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The Procedural Pause by James R. Roberts, MD,
& Martha Roberts, ACNP, PNP​

​Renowned emergency physician James R. Roberts, MD, and his daughter, Martha Roberts, ACNP, PNP, are the team behind The Procedural Pause.

The blog will focus on procedures that emergency physicians, 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.

This blog conveys personal opinions and experiences, and application of the information here remains the professional responsibility of the clinician. Tthis blog is not intended to dictate standard of care, but 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.

Please share your thoughts about the Roberts' posts.


Friday, February 1, 2019

​The slit lamp is a straightforward and user-friendly machine designed to make ocular exams easy. All the buttons, knobs, and lights, however, can be intimidating. This should not dissuade practitioners from getting cozy, driving the joystick, and evaluating ocular issues.

An ED slit lamp with an LED light and magnification power up to 40x. Photo by M. Roberts.

ED slit lamps are designed to be a bit more basic in function than those found in an ophthalmologist's office. Many EDs may house more complex machinery, but the vast majority of microscope and light arm combination is set at one length with one lens and one to two magnification options. Machines may be equipped with several filters (blue, red-free, green, gray), but cobalt blue is really the only one you need to rule out corneal abrasions. More basic versions of slit lamps in the ED still allow for full corneal and retinal exams.

Consider a few things before performing a slit lamp ocular exam:

  • Evaluate the space and lighting in the room. You should be able to darken the room, and make sure you have enough room; the machine often takes up a lot of space next to a stretcher.
  • Check the machine and set up. Test the machine to ensure it turns on, and obtain a wheeled stool for yourself and a chair for the patient.
  • Consider the ability of the patient to participate in the exam. Check the patient's ocular pressure using a tonometry pen before completing a slit lamp exam. See our November 2018 blog post for more tips on how to complete a tonometry exam.
  • Prepare other equipment: tetracaine or proparacaine for ocular anesthesia; tissues or gauze for the patient to blot her eyes; fluorescein dye to visualize corneal abrasions; pH paper if there is concern for acid or alkaline burns; cotton swabs for lid eversion in the case of foreign body; an 18 g needle for deep foreign bodies; a corneal burr for rust ring removal; and normal saline in 10 mL syringes for quick ocular washout.

The most important part about mastering the slit lamp exam is to have everything you need prior to having the patient put her face in the chin rest. Set up the machine for your comfort before examining the patient. This includes setting the focal length of the lens, adjusting the height and width of the slit lamp beam or light, and positioning the overall table.

Watch our video to see how to successfully set up a slit lamp machine for an exam in less than five minutes.

Troubleshooting issues with the machine:

  • Is it plugged in?
  • Is it turned on?
  • Is the bulb blown?
  • Is the beam horizontal or vertical?
  • Is the width a slit or a circle?
  • Is the intensity too bright or dull?

Jim Weighs In

  • It's important to have the patient keep his forehead close to the strap so his eye does not go out of focus.
  • Clean the chin strap and forehead bar with alcohol prep before positioning the patient.

Martha Weighs In

  • Wash your hands, and wear gloves for ocular exams.
  • Use the joystick at the base of the slit lamp to fine-tune your image.
  • Most manufacturers suggest waiting a full two to three minutes after turning on the light to reach maximum intensity and illumination.

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The round silver knob, left, is used to adjust the slit length, slit rotation, cobalt blue filter, and fixation star control. The smaller lever above it changes other filters (i.e., red-free, green). The illumination head with an LED bulb, right. Photos by M. Roberts.

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Eyepieces and diopters should be initially set to zero, left. The joystick, right, is for fine-tuning and precise movements during the examination. Photos by M. Roberts. 

This diagram shows what the buttons do and where to locate certain features of the slit lamp.

Monday, December 31, 2018

Rectal exams are difficult for the patient and require true expertise. You cannot expect to complete a good rectal exam or remove a rectal foreign body without the correct information, good bedside relationship, and the right equipment.

