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The Procedural Pause

Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, CEN, are teaming up to create a new EMN blog, The Procedural Pause.

The blog will focus on procedures that emergency medicine residents and midlevel providers are often called on to perform in the ED. Each case will cover the basics, the best approach for treatment, and pearls and pitfalls.

The Procedural Pause publishes anonymous case studies that required an ED procedure. The site welcomes all providers to share their ideas about emergency medicine, procedures, and experience with similar cases. Application of the information in this blog remains the professional responsibility of the practitioner.

Like all texts, manuals, support guides, and blogs, this site conveys personal opinions and experiences. Providers may approach a patient or procedure in many ways, and this blog is not a dictum nor is it meant to dictate standard of care. It is a clinical guide, not a legal document; do not reference this site in court or as a defense. It is your responsibility to follow your hospital’s procedures and protocol and to practice under the guidelines of your professional license.

Wednesday, October 01, 2014
Part 1 of a Mini-Series on Lumbar Puncture
We love breaking down and simplifying complicated procedures so you can perform them easily and efficiently. The next few blog posts will focus on strengthening your practice.
We want to give appropriate and safe care. We also want to consider patient satisfaction, dignity, and comfort when we complete any procedure. This month, we are focusing on procedures that require perfect patient positioning. Half the battle of any procedure is setting up your stage to perform, no matter how complex or simple the task at hand may be. Successful procedures are all about positioning and patient comfort. The better the positioning, the better the procedure and overall outcome.
Positioning for lumbar puncture.
Oski’s Solution; Lippincott Williams & Wilkins, 2006.

Lumbar puncture anatomy review.
High-Yield Gross Anatomy; Lippincott Williams & Wilkins, 2010.
Consider the correct setup before you start a lumbar puncture. Is the patient young, thin, and tall with a fever? Or older and morbidly obese with altered mental status? Does he have some underlying condition like COPD or heart failure, which makes lying flat or even on his side almost impossible? Does the patient have a history of back surgery or infection that complicates the situation even more? Is he allergic to analgesics or lidocaine — or emergency providers? Next month’s blog will break down the actual steps you need to complete a successful LP, but this month just consider the setup.

Spinal puncture, position, and technique.
Neil O. Hardy, Westpoint, CT.
Indications for Lumbar Puncture
(See Cautions section below for contraindications.)

n Meningitis (CNS infection) with the exception of brain abscess or paramenigneal process
n Subarachnoid hemorrhage
n Syphilis
n Idiopathic intracranial hypertension
The Approach
n Excellent clinical assessment
n Assessing patient stature and mental status
n Obtain consent
n Gathering appropriate supplies for lumbar puncture
n Appropriate positioning and final setup and prep
The lateral recumbent positioning for lumbar puncture, top, compared with upright positioning, bottom.
Atlas of Primary Care Procedures; Lippincott Williams & Wilkins, 1994.

n Grab an LP kit. Get an extra kit and leave it outside the room (to avoid contamination if not used). You don’t want to leave the room once the procedure has started, so also grab an assistant.
n Additional bottle of Betadine or other cleansing solution.
n Extra 1% lidocaine (Kits usually only come with 3 mL vials, and you need 10 mLs.)
n Extra needle: one or two 3.5-inch, 20-gauge needle(s) for adults
n Pillow (Three blankets will also do.)
n Extra set of sterile gloves in your size.
n Versed or Fentanyl for sedation if appropriate.
Lumbar puncture supplies.
Visual Guide to Anesthesia Procedures; Lippincott Williams & Wilkins, 2011.
Lateral Recumbent Position or Side-Lying Position Positioning for Lumbar Puncture
n The patient should be fully undressed for this procedure and in a room on a flat and stable surface.
n Obtain consent. Review pros, cons, and risks vs. benefits prior to procedure with patient or medical beneficiary. Still complete consent with “emergent procedure” if indicated.
n Explain the procedure to the patient. Lessen fears by stating the numbing needle is small and should not be incredibly painful. They may feel pressure once the numbing medication is inserted, but should not feel pain.
n Note to the concerned patient, that removal of CSF from an LP is commonly regenerated within the subarachnoid space within one hour.
n State that the actual procedure itself is not long (5-10 minutes) and that the prepping usually takes longer. Make sure to mention you care about his comfort and safety.
n Assist the patient into a lateral recumbent position, with his back facing you.
n Place a pillow or a few blankets under his head and between his knees. The legs should be parallel.
n Let the patient get comfortable and settle in this position.
n Find your landmarks.
Lumbar puncture positioning, lateral recumbent position.
Lippincott's Nursing Procedures and Skills, 2007.
Finding Landmarks
n Find the highest points of the iliac crests visually and by palpation. Draw an imaginary line between them to the anatomic midline. This is the fourth lumbar vertebral body. L3-L5 can also be felt by palpation in a thin adult or pediatric patient.
n The correct level of entry of the spinal needle is “most easily determined with the patient sitting upright or standing,” and the spinal needle can be “safely inserted into the subarachnoid space at the L3/4 or L4/5 interspace, since this is well below the termination of the spinal cord.” (Lumbar puncture: Technique, indications, contraindications, and complications in adults. UptoDate; Sept. 18, 2013.)
Additional Pearls
n State one of these phrases to the patient: “Curl your back like a cat,” or “Get into the fetal position.”
n They should have neck, back, hips and legs in flexion.
n Set up your LP kit with the patient’s back facing you. Place it within close reach. There is no reason to set up the kit with the patient watching or before you have found your landmarks and feel confident you can complete the procedure.
n An assistant can help with positioning.
Sitting Upright Position for Lumbar Puncture
The steps for prepping this position are virtually the same as the lateral recumbent position. The difference is that this patient is sitting upright and hunched slightly forward. Have the patient place his head on his crossed arms over the mayo stand while he sits on the side of the stretcher. You must determine your landmarks before starting and prepping. Consider the following, however, before using an upright position.
n You cannot obtain the opening pressure in the upright position if you are concerned about increased ICP.
n Patients may become more nervous and uncooperative in this position.
n The upright position is more effective for obese patients.
n You need an assistant for this position and a stable patient.
n It is practical to give an anxious patient an appropriate dose of a benzodiazepine (IV or PO), but use caution in the upright position.

