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.
Friday, May 01, 2015
Today you are the fast-track provider, and you are on the hunt for procedures. You notice a 35-year-old woman signing into triage with a chief complaint of wrist pain.
This patient looks otherwise healthy, is pushing a stroller with her right hand, and is carrying a second child on her left. What’s the emergency? There isn’t one, but it is an emergency to this patient because she cannot push that stroller another day! If she cannot push the stroller, then she cannot get the kids to day care. And, if she cannot get the kids to day care, then she cannot go to work. Ask anyone with children, it is an emergency.
This patient also says she is new in town and did not know where else to go, so she came to your Level I trauma center. Good thing you read this blog because you just made her day.
Chronic, recurrent, nontraumatic wrist pain may throw you for a loop. Words like “rheumatoid” and “fibromyalgia” flash in your mind. Things like “ANA” and “lupus” and “we don’t do that in the ED” also pop into your brain. Red flags such as “fever,” “infection,” and “diabetes” slip from your lips. Stay cool; you can totally fix this chronic wrist pain! Not only can you fix it, you can also feel confident about your diagnosis and treatment plan after reading this article. This month, we are going to touch upon — literally — tenosynovitis of the wrist. This painful chronic wrist pain can be solved with a simple two-touch technique.
Tenosynovitis is somewhat like a permit fish. It is rare, hard to catch, and can put up a good fight. Tenosynovitis is just as reclusive as the permit, and you will never forget it once you see it. De Quervain's tenosynovitis is a chronic but sometimes recurrent problem. The syndrome causes an inflammation of the synovium sheaths that surround the tendons of the extensor pollicis brevis and the abductor pollicis longus muscles of the thumb. The two parallel tendons assist with thumb movement. The cause of this type of tenosynovitis is still not well defined, although one of its nicknames is “mommy thumb.” Overuse and irritation can cause a flareup. Its onset causes significant wrist pain, tenderness, and immobility, so it deserves some attention.
n Identification of De Quervain’s tenosynovitis using the Finkelstein test and two-tap technique
n Familiarization of proper steroid medications for injection
n Steroid injection into the wrist
n Orthopedic follow-up
n Possible surgery for recurrent issues
n Place the patient in a supine or sitting position. Avoid complications from vagal response by making your patient comfortable.
n Identify your landmarks. Locate the radial styloid process and the base of the thumb on the affected extremity.
n Have the patient make a fist. Then ask her to complete the Finkelstein test: Place the thumb into the fist, so the fist is holding down the thumb. Stress the tendons by having the patient tip her hand toward the ground. This should elicit exquisite pain.
Next, use your second and third fingers to identify the area of concern by tapping with these fingers lightly on the radial side of the wrist. Start at the base of the thumb and make your way up the wrist. This is known as the Roberts two-tap technique or Roberts sign. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
Use a marking pen to note the area of extreme tenderness. You will make your injection wherever the patient has the most pain with palpation using the two-finger tapping technique.
n Premedicate the patient with 600-800 mg ibuprofen PO once. If there is a contraindication, consider using 650-1000 mg acetaminophen PO once.
n Order the appropriate corticosteroid from your pharmacy. You should use a long-acting corticosteroid such as Depo-Medrol or Kenalog (there are several brand names for methylprednisolone acetate). Depo-Medrol is an anti-inflammatory glucocorticoid for intramuscular, intra-articular, and soft tissue injection. It is available in three strengths: 20 mg/mL, 40 mg/mL, and 80 mg/mL. The appropriate dose for your adult patient is 40 mg diluted in 2 mL of 1% lidocaine, making a 3 mL dose.
n The lidocaine increases the volume and acts as an anesthetic.
n Clean the area with an alcohol swab.
n Use a 25-27-inch ½ g needle to inject the steroid lidocaine solution directly around the area affecting the tendon sheath. You will not be injecting the tendon directly!n Note: You may consider injecting 1 mL more of the steroid lidocaine solution proximally and completing another injection more distally to cover the entire affected area. See video for more details.
