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, 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.
Monday, February 1, 2016
I find the repair of eyelid and ear lacerations sometimes daunting. In fact, I often allow the ophthalmology service to take the lead with eyelid injuries and plastic surgery to manage severely lacerated ears. Not only are the repair of these unique skin-over-cartilage structures at risk of serious complications, they are also potentially time-consuming.
Ear cartilage is completely dependent on the overlying skin for survival and has unique risks for infection. Perichondritis is a feared complication that is sometimes resistant to treatment and can result in disfiguring complications.
This video allows us to review the basic principles of ear cartilage laceration repair. The truth is that this repair doesn't need to be daunting if you systematically addresses the unique needs of the injured ear:
- Cartilage needs to be covered with skin. The cartilage has no other source of blood supply, oxygen, and nutrients without the overlying skin tightly adhering to it. Consequently, you do everything possible to make sure the skin and cartilage are married up tightly. In fact, experts recommend that you trim away and sacrifice the excess cartilage if skin is missing.
- Cartilage is relatively fragile and vulnerable to tearing during suturing. Cartilage is fragile, and its saving grace is the tough perichondrium layers on its service. Experts recommend sutures be placed simultaneously through the skin and perichondrium rather than the full-thickness of the cartilage. Not only does this ensure a tight adherent relationship between the skin and cartilage, it avoids absorbable sutures buried under the skin. The associated unavoidable inflammatory reactions of buried sutures can leave residual lumpy defects in the cartilage under the skin. Basically, the perichondrial sutures should be the deepest layer of closure.
- The cosmetic outcome is benefitted by your sequence of suturing. Starting to suture on the posterior aspect of the lacerated ear sets the stage for a more successful outcome on the cosmetically — more importantly, externally — exposed ear. You need to suture the anterior and lateral surfaces last.
Effective packing of the finished repair may also be important. Experts feel auricular hematomas are uncommon in simple auricular laceration repair, and some recommend against wound compression that could cause vascular compromise and poor healing. If packing seems indicated, put Xeroform strips into the ear crevices, gauze (4 x 4 inches) behind the ear, fluffed gauze over the ear, and a final pressure dressing to prevent hematoma formation.
And, last but not least, most clinicians will recommend prophylactic antibiotics for the wounds at greatest risk for infection.
Click here to watch the video.
Monday, January 4, 2016
“Like pulling teeth” is a commonly used idiom that refers to something difficult to accomplish. My video this month, however, would suggest that pulling teeth may actually not be all that tough.
I recently spent a week in Jamaica as part of a medical and dental team providing care under relatively harsh conditions. The layout of our makeshift clinics allowed me to work alongside a dentist and two dental assistants. Besides getting the opportunity to pull my first permanent tooth, I was able to enlist the dental team’s collaboration on a teaching video, in which we demonstrate the elemental steps of pulling a tooth.
This video was made in a medically austere environment during which we were plagued by flies and other insects, but it demonstrates nicely the equipment and procedural steps of a dental extraction. And with the right equipment, I found, it is not all that difficult to pull a tooth.
Watch Dr. Mellick’s video of a tooth extraction.