Trick of the Trade: Massaging a mandibular dislocation back in

Continuing the theme of mandible dislocation tricks (protecting your thumbs, post-reduction stabilization), Dr. Daniel Gromis from Advocate Christ Medical Center describes a novel reduction technique, based on the Cunningham shoulder reduction technique using muscle relaxation.


Dr. Rob Orman of ERCast fame had posted this initially on his site, and it's too awesome of a trick for me not to include in my Tricks of the Trade series.

Trick of the Trade:

1. Massage the masseter muscles before and during the procedure
2. Apply rotational force (rather than downward and posterior force) on mandibular ramus

The rotational approach to reduction is similar to the wrist pivot method described in the Journal of Emergency Medicine (thanks to Dr. Graham Walker for the reference).

Reference
Lowery LE, Beeson MS, Lum KK. The wrist pivot method, a novel technique for temporomandibular joint reduction. J Emerg Med. 2004 Aug;27(2):167-70. Pubmed . 

Welcome to the blog team: Dr. Javier Benítez

It is with great pleasure that I introduce the newest member of the Academic Life in EM blog team -- Dr. Javier Benítez. He is an extremely active EM Twitter educator (@jvrbntz), who can efficiently convey key concepts in 140 characters or less! Got a short attention span? Follow Javier's Twitter feed.

Currently, Javier is posting "Question of the Day" tweets, which reference the Paucis Verbis pocket cards on this site. It is a perfect example of a bridge between blogs and Twitter for medical education. He'll also be posting on the blog as well.

Here's a short blurb from Javier:
I went to medical school in SUNY Downstate in New York City where I became interested in emergency medicine and critical care. My other interests include medical education and social media as a tool for medicine. My goals are to practice medicine in an academic institution where I can work closely with medical students and residents. I have used Academic Life in EM as a learning tool and it has proven to be quite effective. It’s an honor to take part on this blog. My hopes are to inspire and educate other learners about the wonderful world of emergency medicine.

Video: A primer on social media (ICEM 2012)

At the recent International Conference in Emergency Medicine (ICEM), the professorial Dr. Mike Cadogan (Life In The Fast Lane) gave a talk on Social Media in Medicine. Thanks to Dr. Andy Neill (Emergency Medicine Ireland) for recording this.

Definitely worth a viewing.


Also take a look at Joe Lex's site FreeEmergencyTalks.net, which now has many podcast recordings from the ICEM conference.

Paucis Verbis: D-Dimer test

D-Dimer: To order or not to order?

That's the question when it comes to risk stratifying a patient for a pulmonary embolism with a low pretest probability. One should consider confounding conditions which may cause an elevated D-Dimer level. There's always confusion about what may cause an elevated D-Dimer besides venous thromboemboli. So I thought I would make a pocket card as a reminder.

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

References

Wakai A, Gleeson A, Winter D. Role of fibrin D-dimer testing in emergency medicine. Emerg Med J. 2003 Jul;20(4):319-25. Pubmed. Free article

Trick of the Trade: Photograph slit lamp findings

How do you capture the image of the eye on slit lamp exam either for the patient or your ophthalmology consult? It's often easier to show someone a photo rather than trying to describe that atypical dendritic lesion, degree of corneal edema, or pattern of corneal abrasion.

You, however, don't have the expensive camera attachment (nor a SLR camera for that matter).

Image from eyephotodoc.com

Trick of the Trade:

Take a photo with your mobile phone camera

• Position the patient comfortably at the slit lamp. 
• Using the viewfinder lens, focus the image of the patient's eye.
• Step away from the slit lamp without moving the slit lamp or the patient.
• Place the camera lens from your iPhone (or other mobile phone camera) up against the viewfinder where your eye was. 
• Take the photo. 

There are several commercial iPhone adapters which help stabilize the iPhone (see second photo above), but I get reasonable high-quality images without them.


Thanks to Dr. Matt Silver (Kaiser San Diego) for the tip and Dr. David Duong for being the eye model.

Tips from 2012 Hot Topics EM Conference

This week, UC Davis is hosting a great conference in Maui called Hot Topics in Emergency Medicine. I've embedded a Twitter widget so that you can read some tips from the week featuring the likes of Drs. Sokolove, Kirk, Bair, Rose, and yours truly. The hashtag is #HotTopics2012.

Trick of the Trade: Converting % to mg/mL

Medication error is something that we all fear in Emergency Medicine and do our best to avoid. Here's a scenario and simple approach for you, provided by Zlatan Coralic, PharmD (Assistant Clinical Professor in the UCSF School of Pharmacy).

You are an emergency physician working in an underserved country. You are presented with an asthmatic kid with severe retractions and tight wheezes. Multiple nebulizers and corticosteroids have failed. You want to try some magnesium sulfate before risking intubation in a place with no reliable access to ventilator equipment. You know the dose should be 1 gm IV over 20 minutes.

A local finds this for you. What does 50% mean?!

Trick of the Trade:
Add a "0" to the % value to get a mg/mL concentration

Examples:

Trick of the Trade: Removing a tungsten ring

A patient presents with a tungsten ring on their injured finger and is unable to remove the ring. Tungsten rings are unique in that ring cutters can't even make a scratch in them. There are even anecdotes of firefighter equipment not being able to cut off these "unbreakable" rings.

Trick of the Trade:
Use a vise grip wrench

While unscratchable, tungsten rings are, however, very brittle and not malleable. Gently apply firm compression using an adjustable vise grip (borrow from your hospital's electrical or engineering department). This will fracture the ring. Carefully collect the pieces, which may have sharp edges. The YouTube videos below interestingly were made by tungsten ring retailers. Thanks to Dr. Gregg Miller (San Joaquin Community Hospital in Bakersfield, CA) for this tip.

(start at the 1:00 mark to skip ahead to the important part)

Happy 4th of July weekend

Happy fourth of July weekend!

Enjoy this 30 second video of a 15-minute fireworks show in San Diego that mistakenly launched all at one time. 

Wow.

Trick of the Trade: Unblocking the obstructed IV line

A patient's PICC line becomes obstructed and presents to your ED for care. She is using it for chronic antibiotics for osteomyelitis. You are unable to aspirate and flush it with saline using a 10 cc syringe. 

Trick of the Trade:
Flush the line with a smaller (3 cc) syringe

Do you remember Pascal's Principle from your high school physics class? I vaguely recall it, but never thought it'd be of clinical importance. Thanks to Dr. Matt Silver (San Diego Kaiser Permanente Medical Center) for this tip, which also applies to flushing any clotted peripheral line.

Use a saline filled 3 cc syringe to flush the line. Generally, it takes very little force on the plunger. No need for a heparin flush. No need for diluted thrombolytic. 

Pascal's principle explains the physics behind it.  You'd think that a larger syringe would transmit greater force. Not true... a small-volume syringe exerts greater pressure per force applied to the plunger than a larger syringe.  If it doesn't work after positional maneuvers and a 3cc flush, the line is likely unusable.