November 2006

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

WHAT A PAIN

To judge the severity of a patient's headache, Dr. Ramsay Hasan in Honolulu, Hawaii, avoids asking, "Is this your worst headache ever?" Instead he asks, "When was the last time you had a headache like today's?" An answer of "never" prompts concern about the possibility of a serious underlying condition such as subarachnoid hemorrhage. Anything less is probably not worth tracking down.

SPECULUM TECH

Dr. Preeti Jois-Bilowich in Riverview, Florida, emphasizes the importance of pelvic floor muscle relaxation to ease the insertion of the speculum for a pelvic exam. Asking a patient to "push down like you're going to have a bowel movement" helps. Dr. Jois-Bilowich also suggests that placing a GC/chlamydia probe into the cervix and leaving it there until you are finished doing the wet prep swab will reduce the time required to complete the exam and get you a better specimen.

DON'T KEEP A COOL HEAD

To keep his stethoscope diaphragm always warm and ready, Dr. Sody Naimer in Goosh Katif, Israel, stores it on top of his office computer monitor. It is held in place by an alligator clamp glued to the side of the housing, which positions the diaphragm directly over the monitor's hot air vents. When there is no heat-emitting appliance handy, one should always remember to warm the stethoscope head in one’s washed palm prior to auscultation.

LIGHTS OUT

When treating patients with painful injuries or conditions, Dr. Gus Garmel of Santa Clara, California, often will turn the lights off in the room as he leaves, an action that seems to help reduce the patient's suffering.

COTTON TO IT

To treat an auricular hematoma, Dr. James DiStefano in Stillwater, Oklahoma, preps the ear, anesthetizes it with vapo-coolant, then drains the hematoma with a 20-gauge needle and syringe. All pretty standard up to that point—but then he covers the area with cotton strips dipped in colloid. The strips form a "cast" over the area as the colloid evaporates to prevent fluid reaccumulation. The cotton stays on for about a week.

MUCUS BUSTER

When a chronic home oxygen therapy patient on a nasal cannula becomes unable to breathe nasally due to mucus congestion, Dr. Michael Hagues from Fortson, Georgia, orders an acetylcysteine high-flow nebulizer treatment. He states this treatment helps to prevent hospitalization. Follow-up with mucolytics like saline nose spray is important. I wonder if oxymetazoline might also help. Acetylcysteine tastes bad and can cause rhinorrhea, so some caution is advisable.

STICKY ISSUE

Regarding the Trick entitled "Acrylic Closure" in the July issue, Dr. Merrill Chandler in El Sobrante, California, notes that acrylic glues are intended only for surface application, not to be injected directly into lacerations. I would wager that some glue almost always ends up in the wound, but agree that the intent is for superficial use. Thanks to Dr. Chandler for the heads-up. Any other voices of interest?

MOTHER'S LITTLE HELPER

Liquid diphenhydramine makes a good home topical anesthetic. In Beverly Hills, California, Dr. Lawrence Adler advised a parent to try it on a screaming child who had managed to get a plastic bottle top stuck on her tongue. A few squirts (or in other cases, a few ml) on the tongue dulled the pain long enough for the parent to get the child’s mouth open and the top removed, avoiding a trip to the emergency department. Diphenhydramine also works for cuts and sores in the mouth.

WEIGHTY IDEA

From Russell Springs, Kentucky, Ms. Jane Gunter, PA-C, reminds us that we can weigh an obese patient (350 lbs or more) using two scales, one foot on each. This technique is not entirely accurate and takes some skill to balance the two scales at once while weight may be shifting, but it gives a close approximation.