Michelle Lin, MD, is a hero to emergency physicians everywhere. She didn't end crowding or ensure higher reimbursement, but her contribution is just as valuable to every doctor who has treated a patient with what she calls “Toxic Sock Syndrome.”
If you've never heard it called by that name, you've no doubt experienced it. EMS brings in a 40-year-old homeless man, and his feet exude a smell that permeates the ED. The culprit: Poor hygiene, perspiration, and proliferating bacteria producing the foul-smelling isovaleric acid. The fix: Use a base to neutralize the acid. The method: Put an antacid like Mylanta or Maalox into booties and onto the patient.
Suppose this same patient also had a large thigh abscess, another offender to the nose. “How do you minimize the smell of pus during the I&D? Pus is in a closed system so why can't we move it to another closed system? Make a tiny lac, just to get the Yankauer in, and suction the pus directly into a closed canister,” said Dr. Lin, an associate clinical professor of emergency medicine at the University of California San Francisco and San Francisco General Hospital.
In her talk at the American College of Emergency Physicians Scientific Assembly in Boston, Dr. Lin outlined several tricks of the trade to help make emergency practice easier, such as the frightened 6-year-old who presents with a scalp laceration after falling against a table corner. After measuring the wound and setting up good lighting, it's time for the staple gun. “You fire one off. What's the next thing that happens?” Dr. Lin asked. “There's crying. The child's crying, the mother's crying, you're crying.”
And how likely is it you're going to get another staple in without a struggle? The answer: Use two staple guns simultaneously. “Now the kid's crying, the mom's crying, but you're out the door writing the disposition,” she said with a laugh.
The HAT Trick
Another handy trick, Dr. Lin said, is to use the hair apposition technique. Because scalp lacerations usually still have the follicles intact, emergency physicians can use opposing hair strands, making a 360° twist of the hair and applying tissue adhesive at intervals along the length of the wound just as you would staples, she said. “Don't tie a knot because it will unravel,” Dr. Lin said, “and patients don't have to come back for staple removal; the hair will just unravel.”
Contraindications to the HAT trick: a laceration more than 10 cm, grossly contaminated wounds, active bleeding from the laceration, significant wound tension, and hair strands shorter than 3 cm.
A 30-year-old pedestrian is hit by a car, and presents with a right index finger laceration and a right second metacarpal fracture. The laceration continues to ooze; how do you stop it? Dr. Lin suggested cutting a finger off a latex glove, cutting a small hole in the fingertip, and rolling it down your own finger. Once, the glove “ring” is rolled up, it's easy to slide onto the patient's finger.
Bandaging the finger laceration requires its own technique as well, Dr. Lin said. Cotton tubular gauze comes with its own applicator, but it often disappears, never to be seen again. Instead, trying using a speculum, which is always available in the ED. Load the gauze tube onto it, she said, and slide it onto finger. For patients who balk at the use of a speculum, Dr. Lin tell them it's called the “Digi-Spec.”
More Tips and Tricks
- ▪ A 45-year-old morbidly obese woman arrives by ambulance for severe asthma requiring intubation. How do you maximize your chances for a successful intubation? Hold the larygnoscope handle as close to blade as possible to maximize lifting force. “Grab at the point where the blade meets the handle; this gives you so much more control when you want to maximize your lifting force,” Dr. Lin said.
- ▪ An 8-year-old boy is successfully treated for a moderate asthma exacerbation. What do you include in discharge instructions? Don't just give instructions, she said; discharge him with an MDI and also consider giving him a spacer. Attach it to a short strip of ventilator tubing and then to the back of a Styrofoam cup. Also determine if the patient is on the correct outpatient asthma medication regimen, and adjust accordingly.
- ▪ A 50-year-old man has eye pain from pepper spray by the police, and the patient is extremely sensitive to application of anesthetic eye drops. How can you apply them more gently? “Blink them in,” said Dr. Lin. Have the patient look toward the ceiling and close his eyes, and then apply the drops into the medial canthus and have him slowly blink the drops in.
- ▪ You try to apply a Morgan lens for ocular irrigation, but the patient pulls it out. How can you irrigate the eyes? Use nasal cannula irrigation. Place the prongs right over the nasal bridge, and even add 10 cc of lidocaine if the patient still has pain. Be sure to have plenty of towels around as the liquid streams over the eyes and down the face.
- ▪ A 25-year-old woman sustains a clean, shallow laceration very near her upper eyelid. You don't want to glue the eyelid shut so how could you safely close the wound with a tissue adhesive? Easy, said Dr. Lin, using a tip from Dr. Hagop Afarian: Cut a small circle out of a transparent Tegaderm dressing, and place the dressing with the hole over the laceration. Apply a wound adhesive to the skin, and any that runs won't get on the patient's skin or glue her eyelid shut.
Other uses for tissue adhesives include securing an avulsed fingernail, an idea from Dr. David Carr, and for closing wounds under slight tension. Put Steri-Strips down and shellac the whole thing down with glue or start with glue on the skin, and layer on top with tape and another layer of glue, Dr. Lin said.