Watch a video of Dr. Roberts demonstrating diagnosis and treatment of De Quervain’s tenosynovitis.
n A plain radiograph is not useful. Refrain from ordering a radiograph if you are quite certain this is tenosynovitis.
n Always consider gout, septic joint, or underlying autoimmune disorder. De Quervain’s tenosynovitis is still not well understood, and there are theories it may linked to lupus, Lyme disease, and other connective tissue disorders.
n Do not repeat injections in a short period of time. Consider telling the patient to wait six months or more before having the area injected again.
n Stenosis of tendons may be an issue. If you feel resistance during injection, you may be injecting the tendon itself, so retract the needle slightly. You cannot inject directly into a tendon. Your goal is to inject the area around the tendon.
n The patient should have complete pain relief in a minute or two if the appropriate area is injected. More solution may be required if not.
n Consider wrist immobilization using a plain thumb spica splint, resting the area, NSAIDs, and ice for patients who decline steroid injection and prefer a more conservative approach. Physical therapy is also an option.
n Oral steroids are not particularly helpful.
n The original pain will recur when the lidocaine wears off. Warn the patient of the post-injection flare — transiently increased pain that may occur in the first 24 hours. You may consider a few other doses of NSAIDs or acetaminophen.
n Temporary distal sensation loss in the thumb from the lidocaine is not uncommon.
n Complete pain relief should be obtained in two to three days.
Jim weighs in: Martha is a real wimp.
Martha weighs in: I had to hold the camera and be injected for this video. What the heck?! Thanks, Dad?
Tip of the Week
De Quervain’s tenosynovitis is most commonly seen in 30- to 50-year-olds and mostly women. It is important to ask patients about their daily activities, job, and even sexual history. Gonococcal infection can cause septic arthritis or tenosynovitis. Beware of injecting or jumping to the diagnosis of De Quervain’s if the patient has a fever. Gonoccocal infections can have an insidious onset and may be confused with De Quervain’s. Pain, redness, and swelling with an associated fever are NOT associated with De Quervain’s tenosynovitis. How can you tell the difference? Look for a painless, nonpruritic rash that consists of small papular, pustular, or vesicular lesions. Splinting is generally not required.
Did your procedure work? Call your patient in 48 hours, and if he is feeling back to normal, you found your permit fish! If your patient is a mother of five and her main job is working as a fishing guide in the keys, then you already know you did the right thing.
Evidence-Based Practice Pearl
Don’t be shy. A steroid injection will help your patient. A collective 2003 study citing the Medline and OVID databases on all published cases of De Quervain’s tenosynovitis found an 83 percent cure rate with injection alone. This rate was exponentially higher than any other therapeutic modality (61% for injection and splint, 14% for splint alone, 0% for rest or nonsteroidal anti-inflammatory drugs). The evidence proves that injection alone is the best treatment for De Quervain’s. (J Am Board Fam Med 2003;16:102.)
Tuesday, March 31, 2015
Part 2 in a Series
Abscess incision and drainage should be loved and adored by all emergency providers because another abscess is waiting just behind the curtain. This month we highlight general guidelines for abscess incision and drainage, and show how to treat one in the video below. We will follow up with some additional videos in the months to come focusing on scalp, vaginal, and facial abscesses. And, just when you think you have seen it all, we will reveal a few more surprises.
Axillary abscess from hidradenitis. Photo by Martha Roberts.
n Identification of an abscess appropriate for I&D.
n If unsure, use ultrasound to identify fluid.
n Consider the use of IV or PO pain medication.
n Incision and drainage (I&D).
n Packing application.
n Follow up with packing removal and/or surgical follow-up.
n Consider premedicating the patient with oral Motrin, Percocet, or Vicodin, or IV medication if local infiltration is not sufficient.
n Obtain laceration tray or surgical kit for I&D.
n Put patient in comfortable position.
n Prep using sterile gloves to keep it a clean procedure, though it is not meant to be a sterile one.
n Anesthetize the skin with 1% lidocaine. Inject slowly.
n Make a horizontal incision using an 11 or 15 blade scalpel, utilizing the entire length of the abscess. Do not make just a small stab.
n Allow pus to discharge freely at first, and then assist with gentle expression of the opened cavity.
n Once the cavity is fully expressed, use forceps to delicately break up any of the capsule inside the abscess.
n Depending on the size of the abscess, rinse with gentle jet lavage: 30-50 mLs of sterile water. Four to five sterile flushes usually do the trick.
n Pack the abscess with ¼-inch or ½-inch packing gauze. Soak the gauze in Betadine prior to insertion to allow for pliability.
n Cover the abscess with sterile gauze and leave in place for 24-48 hours. Try to use as little tape on the skin as possible to avoid further discomfort.
n If there is an associated cellulitis, then antibiotics may be required. Antibiotics are usually not indicated. We will cover this in future blogs.