Upright sitting position for lumbar puncture with anatomy review.
Lippincott Concise Illustrated Anatomy, 2011.
Patient in appropriate upright sitting position.
Manual of Clinical Anesthesiology; Lippincott Williams & Wilkins, 2011.
n The opening “pop” you feel is the needle penetrating the surrounding ligaments.
n Never complete an LP with infection near the puncture site (i.e. cellulitis, open sore, wound, etc.)
n Completing an LP in a patient with a space-occupying lesion (i.e., abscess, tumor) causes risk for brain herniation.
n Relative contraindications include coagulopathy, increased ICP caused by space-occupying lesion, and severe thrombocytopenia.
n Thirty-one percent of adult patients have termination of the spinal cord at L2; the rest, above.
n Needle choice and bore size can influence the risk of a post-LP headache.
Become familiar with both types of spinal needles: standard point (triangle shape puncture (Quincke) vs. pencil point (Whitacre or Sprotte). The Whitacre needle has been associated with decreased risk of post-LP headache. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
n Note: Pediatric LP considerations will be covered in a future blog post.

The 22-gauge, 3.5-inch Quincke spinal needle is the most common one used by many practitioners for image-guided injection (22-gauge with black hub, 25-gauge with light blue hub; tip of 22-gauge needle is shown at various angles of rotation). The Quincke needle has a sharp bevel that advances easily through tissue planes. Most manufacturers produce a needle with a central stylette that has a small notch in the hub. The notch lies on the same side as the needle’s bevel face, and can be used to determine the direction of the bevel as the needle is advanced.
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine; Lippincott Williams & Wilkins, 2011.
Procedural Pearl: What’s with the headache? Patients with idiopathic intracranial hypertension (IIH) will often have normal neuroimaging studies. The increased ICP may be ongoing and cause headaches worse with position changes, coughing, visual loss, chronic pain, or cranial nerve palsies. The only way to diagnose and relieve IIH is to complete an LP. The opening pressure, therefore, should be obtained with a manometer on every patient with a headache, altered mental status, or chronic headache receiving an LP in the ED. Normal pressures are between 7-20 cm H20. Any elevation should be alarming and noted to be abnormal. The concern for IIH would be if the opening pressure was 25-45 cm H20. (Roberts & Hedges, 2014).
Note on Local Anesthesia: A generous amount of 1% plain lidocaine can render the procedure almost totally painless. After a skin wheal, advance the long 25-gauge needle in the same direction and depth that the spinal needle will follow. Anesthetize deeply and widely using 5-6 mL of lidocaine. We’ll get into more of this next month.
Tip of the Week: This month’s tip of the week comes from Dr. Amie Woods at Inova Fairfax Emergency Department. Dr. Woods suggests using a bit more lidocaine to numb the area effectively before completing the actual LP. It is more comfortable for the patient and allows you to complete the LP with virtually no discomfort. She suggests drawing up an additional amount of 1% lidocaine in a 10 mL syringe, maintaining sterility.
Go Green: We know it’s not appropriate to save pieces of a kit used for a lumbar puncture, especially if the kit was taken into a room and used for a patient on isolation. This is why we suggest leaving the second kit just outside the door within reach, and having an assistant hand it to you if you need to start over.