Ensuring your patient has confidence in your ability is vital. Take the time to get to know what equipment is available in your ED. It's important to know what to do before a patient comes to your department with a rectal complaint.


Most departments have a box dedicated to the anoscope. It typically will have two handles for light sources and two sizes of obturators with casing. The items that are not opened will remain sterile, but all other items must be sent to central processing for cleaning and sterilization after use. Photos by Martha Roberts.

The majority of patients who need rectal examinations typically require simple digital exam and proper questioning. A formal anoscopic exam may be necessary if a patient has inserted an object into his rectum that needs removal. It may also be useful to evaluate rectal pain, bleeding, and hemorrhoids. This may often require an x-ray of the abdomen or pelvis.

The anoscope is an excellent tool to complete the full exam. Pelvic speculums may be used if one is not available. A rectal block or expert consultation is warranted if the procedure requires more intricate steps.


Obturators and scopes in two various sizes. Photos by Martha Roberts.

A patient with a rectal foreign body is often afraid to discuss what happened. Occasionally, patients may not know if objects are still present. This should not shock you or deter your questioning. Your task is to discuss this objectively with the patient in a nonjudgmental way. They are more likely to discuss the object inserted if they feel comfortable with you. It is important to know when, how, and where but never why.


This patient at first said she fell on top of something before saying she purposely placed an object in her vagina. No foreign body was found on vaginal exam, but a plain A/P radiograph of the pelvis showed a foreign body in the rectum. After several rounds of questioning and some lorazepam to calm her, she explained what happened. We let surgery handle the case under sedation because the item, a vibrator, had several pieces and was too far inserted for simple bedside retrieval.

Occasionally, patients may have objects that migrated, like a patient with a recent gastrointestinal procedure that involved esophageal clipping. The clip had migrated into the rectum and could not be passed.


These images show various endoscopic clips and a feeding tube in the abdomen. The square clip at the anal canal was identified as an Ovesco or bear claw clip, which was used in an upper GI procedure the patient had months earlier. The clip is hard, sharp, and dangerous. This patient required expert consultation once our anoscopic exam failed to remove the piece adhered to the anal canal.

These objects are sharp and can cause harm if you do a digital exam. Take a thorough history before doing a digital rectal exam. You can remove the object if you feel confident that you can without an anoscopic exam. If not, complete a full anorectal exam using these pearls:

The Approach

  • Identify the foreign body in the rectum.
  • Remove it with an anoscope.
  • Use a rectal block if needed for pain control.

Key Concepts

  • Inspect the anus and perform a block if needed.
  • Insert the scope into the rectum properly using excessive lubricant.
  • Remove the obturator and visualize the rectum.
  • Inspect the anorectal mucosa while withdrawing the scope.
  • Rotate 90 degrees and visualize a full 360 degrees.

The Pause

  • Involve specialists early if colorectal or surgical consultation is needed. It is not appropriate to do multiple rectal exams and anoscopic exams for patients with difficult foreign bodies. This can cause trauma and physical and emotional harm to patients.
  • Immediately discuss the procedure with the patient. Most if not all patients would like to know what objects or equipment might be involved in the process. Show them the equipment and explain the procedure before starting. Maintain a nonjudgmental attitude that is reassuring for the patient. Consider prior medical history such as anxiety, depression, and PTSD.
  • Offer anxiolytics or pain relief during this procedure. This may mean the use of oral or IV benzodiazepines or narcotics. Propofol may be indicated for procedural sedation if the object is far up in the rectum.