n When the patient returns, wash out the cavity gently. You do not have to anesthetize the patient for this procedure; just be kind to this sensitive area.
n Bonus: If the capsule floats right out, that’s a good sign! Look for a white coated gel-like discharge in sac formation. If the abscess capsule is obvious in the cavity, attempt to remove it.
n Do not be afraid to complete I&D a second time (in 24-48 hours) if the wound has not appropriately drained. This will require anesthetizing the area again.
n Do not make the incision too small because it will not drain correctly. Be sure to make it the full length of the abscess. Bigger is better!
n Do not I&D a complicated abscess of the face, neck, or foot. You may consider getting ENT, plastics, or podiatry involved for these wounds because airway, scarring, and diabetes may not allow for standard and safe healing.
n If you see one abscess, there may be more. Discuss this with your patient. Consider surgical consult for pilonidal abscesses because they tend to recur. The entire cavity may need to be completely and surgically removed. Marsupialization is only beneficial for Bartholin cysts or abscesses.
Tip of the Week
Treating an abscess in a pregnant or post-partum woman? No big deal! You can do it using good judgment and proper follow-up. Stay tuned for future blogs and video workshops when we address vaginal abscesses during and after pregnancy.
Evidence-Based Practice Pearl
What about the immunocompromised patient? These patients make us a bit weak in the knees know. Leave it to the Canadians to help us piece together the literature. A large meta-analysis and database search by Korownyk and Allen suggests even patients who are immunocompromised do not necessarily need antibiotics. Incision and drainage is the treatment for almost all abscesses.
I&D under local anesthetic is “generally sufficient for abscess management” for patients who have no confounding risk factors, the authors write. They also note that “there is no compelling evidence for routine cultures or empiric treatment with antibiotics.” And as far as cultures go, level II evidence reveals “routine cultures do not change management or outcome for patients presenting with abscesses.” We hope that clears things up for some of you, including the abscess! (Can Fam Physician 2007;53:1680; http://1.usa.gov/1vzP7rC.)
Watch a video of Ms. Roberts draining an axillary abscess.
Monday, March 02, 2015
This month we want to touch gently on treating pilonidal abscesses as we continue on our series on abscess incision and drainage. A pilonidal cyst or abscess is a fluid-filled pocket of dead skin cells, or pus. These pockets occur on the back over the tailbone, coccyx, or natal cleft. Pilonidal cysts often remain cysts and do not get infected. If the abscess is ignored or spreads (forms a fistula), then the practitioner should be concerned with a possible bacteremia or systemic infection. Infected pilonidal cysts are painful and sometimes dangerous.
A pilonidal abscess is lurking beneath the surface just above the natal cleft. It is much deeper than it actually appears when palpated. The scarring present is from prior I&Ds of the abscess. Photos by Martha Roberts.
Patients often present to the emergency department embarrassed and unsure of their diagnosis. They think they are doing something wrong, are unclean, or do not wash themselves well. This is not the case, and it is important to assure them they did not cause their ailment. Patients mainly complain of pain over their spine or above their buttock, redness or swelling over the area, discharge, and if infected, fever, nausea, or possible signs and symptoms of sepsis.
Many theories explain why some people develop pilonidal cysts or abscesses. Occasionally they occur due to ingrown hairs or infected hair follicles. Another theory is that pilonidal cysts appear after trauma to that region of the body. “[Many] soldiers developed pilonidal cysts that required a hospital stay” during World War II, and some physicians thought they formed because of the irritation from riding in bumpy Jeeps. The condition was actually called Jeep disease or Jeep seat. (Int J Res Med Sci 2014;2:575.)
This retrospective study found that pilonidal cysts are most common between ages 20 and 30, and affect men more than women. The study also suggests it is more common in physically active age groups and does not show any preference to sedentary workers.
Note that incision and drainage is only completed on abscesses that do not involve the rectum or anus. If you are suspicious of a larger area of infection or fistula, order a CT of the abdomen and pelvis with IV contrast. Always discuss your patients with a colorectal specialist in-house (if you are lucky) or as an outpatient for close follow-up. Rechecking the wound and removing the packing yourself (or by the specialist) in 24-48 hours is ideal for the patient.