Wednesday, September 03, 2014

As we approach the end of summer, we pay tribute to a special nerve block. This particular block is crucial for treating lower lip lacerations that may be related to slips and falls at the pool or skateboarding. We are going to ask you to go mental, as in blocking the mental nerve of the face.


The mental nerve is an extension of the inferior alveolar nerve, which branches primarily off the trigeminal nerve. It is a sensory nerve that provides sensation to the lower chin and lip. It does not supply sensory innervation to the lower teeth, although some patients report mild anesthesia to their teeth. Three branches come out of the foramen; two go to the skin of the chin and one to the lower lip.



Mental artery and nerve positions.


Head and neck regional anesthesia is useful for a variety of reasons. A single but precise nerve injection allows the practitioner to spread a large area of anesthesia to specific parts of the face for suture repair. The injured area may be delicate and sensitive, especially complicated injuries to the lip. Many facial nerve blocks are accomplished by using landmarks that are easily identifiable. Intraoral needle entry may help avoid additional trauma to the outside skin surface. A nerve block allows suture repair without distortion or swelling that can occur with local injection. Finally, the procedure itself commands straightforward knowledge of the anatomy and requires only a few simple supplies.


Supplies for mental nerve block: gloves, 3 or 5 mL syringe, 25 or 27 gauge 1½-inch needle, topical anesthetic, and bupivacaine. Photo by Martha Roberts.


Injectable Sesorcaine (bupivicaine) and topical anesthetic (Benzocaine 20%). Photo by Martha Roberts.


The Approach

·         Identification of mental nerve and other facial landmarks

·         Topical anesthesia of mucosal entry point

·         Mental nerve block

·         Suture and repair as needed


The Procedure

·         Sit the patient upright at a 45- to 90-degree angle.

·         Place side rails up on stretcher so the patient can hold onto them as you inject. Patients have a tendency to grab or swat away your hand in response to the initial injection.

·         Identify your landmarks. Have your patient look forward and draw an imaginary line from the pupil down to the lower jaw. The mental nerve is midline to the pupil.

·         Place your pointer finger in the mouth along the gum in line with the pupil. Locate the foramen of the left or right side of the mental nerve. To do this, palpate 1 cm below the base of the second premolar (tooth #20 or #29, fifth tooth from the midline) between the lip and teeth. The foramen may be very difficult to palpate.







Photo courtesy of The Clinical Practice of Emergency Medicine, Lippincott Williams & Wilkins, 2001.


·         Generously squirt or squeeze topical anesthetic of your choice onto cotton-tipped applicators and place them on your landmark(s). The applicators are placed on the mucosa at the base of the space between the teeth and lip. Leave in the patient’s mouth for three to five minutes.

·         Draw up 3-5 mLs of bupivacaine into a 3 or 5 mL syringe. Obtain 25 or 27 gauge 1½-inch needle for injection.

·         Grab the lower lip with thumb and pointer finger with non-dominant hand and pull it gently outward, as if you are holding a large mouth bass.

·         Use your dominant hand to inject. Position your needle perpendicularly to the second molar, and insert the needle. Click here to watch a video of Dr. Roberts demonstrating how to do this step-by-step.

·         Insert needle and aspirate to ensure you are not injecting into an artery.

·         Inject 3-5 mLs of bupivacaine just above the foramen and remove the needle. Use a fan-like distribution of anesthetic about 1 cm to each side of the injection to ensure good anesthesia.

·         Massage area of injection on the outside of the face to help with distribution.

·         If the patient has an injury that crosses the midline, identify both landmarks and complete steps to both sides of the face.

·         Allow 3-5 minutes for full anesthesia to take effect.

·         Complete your suture and repair as needed.



Distribution of anesthesia from mental nerve block (top). Anatomy (center). Approach and positioning of injection (bottom). Photos used with permission from Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014, pg. 551.


The Cautions

·         Remember that the full length of the needle should never be fully inserted when using an intraoral approach for any nerve block.

·         Do not change the direction of the needle while it is inserted during injection. Pull back and change position.

·         Aspiration before injection is key.

·         Minimize pain by injecting anesthesia slowly.

·         Use a topical numbing agent whenever possible to minimize pain prior to injection. This block is nearly painless with proper topical anesthesia and a slow injection.

