Monday, March 15, 2010

Everyone already knows this, right?: Hemeoccult cards, bedpan pelvic exams.

Not sure whether a hemeoccult card is (trace) positive?

Flip it over and look at the poo side.

Also: How to do a pelvic exam on a flipped-over disposable bedpan!

It is way, way easier than using the goddamned pelvic cart we have in my ER.  Wayyyy easier.  (A pelvic cart, for the uninitiated, is a rolling table with stirrups that, positioned at the end of a regular ER stretcher, turns it into a pelvic bed... once you fold out the top, and have the woman scootch herself down, and pull the stool out, and get all your whatsits in a row.)

But there's a catch to using the bedpan method: You *have to*, have to, have to, have the lady scoot her butt down so that her vag is *hanging over the edge* of the bedpan, which, incidentally, you should have positioned with the front side front (as if she were going to pee on it, again, but flipped... coronally).  Otherwise, you can't fit the speculum handle vertically across her perineum without its banging the bedpan.  You dig?

There you go.

Wednesday, February 3, 2010

Intubation trick, subclavian trick.

Tube trick!

When you intubate a patient, and you're not sure whether or not your tube is in the trachea, and the only stethoscope you have available just *sucks* and you can't hear breath sounds for crap, blow up and deflate the balloon on the endotracheal tube a couple of times, while palpating the trachea (basically, put your hand on the patient's anterior neck). If you can feel the balloon -- or, more likely, the friction of the balloon against the tracheal rings -- you know you're in position.


Subclavian line tricks!

1. This is revolutionary and yet ridiculous: Curve your needle, the needle you use to find the subclavian; I guess it's a long (2.75", say some of the websites I'm checking) 18 gauge. Point the bevel up (as always), then just put a very soft curve in it. I'm talking a *very* soft curve; you're not hockey-pucking it. Pretend you're bending the needle around, say, a very large (cylindrical) pickle jar. Great! *Now* find your landmarks -- 1/3 of the way into the clavicle from the sternum, and aim for the sternal notch, perpendicular to the long axis of the patient's body, and go. The curve of the needle will keep you fairly shallow, and therefore from dropping the lung.

2. Let's say you're called upon to insert a subclavian, and as you're advancing the guidewire, you meet resistance. The wire continues to feed, but you're just not sure of the positioning: Is the wire feeding down into the chest (yay!) or has it kinked, and now you're feeding into the jugular vein instead? Fear not! Pull the needle you've just inserted the guide wire through but leave the wire in place (so that the wire is the only equipment that remains in the patient). Then, take a flexible angiocath (there should be one over one of the needles -- I think it's the 20-gauge - in your triple lumen kit) and feed the angiocath over the wire. Then -- and this is scary -- pull the wire. Blood should continue to flow out of the angiocath, indicating that you're in a vein. More importantly, though, the angiocath is soft and flexible, and should travel in the direction of least resistance (down, not up). And! And now you can make sure your wire doesn't have any kinks in it. Reinsert the guide wire *backwards* (don't insert the flexible J-bit end, but the other side). Sometimes that J-shape curls up in the vein and it's too big for little people.

Ta-da! Pull the angiocath and proceed as you would normally. You can now be at least somewhat more secure that your line is heading where it needs to be. Plus, you haven't lacerated the subclavian with unnecessary guide-wire mucking.

Sunday, January 24, 2010

Regular Gastroenteritis Gives Really High WBCs

Don't panic. In fact, it helps you be sure of the diagnosis. More and more, I'm finding when I do a CBC on gastro to maybe rule out something else or something, white counts of 22-25,000 are not uncommon. Who knew?

Regular Gastroenteritis Gives Really High WBCs

Don't panic. In fact, it helps you be sure of the diagnosis. More and more, I'm finding when I do a CBC on gastro to maybe rule out something else or something, white counts of 22-25,000 are not uncommon. Who knew?

Thursday, November 19, 2009

Difficult IV Access Trick

Ok, they call you because they can't get an IV in someone. You think, What the hell? They couldn't do it, and I just started so somehow they think I can?

I suck at IVs, I sucked at them for a long, long time. Lately, it's been going better. One day it just suddenly got a lot easier.

But for the truly hard stick - here's my favorite tip. Get a towel and run it under hot water (not too hot to burn, but hottish).

Put the hot part of the towel on the place you want to stick - antecubital, hand, whatever. Leave it there for a few minutes.

This causes vasodilation - often a good vein will pop up, and if not, a bad vein will still be easier to stick.

It has the added benefit of calming things down a little. The patient has been stuck probably several times by an increasingly irritated nurse, and is probably increasingly irritated himself...the time that the towel sits there gives a little break for everyone to relax.

And - when really screwed - you can get a tiny IV from pediatrics. Unless you are in a serious resuscitation situation, it's probably fine. If people bitch about this, tell them that smaller IVs allow better blood flow around the cannula and are less likely to get infected.

What to do about Type 2 Diabetes and Hospitalization

You are admitting someone with type 2 diabetes and they come from home with a slew of the oral hypoglycemics - the metformin, sulfonylureas, whatever. You can't quite remember which one might cause lactic acidosis or which might drop someone into hypoglycemia.

Here's what you do: stop all of those drugs. Write on the orders for four glucose checks, and then write this chart:

Regular Insulin:
Blood Glucose:
<150 - no insulin
150-200 - 3 units
200-250 - 5 units
250-300 - 8 units
300-350 - 10 units
350-400 - 12 units
>400 - call physician

Your ward or ER might even have a stamp with this on it or a pre-printed sheet.

If you do a search on "sliding scale insulin" - you'll see that this approach is on the way out, considered bad by the experts because it "chases after glucose levels" rather than trying to keep them even. Your hospital MIGHT have a better protocol, but there isn't a standard one out there. And your goal is not, at this point, perfect glycemic control, but rather to not kill a patient. Most senior doctors trained with this kind of treatment. If your hospital has a better system or even a computerized one, or an endocrinologist who is interested in the subject, great. In fact, please share. But if not, you won't kill someone like this.

What to do when you need to give a drug, you don't know the dose, and don't have time to look it up

This happened to me the other night. A patient had dangerously high blood pressure, and legitimately had reasons she could not take most of your first line blood pressure drugs.

The blood pressure needed to come down, and fast, so I decided to give nitroglycerin under the tongue. Unfortunately, the particular department only stocked a type that I was unfamiliar with, and didn't know the dose.

Here's what you do: ask the nurse to show you the available pills. If you want to look like you know what you are doing, pretend like you want to see because you are weighing your options, or like you doubt that this department will really have what you want.

In this case, there were 3 different dose pills of the drug. The highest dose pill was 6 times that of the low dose one, hinting at a wide therapeutic window.

Then, use one pill of the very lowest dose there is. Unless it is a strange drug, a drug that requires a very slow titration to full dose, or a drug like digoxin, you will rarely go wrong. Since I saw that my lowest dose was 1/6 of the highest one, I figured that even if the one pill didn't work, I could easily add another. She was naive to this drug.

Sure enough, a few minutes after sublingual administration, her blood pressure was reasonable - not great, but she wasn't going to have a massive stroke because I didn't know what to do.

Remember, as scary as it is to mess with a drug you don't quite know about, if it's common, the lowest dose pill is probably taken by millions of people every day.