It’s time to stop packing pilonidal cysts. We challenge you to try a new approach if you have not already! Vessel loop drainage is used in place of packing sutures. Vessel loop is a plastic material used to circle around the abscess and keep it open to drain. It is especially useful for abscesses in the axilla, groin, and, of course, with pilonidal cysts. The Chinese have used a similar technique called suture-dragging therapy for more than 40 years. (Case Rep Surg 2014; Article ID 425497:1.)
Vessel loop is a modern-day take on this already successful technique. This technique is best described as taking the suture thread itself and forming a loop around the abscess or channel of the abscess. The track is kept open, and each day the patient moves the threading back and forth in the cavity to help express the leftover pus in the cavity. Occasionally, a wound vac is used over larger abscess cavities to help suck out the pus. This treatment can be used with or without marsupialization where the entire cavity or pocket is cut out and excised. The Chinese admit that the incidence of pilonidal sinus in China is low, but the misdiagnosis rate and recurrence rate are high.
Overall, they found that suture-dragging therapy was less invasive, and could speed up sacrum wound cavity healing. Countless research articles also found that positive and negative pressures accelerate healing by increasing local blood flow and the rate of granulation tissue formation.
Jim weighs in: “I’ve been doing this for years.”
Martha weighs in: “If I could just get my ED to stock it….”
Abscess drained using vessel loop drainage technique. Photos by Martha Roberts
Stay tuned for next month’s blog when we bring you some pretty ugly abscess I&D videos. We will walk you through the step-by-step process of draining these abscesses correctly.
What is your best tip for draining an abscess?
Wednesday, February 18, 2015
This spring, more advanced providers will be graduating from nurse practitioner and physician assistant programs than ever before. With that in mind, we want to take a break from procedures and focus on transitioning to becoming a provider.
If it were easy, everyone would be doing it. Always let the patient be your guide when you work in the emergency department. Don’t get hung up on workplace drama or fear of making a mistake. No one is perfect, and it will take time to find your niche. It is up to you to do a good job and seize the day, each and every day from here on out. We only hope we can help you find success in your practice while having some fun along the way.
— Jim and Martha
By Martha Roberts, ACNP
One of the best days of my life (aside from my wedding and the birth of my daughter) was the day I graduated from my nurse practitioner program at Georgetown University. Soon to follow this incredible accomplishment was the day I passed my acute care board exam and received my license and DEA. At that time, I was pretty sure nothing could top those events in my scholarly journey, aside from maybe a future publication, crucial patient save, or fancy paid guest lecture. Needless to say, I was like a freight train — full speed ahead!
As I finished my five-year journey as a registered nurse, I thought to myself: “I will be a nurse forever.” This was not an end to a career but the start of nursing voyage. Optimism was definitely one of my strongest qualities, but nothing could have ever prepared me for the hardships to follow. No one could have prepared me for what came next. The transition from RN to NP was not at all what I expected.
Fortunately for me (I once thought), the hospital I had worked for as an RN asked me to stay on as a midlevel provider. It was unexpected because I had already accepted a position far, far away! The current nurse practitioner pool in this country is competitive, growing, and constantly changing. There are so many exciting opportunities for new graduates. The midlevel role is becoming more important, as is our presence within all hospital care areas. I wanted to explore a new care area and a new hospital, but it seemed to make sense for my family and me to stay. I didn’t need to learn a new computer system or become familiar with a new place. The team I came from stood behind me 100 percent, and I was ready to make them proud. The proposed transition from RN to NP in my hospital seemed like a fuzzy, warm day in spring: easy, care-free, and budding with adventure. I was right about only one of those three things.
I forgot one oddity, that the age-old phrase from the more experienced nurses in our department was, “We eat our young.” I thought this would never happen to me; I had “fans!” I always felt my hospital would be different because I had friends and people I trusted to support me through my undertakings. I assumed they would be supportive and caring and hopefully a bit forgiving as I made mistakes and triumphs as a newly-minted provider. I envisioned days where we all would work as a team to help patients, and everything would move like clockwork. What was shocking was how unfriendly, unprofessional, and cruel the majority of my nursing colleagues were during my role change.
The day I arrived to the ED in my newly-ironed and embroidered white coat, I received a few heckling comments in a “loving way,” but they had jealous undertones. When I put in orders for the first time, my nursing pals scoffed at me, and said things like, “Are you sure you want that?” or “Don’t you mean x-ray, not CT?” It was beyond stressful. When I made a mistake, my fellow nursing friends relished in my shortcomings and made me feel like a complete amateur. Instead of being helpful, they were hurtful. They were quick to tell my higher-ups that I was a failure, and they rarely said, “Good job.”