·         Always take into consideration that any injection to the face causes anxiety for the patient. Be sure to explain to the patient your procedure before injecting so that he remains still and comfortable while you work.


Tip of the Week

Next time you head to the dentist, why not ask for some one-on-one teaching? These guys are experts when it comes to facial anatomy and nerves. Although there is some mild anesthesia provided to the first and second premolars by blocking the mental nerve, you should note this is NOT the primary procedure for actual dental work or dental blocks. Please see our blog from March 2013 for more information about the inferior alveolar nerve block. (


(NEW!) Evidence-Based Practice Pearl

A randomized, controlled, double-blind study in the Journal of Endodontics by Whitworth et al. found the speed of injection reduces the pain of injection while performing a mental nerve block. About 50 percent of the tested patient population reported anesthesia to their first molars, bicuspids, and lateral incisors. For all your statistical nerds out there, the P value was <0.001.

Wednesday, August 06, 2014
It’s summertime, and people are spending a lot of time outside in their yards, at the pool, traveling, hiking, and getting their fingers caught in things. That makes it the perfect time for a tribute to finger lacerations, specifically those with nail bed disruption and avulsion.
You will need to do a bit of handy work yourself if you work in an urgent care center that does not have a hand specialist on call 24/7. Finger lacerations can be complicated, but you simply need to keep in mind the basic principles about repair of soft tissue injuries. It is also important to identify tuft fractures and tendon disruption.
Hand injuries are incredibly common and amazingly painful. Sometimes a hand injury can keep someone out of work for several weeks, especially if the patient works in an industrial environment or in areas where he may be exposed to chemicals. Close follow-up is indicated and often times antibiotics are warranted to avoid complications because our hands and fingers are so susceptible to infection. Pediatric hand injuries are even more frustrating for parents and kids alike. We encourage you to read our previous blogs about soft tissue injuries and brush up on the basics. (
Finger laceration with nail bed disruption. The proximal base of the nail is totally avulsed (left) and overlying the eponychial fold. The avulsed nail should be replaced anatomically but left attached to the intact nail bed. Credit: Martha Roberts
The Approach
 Ring removal
 Digital block
 Radiographs
 Relocation of digit if necessary (see previous blog:
 Wound care: clean, debride conservatively, nail removal or repair, and suture repair
 Nail replacement
 Bandage and splint
The Procedure: Initial treatment First take off that ring!
You will need to use a ring cutter if ring removal is not possible. Substantial swelling will occur with the injury itself and with digital block.
 Order appropriate radiographs of the finger, not just the hand, after examining the patient. Appropriate views include the AP, lateral, and oblique. Lateral views of the finger allow the provider to see subtle dislocations and avulsion fractures. A tuft is the most common fracture.
 Have the patient on a stretcher in a comfortable position. The patient most likely to syncopize during treatment is a young man in his 20s and 30s (proven by our own research). Digital blocks are routinely necessary for this type of injury. Note: Skin repairs are done after the dislocation is reduced.
 Clean the area with saline or tap water. A recent multicenter comparison of tap water versus sterile saline for wound irrigation in more than 600 patients found that both irrigants had equivalent rates of wound infection. (Acad Emerg Med 2007;14[5]:404.)
    Use a betadine solution or other antiseptic to clean the area.
 Do not soak for long periods of time. Five minutes is sufficient.
Nail Removal and Replacement
 Remove the nail from the nail bed completely if the nail bed requires sutures. Place small scissors between the nail and nail bed and spread/advance them, being careful not to cut the nail bed. Save the nail; it will be replaced after the repair. You may use a piece of the suture packet cut in the shape of the nail instead if the nail is not reusable or missing.
 Place a hole for drainage in the middle of the removed nail.
 Leave the nail in place if it is adhered to the eponychial space. But you must repair it if the nail can be lifted off and a laceration is underneath. Remove the distal pieces if the nail is shattered into pieces, but keep as much of the original nail left intact to the eponychial space as possible.
 Extensively clean the area under the nail, removing any debris or foreign bodies. Do not injure the intact nail bed.
 Use a 6.0 or 7.0 absorbable suture for nail bed laceration repair. Remember that the new nail will grow over the repaired nail bed, and it should be flat and well aligned to prevent permanent nail deformities. Complete lateral nail lacerations first. (Roberts JR, Hedges JR, Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.) A finger tourniquet should be routine, but don’t forget to remove them.
 Replace the nail in its original position once lacerations are repaired. Use a 4.0 removable suture to secure the nail back into the eponychium using four to six sutures, depending on the size of nail.
 The nail is replaced not only to act as a protective agent during the healing process, but also to facilitate growth of new nail by maintaining the fold. This helps prevent nail splitting or deformities. Note: Nail growth occurs at a rate of 0.1 mm/day, and it takes about six months for full regeneration of the nail. (Roberts & Hedges, 2014.)
Replaced nail to eponychial space with applied sutures to stabilize it.
Credit: James R. Roberts, MD
Wound Care and Splinting
 Apply a bulky dressing with a finger splint for simple DIP injuries.
 Splints will be kept on for two to three weeks or longer depending on fracture or severity.
 Larger areas of injury may need full volar or dorsal splints. (See below.)
Discharge Considerations and Other Essentials
 Tuft fractures are open fractures, but routine antibiotic use is controversial, and infection rates are actually low. Suggested antibiotics to consider: First-generation cephalosporin such as cephalexin 500 mg qid for five to seven days or antistaphylococcal penicillin such as dicloxacillin 500 mg PO qid five to seven days. PCN allergy? Consider clindamycin 300 mg PO qid for five to seven days. Warn patients about diarrhea and upset stomach. Diabetic patients may need extended day coverage.
 Wound care is mandatory. The patient should not remove or get the dressing wet for the first 24 hours. Then, dressing changes can be completed once a day or as needed. Pain medication should be taken prior to dressing changes.
 Follow-up should be within three to five days.
 Pain medication should be given to the patient because digital blocks wear off quickly.
 Sutures of the replaced nail are removed in seven to 10 days if the patient is followed in the ED. A totally avulsed nail, if replaced, may grow normally, but a new nail will push out the repaired nail. The old nail can be removed in two to three weeks once the eponychial fold has new nail growth. The nail bed may be uncovered for a few weeks if the replaced nail is removed, but this area dries and become less sensitive. It is important to keep this nail bed clean as the new nail grows over it.
This patient did not suffer any tendon involvement, but it is important to examine the patient for tendon injuries and follow up with a specialist. Patients often need to be taken to the operating room for exploration and repair if they have complicated injuries. Consult your hand specialist if you suspect tendon involvement.
 Use a thumb spica splint for flexor or extensor tendon injury to the thumb.
 Immobilize the entire hand and wrist using a dorsal splint for flexor tendon injury to the finger.
 Use a volar splint from forearm to fingertips for extensor tendon injury to a finger. Note: A patient may have an ulnar injury, not a tendon injury, if he cannot extend the PIP and DIP joints of all fingers (but does not have lacerations to each finger). (Semers NB, Practical Plastic Surgery for Nonsurgeons, 2nd edition, New York: Author’s Choice Press, 2007.)
Tip of the Week
As you may already know, some antibiotics such as cephalosporins and penicillin can increase the rate of bleeding by increasing the INR in patients who are on warfarin. It is important to take a full history, and ask patients about their medications, no matter their presenting problem.
Go Green
Have you ever noticed a piece of hospital tape stuck to your shoe, and then found it just wouldn’t budge when you tried to remove it? And one week later, it’s still there? Leftover hospital tape is great for all kinds of home projects! It’s strong, durable, and sticky. It’s good for patching things, painting projects, and can be used at the base of your door to prevent drafts. You can use it to fix a shoe, too. Offer it to your patient first, but if you were going to toss the extra tape, save it for a project and reuse it!
Dr. Roberts is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years. Ms. Roberts is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA. Read their blog, The Procedural Pause, at