The Procedure

  • Allow patients to be comfortable. The lithotomy position is preferred. Another way to complete this procedure is to have the patient lay on his side in a left lateral position or fetal position. A partner may help hold the gluteal cleft open for larger patients. A patient may prefer to be on his back if a gynecological bed is available.
  • Always tell a patient what you will do before touching him.
  • Insert all equipment slowly and give relaxing messages to your patient.
  • Excessive lubricant is suggested.
  • Be patient. It may take a few deep breaths or encouragement to relax the muscles of the anus.
  • See our video below to see how to insert the anoscope.
  • Once you have targeted your object, you will need to remove it with the right equipment. Make sure you have forceps, tweezers, and hemostats ready. Do not make a patient wait while an assistant gathers this equipment.
  • A rectal block prior to internal exam may be appropriate, especially if painful hemorrhoids are present.
  • Draw up two 10 mL syringes of 1% lidocaine. Anorectal blocks involve anesthetizing the subcutaneous tissue of the anus using a 27 g needle (about 2 cm) with 1% lidocaine or bupivacaine.
  • First complete a subcutaneous circle of local anesthesia around the anus, about 2 cm in diameter. Inject at the 12, 3, 6, and 9 o'clock positions. Inject 3-4 ml in each area while holding your needle at a 45-degree angle laterally. See our video for technique.
  • You can then dilate the rectum with a speculum or obturator for your exam and complete further pain relief blocks. Be sure to visualize a 360-degree spectrum of the rectum.


Watch a video showing how to use an anoscope and how to do a rectal block.


  • Sharp foreign bodies need expert consultation. These can be dangerous for the patient and can tear the skin and rectum. It can also be dangerous for the provider and cause injury.
  • Patients must be comfortable and relaxed. Attempt to do this without medications, but occasionally oral or IV anxiolytics such as lorazepam or diazepam are appropriate. Pain control is not typically necessary, but it depends on your assessment.
  • Moderate sedation with propofol may also be an option. Discuss options with the patient and your surgical team.
  • Perforation of the rectal mucosa can lead to abscess formation.
  • Food, wood, and glass can cause perianal infections and lead to sepsis.
  • Because of potential complications, rectal foreign bodies should be regarded as serious emergencies and treated expeditiously.

Tuesday, December 4, 2018

The atomizer is a handy tool to instill life-saving medication into the nose, and you should consider stocking them if you don't already. An atomizer can be used to administer naloxone and countless other drugs as well as for moderate sedation and pain control. Pediatric and adult patients alike can benefit from intranasal fentanyl or Versed. Studies on intranasal epinephrine for anaphylaxis also look promising, but it does require a higher dose—5 mg instead of 0.3 mg. (Asian Pac J Allergy Immunol 2016;34[1]:38;

The atomizer is easy to use and can be attached to any syringe. Each spray creates a fine mist, which can penetrate the mucus membranes. You can administer about 0.5-1 mL of fluid per pump. Keep in mind the dosage of intranasal medications is often higher than that of IM, IV, and oral doses.

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Dr. James Roberts demonstrates the use of a traditional atomizer.

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Three 1 mL syringes with standard-sized atomizers. Photo by M. Roberts.

Opioid Struggle

More than 33,000 people died from opioid overdoses in 2015, including prescription pain relievers, heroin, and fentanyl. (National Institute on Drug Abuse. Naloxone is a nonselective and competitive opioid receptor antagonist, and reverses central nervous system depression caused by opioids. It can be used intravenously, intramuscularly, intranasally, and even nebulized.

Naloxone has been around for almost 50 years. It is well researched, well studied, and abundantly used. The drug has been FDA-approved since 1971, and is on the World Health Organization's list of essential medications. (

If you are ever in doubt about whether to administer naloxone, err on the side of caution and give it. Do not wait for an intravenous line. The side effects (tachycardia, agitation, sweating, and vomiting) are minimal, and the benefits outweigh the risks. You may need to give additional doses, and some patients end up on naloxone drips to remain semi-conscious.

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Narcan (naloxone) individual spray units.