It really did not matter what I did or how hard I worked. Each day was more difficult than the last. Instead of learning from my experiences, I questioned every decision and order. I didn’t sleep, I cried to my husband and boss, and thought to myself, “I am never going to be any good.” Peculiarly, this helped me learn, and it motivated me to go above and beyond what was traditionally expected. At times, it was painful and frustrating, but I knew the time would come when my nursing friends would say, “You passed the test; we trust you.” That day has yet to come.
While my “fans” found ways to make me feel like a flop, I used their evil for good. I helped publish a text, worked on various side projects, taught, and tutored while I wrote a monthly column. I made procedural movies and took out my frustration running laps around my alma mater. I spent time volunteering outside of work, helping others anonymously, and donated efforts to those who just appreciated a helping hand. I tried not to focus on criticism and instead to capitalize on accomplishments.
What I realized was the more the other providers, hospitalists, and attending physicians liked me, the more my nursing friends hated and disrespected my title. I would order a pelvic exam or lumbar puncture and ask for nursing assistance. The nurses would say, “You are being too needy” or “Come on, you can do that yourself, can’t you?” It was depressing and disheartening. My future seemed desolate and devoid of growth. Then, one of my most beloved attendings gave me some advice I will never forget. “You were a great nurse, but it’s time you start thinking like a provider and less like a nurse.” When he said this, I frowned because I felt like I was still a nurse! He went on to say, “You will always be a nurse at heart, but you need to embrace the cycle of change. No one will respect your evolution until you do.” Although I was still confused about how I would get my team to accept me, I pondered how I was going to change and evolve. From that point on, I started actually thinking like a provider.
A provider talks to her team and doesn’t just divvy out orders. I noted how nurses responded to certain providers I knew were well liked and avoided the behaviors of those they abhorred. I treated the patient as the number-one priority, and the arguments about care technique faded like ghosts. I paused and listened to my team in hopes they would see my growth and good intentions. I took it upon myself to grow each day by speaking less and listening more. I shook hands with my colleagues instead of forcefully instructing their hands.
What I have learned from my change is to practice free of judgment — judgment of myself, my abilities, and others. There will always be people, providers, patients, and personnel who wish to keep you from reaching your goals. You will be tested each shift. What you must discern is the fact from the fiction. Be the best provider you can be without seeming pompous. Be the fastest provider that you can be without being unsafe. Be the most effective provider you can be without being unforgiving. There will always be ups and downs in the emergency department, no matter your role. The true lesson to be learned is how you deal and react to the positive and negative results. Literally.
Do not make a decision based on emotion. Remember when in doubt, check a TSH. Use your brain and the skill set you have so dearly fostered to help guide you during your time of transition or when you are lost in translation. When your team asks you, “What will you do now?” Your answer should be something, even if you are unsure. There will always be that one person who will never like you and that one patient you can never fix. In turn, there will always be an opportunity to teach and a minute to stop and recalibrate. The true champion is the one who can recognize the difference between the two.
Finally, do not beat yourself up over policies, people, or patients you cannot change. Instead, improve on the things you know you can amend. Hindsight is 20/20. When you judge someone or something, you automatically assume someone else is wrong. Believe in yourself and your final decision.
One of the best days of my life was the day I quit my job at the place I felt safe. As it turned out, I wasn’t safe there at all. As difficult as it may be to make a transition to a place where no one knows your name or your practice style, you can always depend on yourself and your training. You cannot teach kindness or a gut feeling. The dose makes the poison, so keep your daily dose of self-inflicted poison light. Board exams are easy to pass when you are up against a pack of wolves. Take a breath in the stockroom, and remain par for the course. Keep your heart open, and I guarantee you that you will continue to find success.
Thursday, February 12, 2015
Part 1 in a Series
We are pleased to bring you our first full-length tutorial on abscess drainage. Part 1 of this series focuses on set up and basics for all beginners.
It is important to note that you should practice on injection techniques and how to properly hold instruments before draining your first abscess. No one likes a shaky, unsure hand. We also believe in the “see one, do one, teach one” mentality. Be sure to check out the stockroom at your facility so you, too, can become familiar with all of the equipment used to drain an abscess properly.
Stay tuned for next month’s blog when we get down to draining the real thing. We have every abscess from the neck down!
Now, on with the show!
Click here to watch our video.