Wednesday, June 11, 2014
This is what you signed up for, right? A career where you are a multitasking, highly-skilled medical practitioner in a fast-paced emergency department. This place is predictably unpredictable, but you are saving lives, and it feels good! The problem is, you cannot help feeling unappreciated, underpaid, overwhelmed, and exhausted. You are finally living the dream, but the dream consists of working weekends, double-call, and every other holiday. You miss lunch while still gaining a few pounds. You gain incredible insight into a very broken care system. Feeling more like a nightmare? It’s certainly not what you expected.
Now you have to deal with demanding patients who expect customer service perks. The patients who say, “Do more tests,” and insist on instant gratification. The audacity! You are frustrated that your clientele is telling you how to do your job. The degree behind your name means nothing because Google has allowed your patient to complete a self-diagnosis. This place is for emergencies, not primary care. These complaints are not emergent at all.
You feel justified by your disdain because you are not alone. Your colleagues exchange glances when a patient demands a head CT, or you hear a deep sigh from a co-worker when a patient asks for a stat MRI for back pain he has had for eight years. The nurses agree that your narcotic-seeking patient is simply that, and needs security to escort him out. Mr. Jones is back again for a refill of his blood pressure medication. Now you see one more person just signed in with a stubbed toe.
This is not what you signed up for at all. Breathe. Stop for a minute and regroup. Now, slap yourself. Maybe you need to slap yourself twice. This is what you signed up for! The ED is not just for emergent concerns. It is a care center where people know there are doctors and nurses. It is not just for emergencies like strokes, MIs, and blunt trauma! It is for patient care, in general, and their satisfaction. Until you realize patient satisfaction is part of the care plan, then you are going to continue to live a miserable existence in your department. Let us explain.
Back when organized medicine was — wait a second — has it ever been organized? No. Never. There are buildings with roofs, medications, tools, and machines that help you make decisions, but it’s not exactly organized. The ED is full of chaos. What about resources — or lack thereof? Your local resources exist, but most of the time they are almost impossible to utilize. Now, add the following fun facts: Your patient may not be able to read or write or speak English. He might be elderly or broke. When these types of patients ask you for a helping hand, why do you act so annoyed? We all know your badge doesn’t say S. Smith, Waiter. It doesn’t say J. Jerk, either.
Your badge says Emergency Physician or Nurse or Physician Assistant or Nurse Practitioner. This role is more than knowing how to diagnose and treat heart failure or catch early sepsis. This role is about providing total patient care and making people feel better, even the ones who don’t quite get it. It is about making people happy and motivated to play an active role in their own health care. After all, a happy patient trusts you, and isn’t that what this is all about?
Recent personal opinion columns scold and mock our demanding patients and hospitals that stress concern about patient satisfaction scores. Most of these rants reiterate the same themes about non-emergent patients demanding non-emergent testing or treatment. Many ED providers complain that patients don’t understand our overwhelming jobs, and visit us with complaints that should be seen somewhere else. Well, the ED is that somewhere else.
Providers whine that nonsensical satisfaction scores should not be part of our job evaluation. The patient’s opinion should not be a factor or used as an evaluation tool. Nonurgent patients should understand we are busy with other emergencies, and they need to wait. This may be true, but we don’t need to broadcast to them that maybe they are not as important. We also don’t get to say their patient satisfaction scores simply don’t matter, that only the admissions’ and critical patients’ scores are read.
It’s controversial. Patient satisfaction, however, is important in the ED and so are the scores — to an extent. What people think about your care should matter to you and your facility. It should be measured and monitored. You should want to change your practice based on negative feedback.
Also important are refills, toe pain, dental pain, and well checkups. The ED is not just for emergencies, and it will always be that way. It doesn’t matter what a patient’s needs are; you must provide aid. The challenge is not the difficult intubation or rushing a stroke patient to the CT scanner within the window. Those steps are easy for you because they define your job. The real challenge is to accept that the ED will never be what you want it to be or operate the way you see fit.
It is also a challenge of your character. Patients are going to remember you, and their opinion matters regardless of who they are and what their complaint is. Their opinion should also matter to you because this also defines your job. This should not be seen as a chore but as a job that you want to master. You may yearn to explain to people what constitutes a true emergency. In the end, though, whatever brought them to the ED is an emergency to them, and they need your help. Your definition doesn’t matter.
As ED providers, we prioritize. Most days, we make a difference and people appreciate our efforts. Other days, we see demanding patients who are not as privileged with our educated minds or who do not have the financial solution to their health care needs. We must accept that the ED is a mixing bowl of complicated cases and part of our job is to find a recipe that works for each patient. The ED is a place for compassion and creativeness, not for complaining, personal bias, or judgment.
No, we do not have to prescribe antibiotics for every cough or runny nose to boost our scores. Not every patient gets a CT or an x-ray just because he asks for it. Providers seem so annoyed by the requests. Find a middle ground with alternative options if you can. Considering patient satisfaction as a goal is not giving in to Press Ganey. It is important to reexamine how you practice and how you treat people, even the incredibly ill-advised ones. As providers, we are still allowed to exercise our clinical judgment to make a decision about patient care and not get irritated at patients when they ask for or demand things. Do not lose sight of creating a relationship through communication, trust, and ultimately, kind rapport. Don’t fall into the I’m-the-provider-and-I-know-best mentality. We can explain our thought process to patients and reassure them about our decisions whether to do testing.
Our jobs as ED providers include saving lives, but they also include considering patient satisfaction. These scores should not be exempt just because we make life-or-death decisions. Our profession should be respected and some patients need to wait, but being callous is never justified. Maybe we can look past the initial insults of certain patient complaints and find a deeper meaning. Not all of the scores are accurate or reflect the total picture of who we are as providers. No one is perfect, and we should accept that there is always room for growth and change.
We have a privileged job, but it does not mean we are allowed to be pompous. Patient satisfaction, courtesy callbacks, answering questions, and going the extra mile not only make a difference to our patients, they define our role as care providers. Rolling our eyes at our regulars will not make them stop coming. The next time you feel yourself wanting to say, “That is not my job in the ED,” think again. It is your job, and it is going to keep being your job. Consider patient feedback realistically. Treat everyone with compassion and courtesy, and I guarantee the rewards will not be what you expected.
How important is patient feedback to you?

