M2E Too! Mellick's Multimedia EduBlog
E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.
By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.
Monday, June 27, 2016
Multiple methods are touted for reducing anterior shoulder dislocations, and every emergency physician seems to have gravitated to one or two methods that he uses routinely. Why someone prefers one technique over another is not clear, but the factors for technique selection seem to be training, ease of application, and prior successful experiences.
Every reduction procedure will have some degree of applied rotation, torque, and traction, and pain is a common and unavoidable theme. Unfortunately, not all shoulder reductions are created equally. Variations in human anatomy, time duration of dislocation, and the actual location of the humeral head relative to the glenoid fossa will contribute to the reduction technique selection process. Consider the worst-case scenario of the intoxicated weight lifter who presents after dislocating his shoulder many hours earlier.
Our attempts to overcome the serious muscle spasm holding the humeral head in its newly found location involve rotational torque, traction force, leverage maneuvers, relaxation techniques, and medications. Unfortunately, some reductions will still require a visit to the operating room and general anesthesia. And some shoulder dislocations can be successfully reduced without pain and muscle-relaxing medications, but those are less frequent and are usually performed immediately after the dislocation event.
Some procedures are definitely more expedient than others and how busy the emergency department is at the time of presentation may determine the method. Those are the procedures that simply lets the patient reduce himself while you are seeing other patients. On the other hand, a procedure like the traction-countertraction technique requires procedural sedation, more than one operator, and prolonged force, and it ends up being an endurance contest between the patient and the clinicians. The Stimson technique comes to mind when I think of expedient shoulder reduction procedures. The patient lies prone with the affected extremity hanging off the edge of the bed with 10 to 15 pounds of weight attached while the emergency physician continues managing the emergency department.
But now the Davos Technique for anterior shoulder dislocation reductions enters the scene. The technique was described recently in The Journal of Emergency Medicine. (2016;50:656.) It is known as the Davos technique because the physicians who first described it worked at Davos hospital in Switzerland. In reality, this technique has been around for a while, and was first described in 1993. (Z Unfallchir Versicherungsmed 1993;Suppl 1:215; Helv Chir Acta 1993;60[1-2]:263.) Nevertheless, it has never gained traction until now, if you'll pardon the pun. The Davos technique has been described as a nontraumatic, patient-controlled, and auto-reduction technique that does not require the use of anesthesia. (J Orthop Trauma1997;11:399.) It is used only for anterior dislocations, and has a reported success rate of 60 to 90 percent. (J Emerg Med 2016;50:656; J Orthop Trauma1997;11:399.)
The reduction procedures steps are described as:
- Standard pain and muscle relaxation medications can be used for these patients.
- The patient sitting on the gurney holding the injured extremity with the other hand is asked to flex the ipsilateral knee as much as possible.
- The physician assists the patient to place both hands in front of the flexed knee.
- The hands are then tied together using an elastic band at the wrist joint, not the fingers. (This allows the patient to avoid crossing the fingers, possibly increasing muscle tension.)
- The elbows should be kept close to the thigh to assist muscle relaxation.
- The physician or nurse sits on the patient's foot and may help stabilize the wrists against the anterior tibia.
- The patient is instructed to lean his head back and to let his shoulders roll forward (shrug), extending and relaxing all the muscles. The neck extension exerts a constant traction on the injured shoulder, and the dislocation is reduced without any additional maneuvers.
- Once reduction occurs, the usual and standard post-reduction interventions, such as radiographs and sling application, are performed.
- I could not independently confirm the information, but this method has reportedly been used for more than 20 years by US Navy Seals and US Marine Corps Reconnaissance. When shoulder dislocations occur during fast boat recovery, they go to the back of the Zodiac or combat rubber reconnaissance craft to reduce the dislocated shoulder using this technique, among others. (Personal communication.)
I would rank shoulder reduction techniques from greatest to least use of required force in this order:
9. Traction-countertraction technique
8. Stimson technique
7. Milch technique
6. External rotation technique
5. Spaso technique
4. Fares technique
3. Scapular manipulation
2. Davos technique
1. Cunningham technique (Read an article about this method in the June 2011 issue of EMN at http://emn.online/1OkBjFn.)
Two of these techniques can potentially be accomplished while the emergency physician continues managing the emergency department. Of course, any medicated patient still requires an emergency nurse carefully monitoring the reduction. Nevertheless, traction forces are set in motion by the Stimson and Davos techniques and don't necessarily move along faster with the physician in the room. Even though the Davos technique requires someone sitting on the patient's foot and stabilizing the bound wrists, it probably doesn't have to be the physician. Nevertheless, for safety reasons a member of health care team, not a family member, should fulfill this role.
Watch a video of the Davos technique being performed.
Watch a second video showing 10 other ways to reduce a dislocated shoulder.
Thursday, June 2, 2016
I have serious issues with the current management recommendations for fingertip felons. I hate the thought of blindly "slicing and dicing" fingertips as treatment. I agree that fingertip abscesses should be drained, but I really question whether current approaches are the best. Thankfully, the really aggressive techniques of the past such as the through-and-through, hockey stick, or fish mouth incisions are no longer recommended. Currently, the unilateral longitudinal approach and the volar finger pad longitudinal approaches are recommended in textbooks. Unfortunately, even these recommendations are based purely on consensus and have almost no supporting evidence-based literature. The research is essentially nonexistent, and these treatment recommendations come from consensus opinions based on clinical experience. (J Hand Surg Am 2012;37:2603.)
