to use when carboxyhemoglobin levels are not readily available: Mix 1 ml of blood with 10 ml of water, then add 1 ml of 5% sodium hydroxide. Oxyhemoglobin will turn brown while carboxyhemoglobin will turn straw yellow to pink.

 
NEEDLEWORK

In Beverly Hills, Dr. Brady Pregerson favors draining a subungual hematoma with an 18-gauge needle. With 30 seconds of back-and-forth twisting, he gets a good-sized drain hole. He puts a bandage over the hole to keep it moist so it will remain open and fluid will be drawn into the gauze. Just in case the hole dries and closes, he gives the patient a spare needle to take home.

 
NOT JUST JELLY

To further clarify her Trick on lidocaine jelly anesthesia for lacerations (EM, September 2001), Dr. Vikki McKane in Albany, New York, emphasizes that immediately after she applies the jelly she injects a local anesthetic through it into the wound, and only then cleans and explores the wound. She cautions that the lidocaine must be injected slowly-a critical point. Slow injection is by far the most important principle in minimizing pain from local anesthetic infiltration. I still find topical anesthetic jellies slow to work, requiring about 10 minutes to achieve significant effect.

 
SPECULUM SHEATH

To do a pelvic exam on a patient with collapsing, redundant vaginal walls, I have tried the trick sent in by Dr. Edgar Billowitz in Santa Fe, New Mexico, with only partial success. He covers the speculum with a latex glove finger tip, cutting open the ends to allow a view. For me the glove finger sometimes tears and other times I cannot see much anyway. A bigger speculum always helps. Readers who have further suggestions or data on this subject are encouraged to send them in.