Tuesday, May 06, 2014
Olecranon bursitis, also called baker’s or Popeye elbow, can be a painless or an irritating condition involving the bursa located near the proximal end of the ulna in the elbow over the olecranon. Normal bursae sacs generally are filled with a small amount of fluid, which helps the joint remain mobile. The sac can swell under the soft tissue from overuse or when the area sustains an injury from a bump or fall.
Normal bursae are usually small, but they can grow to be quite large, swollen, and occasionally even infected when they become irritated or inflamed. The swelling is obvious because the space in this area is limited, and drainage of the fluid may be necessary. Physical examination of patients with uninfected olecranon bursitis demonstrates an annoying but supple lump on the posterior elbow; it is unsightly yet only minimally symptomatic. It may have even gone away by itself in the past. Infected bursae usually reveal a warm, red, quite tender, and painful bulge over the elbow with limited range of motion. Patients feel most comfortable in the flexed position and have difficulty extending their elbow because of the pain and swelling.
Most aseptic/sterile swellings are merely cosmetic and not especially bothersome. Many come from resting the elbow on a bar while drinking. Recurrences are common after simple drainage. Very red, hot, and painful bursae enlargement usually means gout or an infected bursa. Infected bursa must be drained and treated with antibiotics, and a cure is not always easy. Infected bursae demonstrate less floppy swelling and more diffuse redness and tenderness.