It's possible, however, that even these incision and drainage techniques may be unnecessary in a large percentage of these infections. The problem is that ultrasound adapted to avoid near field acoustic distortion is not being used consistently. Documentation of an abscess clearly justifies an intervention. It's entirely possible, however, that a simple large bore needle aspiration of the abscess may be the only intervention needed in addition to appropriate oral antibiotics. I agree that these infections are a compartment syndrome of the finger pad. These fingertip infections are not your typical compartment syndrome, however.
The compartment of the fingertip is actually 15 to 20 small compartments, which means the normal, healthy finger pad is divided into multiple small compartments by 15 to 20 septa that extend from the periosteum to the skin. Consequently, the same 18-gauge needle used to aspirate an abscess can be redirected to decompress these tiny, engorged compartments. It's highly possible that we have accomplished a kinder and gentler compartment release if the fingertip is vigorously massaged after the needle decompression to express fluid from the compartments through the needle tracks.
My agenda for wanting to find something less invasive is because the fingertip is rich with sensory nerves and blood vessels. I could not find a study, but I strongly suspect that the residual morbidity of the current approach with the fingertip incision and drainage procedure is significant and includes finger pad instability, pain, and numbness. We must find a kinder and gentler, evidence-based approach to treating felons.
Watch a video demonstrating techniques for treating felons.
Monday, May 2, 2016
It's clear to me that emergency physicians have a number of mental blocks when it comes to managing priapism, which means this penile compartment syndrome is often allowed to languish while we wait for the urologists to come to our rescue.
In this video blog, I remove some of the performance anxiety associated with this condition by teaching how to mix up the phenylephrine used for intracavernosal blocks. And, in the second video, I demonstrate how to set up an aspiration and irrigation system, which dramatically simplifies the entire process.
Watch the first video here.
Watch the second video here.
Friday, April 1, 2016
I purchased a neat little tool that allows me to use my iPhone 6s to take videos and photographs of the external surface of the eye. I am still learning how to maximize the photographs and videos, but the clinical and educational possibilities are really exciting. The Eidolon Photo Bluminator has the potential to take excellent still photographs and high-quality videos of the external surface of the eye.
This tool allows photo filters that have blue LED light for fluorescein photos of the cornea or white LED illumination for photos of the anterior segment. Both are options for taking photos or shooting video. The lens provides 7.5 times magnification, and is designed specifically for ophthalmic use. The device fits the iPhone 5/5s, 6/6s, 6s plus, and iPad mini.
The teaching applications of this tool are as outstanding as the clinical applications. I have already used it at least once to send a video to the ophthalmologist on call. I work in a teaching hospital and ophthalmology residents are immediately available, so sending videos are probably not a major asset to me. Consider the value of this tool, however, in the hands of an emergency medicine health care provider working in a rural emergency department and the added ability of explaining his findings with actual pictures or videos for the consulting ophthalmologist. This little tool is the answer from a clinical teacher's perspective.
Like most digitally magnified pictures on the iPhone, the image becomes slightly grainier when enlarged, so I don't do that. The company actually recommends that the iPhone zoom be set at a middle-magnification setting for still photos unless the entire orbit is of interest. One can select the 1080p video at 60 fps instead of 30 fps, however, for the iPhone video option. One can take high-quality videos for teaching files or to share easily with consultants. The iPhone has the Mail Drop option for video files too large to attach to an email. The link for immediate access will arrive in an email sent to the consultant.
The iPhone also has other tools that may help with the quality of the photos. You can hold down the shutter icon on the screen or on either of the volume buttons to start a rapid burst of pictures for patients whose eyes are moving or blinking, and you can then select the best one. A number appears on the screen showing you how many shots were taken. Clicking the actual picture brings up the select option, and pressing select will put a gray circle under the best photo. You can, however, make your own selection and press done. Regardless of what you choose, you can save all of the pictures or only the ones you want.
To watch the video, click here.
If you need both hands, you can hold your finger on the screen on the object on which you want to focus, and it will "AF Lock" onto that distance, allowing you to move around and then get your phone back into position for taking a shot. The brightness of the picture can also be adjusted with the sun icon slider to the right of the focus box.
The HDR setting can be used to compensate for the dark/light areas of the eye and correct for better lighting. The downside of using the HDR setting is that it increases the chance of blurring.
Besides the grainer pictures with the higher digital magnification, I have found the actual defect on the corneal surface may on occasion be surprisingly not-so-obvious with a head-on view of the curved surface of the eye. My work-around for this is to have the patient turn his eye to the appropriate side so the lesion will become immediately more apparent.
Tuesday, March 1, 2016
Paracentesis, or a peritoneal tap, is a procedure emergency physicians often perform to obtain ascitic fluid for diagnostic or therapeutic purposes. Catheter aspiration of fluid is performed to determine the etiology in new onset ascites, to look for infection or presence of cancer, or simply to relieve pressure from a painful, distended abdomen that sometimes can interfere with breathing. Contraindications to the procedure might include an acute abdomen, severe thrombocytopenia, or a coagulopathy. Relative contraindications include pregnancy, a distended urinary bladder, abdominal wall cellulitis, adhesions, or distended bowel.
Our video this month is one of the best step-by-step presentations you will ever find for safely performing this procedure. Richard Gordon, MD, expertly shows how to use an ultrasound to window-shop for the best location to insert the peritoneal catheter. He expertly points out other potential mistakes commonly made by novices throughout the video.
Click here to watch the use ultrasound to locate the best spot for the peritoneal catheter.
More than four liters of ascites were removed from this patient during the peritoneal tap.