External soft tissue view of the left elbow. (Photo by Martha Roberts)

This patient had nonseptic olecranon bursitis. (Photo by Martha Roberts)
The Approach to Nonseptic Bursal Swelling
• Radiographic evaluation of injury (only if concern for underlying bony injury)
• Bursal needle aspiration using ultrasound
• Specimen sampling, WBC, gram stain, and cell count to help determine if infected
• ACE wrap plus sling if needed; pain control
• Orthopedic follow-up
Radiographic views of the left elbow. The left lateral elbow shows moderate soft tissue swelling over the olecranon without bony injury, left. The left AP view of the elbow shows that the IV line was inappropriately placed in the affected arm. (Photos by Martha Roberts)
The Procedure
• Premedicate patients who may require analgesia.
• Place the patient in a position of comfort with the affected elbow within your arm’s reach. Effective positions include allowing the patient to give himself a hug by placing the arm across his chest or having him lie on his unaffected side with his elbow propped over a large drape.
• Place your US probe over the affected area and assess for the highest area of fluid collection. Mentally note this area using landmarks, and remove the probe once located.
• Apply antiseptic to the site. Apply sterile gloves.
• Inject 1-2 mls of 1% lidocaine using a prefilled 25g needle to anesthetize the affected area.

Properly positioning your patient is key to a successful procedure. (Photo by Martha Roberts)
Ultrasound showing large fluid-filled bursa sac over olecranon.
Gauze, aseptic cleaner, injection needle, and lidocaine. (Photo by Martha Roberts)
Lidocaine with epinephrine may be used. (Photo by Martha Roberts)
Identified injection site determined by guided US. (Photo by Martha Roberts)
• Remove the 25g needle, and wait one to two minutes.
• Insert 18g needle attached to 10 mL syringe to same entrance site, and begin draining the fluid from the bursa sac. Use a sterile technique. Consider using sterile US probe covers.
• It may be necessary to “milk” the area of fluid to help drain the site as you pull back on the syringe.
• Remove the 18g needle once aspiration is complete, and apply a BandAid or dressing.
• Send a specimen of the fluid to the lab with appropriate orders.
• Apply an ACE wrap over the site for compression, and offer the patient a sling for added support.
• Remind patients to do shoulder exercises if a sling is applied to avoid frozen shoulder complications. Do not splint the extremity.
• Arrange orthopedic follow-up within 24 to 72 hours and strict return precautions.
• NSAIDs are the treatment of choice for pain and decreased swelling. Oral steroids are not indicated.
Approximately 5 mLs of clear, yellow fluid were removed from the bursa. No blood or pus was noted. Results were properly labeled and sent to the lab. Occasionally this sterile fluid is blood-tinged. (Photo by Martha Roberts)

Septic bursitis usually results from a traumatic bony injury, and a wound or cellulitis will most likely be associated. Literature review reflects that more than 70 percent of septic arthritis cases are related to traumatic injury. (Roberts & Hedges. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.) Consider your high-risk populations to be those who are immunocompromised, diabetic, alcoholic (chronic injury or fall), or have jobs that may involve crawling on elbows or forearms.
Pus or cloudy discharge will be present on bursal aspiration, and is used to make a bedside diagnosis. Cell count may be more than 200,000 per mL. Gram stains may be negative about 30 to 50 percent of the time, even with septic bursitis. Cultures may reveal Staphylococcus aureus (80%) or streptococcal organisms; gram-negative cultures are rarely seen. (West J Med 1988;149(5):607.)
Septic bursitis does not always present with a fever. (Roberts & Hedges, 2014.) Treatment of septic bursitis for successful outpatient therapy (not diabetic or immunocompromised) includes clindamycin 450 mg PO three times a day for one week or Bactrim 2 DS tabs PO twice a day for one week. IV antibiotics such as vancomycin, clindamycin, and linezolid are given for severe cases during inpatient management. Remember, low WBC count and negative gram stain do not rule out infection. (Levine B. EMRA Antibiotics Guide. Emergency Medicine Residents’ Association, Irving, TX: 2012.)
Nonseptic bursitis may result from a gouty attack or arthritic flair. Drainage will be yellow-tinged or straw-colored but clear. It may also be slightly blood-tinged, and may have an erythrocyte count of 20,000-30,000 per mL. The leukocyte count may be 10,000-20,000 per mL, but is rarely high. Crystals may be seen and give rise to suspicion of gout. Overall, the cell count will be less than 6,000 per mL for nonseptic bursitis. (McAffe & Smith, 1988.)
• Is your patient on blood thinners? You can still drain the bursa carefully. But make sure he is not taking over-the-counter medications that could be an issue if he is also taking Coumadin, ASA, or Plavix. Glucosamine sulfate, a popular but controversial supplement for treating osteoarthritis or inflammation, may be something the patient uses. You may want to advise him to avoid vitamin C and Omega 3s as well.
• If patients are looking for an “organic” treatment, suggest acupuncture, physical therapy, or massage. Always suggest orthopedic follow-up, however, as primary advice.
• What is the bigger picture? Olecranon bursitis may be caused from a lupus flair or uremia. Be sure the patient has proper follow-up. It doesn’t hurt to consider warning signs of other systemic diseases besides gout or arthritis.
• IV placement: Do not place intravenous lines in the affected arm if at all possible. As noted in the image above, the nurse placed a line in the arm with the known injury. The patient needed pain medication during the procedure, and it was difficult to administer because of positioning. Discuss this with your team if you are ordering labs or need IV access.
• Bursal aspiration: We all know your first thought may be to get rid of that sharp quickly! Don’t forget, however, that you need to send what you drain to the lab! Be careful with your fluid-filled syringe after you drain the bursa pocket. Do not recap the needle. Instead, immediately transfer the specimen to your sample containers and send it to the lab.
• Are you cleaning your ultrasound machine appropriately? This is as important as doing the procedure itself because we can’t do our jobs effectively without the right equipment. Be careful what you use to clean the machine because heavy cleaners or abrasive pads such as CaviWipes may cause irreversible damage. Remove gel from the transducer immediately after use with soft gauze. Refer to your specific model’s requirements for appropriate cleaning guidelines, but keep in mind a neutral pH is best.
Tip of the Week
Our friend Eugene Lee, MD, at Inova Fairfax Hospital ED reminds us that an open dialog with our orthopedic team is important and necessary. Previous treatments of bursitis should always be taken into consideration; chronic olecranon bursitis needs close follow-up. The orthopedic team should be consulted if you are at all considering injecting steroids into any bursa, especially if the bursa was recently or previously drained or a septic joint is suspected. Ruling out septic bursitis is imperative before injecting steroids into any bursa.
Some studies say, however, that 20 mg intrabursal injections of methylprednisolone acetate may be an effective treatment regimen for nonseptic olecranon bursitis. (Arch Intern Med 1989;149[11]:2527.) Please take into consideration, however, that the literature review of these data is limited because of sample and study size as well as inconsistent results. More information on this topic is welcome, and we encourage your comments!
About the Author

James R. Roberts, MD & Martha Roberts, ACNP, CEN

James R. Roberts, MD, is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years.

Martha Roberts, ACNP, CEN, is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA, and is Dr. Roberts’ daughter.

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