The general cost of Narcan nasal spray 2 mg/2 mL dose kits is less than $100. (GoodRx. Many insurance companies will cover all, some, or part of the cost, up to a co-pay or outright cost of $144. Medicaid, however, may not pay for the atomizer, and those patients may need an IM injection kit. You will want to consider the patient's insurance plan when prescribing this; only 63 percent of Medicare Part D and Medicare Advantage plans cover generic naloxone and Narcan, according to GoodRx. (

Pharmacies also sell generic naloxone for $20 to $40, and distribute a full naloxone kit with an atomizer or autoinjector, which includes everything needed to reverse an overdose. Some also distribute it without a prescription in more than 45 states. (USA Today. April 6, 2018;

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Watch as Dr. Roberts and Ms. Roberts talk about all things atomizers and naloxone. Stay tuned at the end of the video for an interview with Edward Bernstein, MD, a professor and the vice chair for academic affairs in emergency medicine at the Boston University School of Medicine.

Jim Weighs In

  • Consider using naloxone for clonidine overdoses. (Ann Emerg Med 1986;15[10]:1229; Clin Toxicol [Phila] 2018;56[10]:873.) We get a lot of calls about this to poison control. Our current recommendation for clonidine overdoses includes trialing naloxone for severe confusion or mental status changes.
  • Children and suspected overdose patients who are unresponsive should receive a dose or two of naloxone.

Martha Weighs In

  • Commandeer another piece of valuable equipment in your ED if you do not have an atomizer. The nebulizer can be used with a naloxone solution just like you would do a breathing treatment. This can be critical when you do not have IV access. Pour the solution into the nebulizer, turn it on, and let the patient slowly wake up. Bolus IV doses may be necessary.
  • Do not dump the syringe liquid (2 mL) into the nostrils. It causes patients to gag and vomit and can be a huge aspiration risk.

Additional Links

  • Prescribe to Prevent ( This website is run by prescribers, pharmacists, public health workers, lawyers, and researchers working on overdose prevention and naloxone access, and offers information about prescribing and dispensing rescue kits and other resources.
  • Dr. Edward Bernstein's Project ASSERT (Alcohol & Substance abuse Services, Education and Referral to Treatment; This program in Boston Medical Center's emergency department helps patients find treatment and care. Read an abstract about Project ASSERT at

Friday, November 9, 2018

Identifying and managing disease often requires the delicate and skillful use of temperamental emergency department machinery. The ability to apply these may appropriately help determine a difficult diagnosis.

Glaucoma, we all know, can cause blindness, and acute narrow angle glaucoma refers to the angles within the eye that are not as wide and open as normal. People with acute angle glaucoma have abnormal anatomy within the eye where the angle changes as the eye is dilated. This can cause blockages of fluid drainage from the anterior to posterior changes resulting in increased intraocular pressure. It ca lead to acute angle closure or crisis if the drainage canals become blocked in an eye with narrow angles. A sudden and rapid increase in the intraocular pressure can lead to a variety of symptoms and cause damage. Damage to the optic nerve can occur and cause permanent blindness if the pressure is high enough.

Patients presenting with potential acute angle closure or crisis should be treated without hesitation. Some patients may know their diagnosis, but many may not be aware of the risk. The proper use of the tonopen to measure ocular pressure is crucial to making this diagnosis. Providers must first recognize the classic signs and symptoms of angle closure. Patients often complain of a headache, unilateral eye pain, halos, painful vision, loss of vision, or nausea or vomiting. Patients may have decreased visual acuity or inability to read, an angry red eye, a dilated pupil, or a hazy cornea. Symptoms may mimic a migraine headache, but the astute provider will notice that the ocular symptoms are much more pronounced in angle closure. This is when the tonopen is put to use.

Most tonometry machines come with a user manual and an instructional video that are well worth the time to read and watch. Several types of tonopens are available: Some need to be calibrated, and some are ready to use. Use whichever is easiest for you to master.

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The tonopen is delicate and must be handled with care. It should be stored in a hard box with padding. Store it with a cover on the tip to protect it. Use a condom cover cardboard wrapping to cover the transducer while it is in the box. Be sure to use the right tip cover for your tonopen to ensure accurate readings. Photos by Martha Roberts.

The Procedure

  • Have the patient sit comfortably in a chair or on a stretcher. You can take a pressure with him lying flat, but it won't be accurate and is more difficult.
  • Consider managing the patient's pain first and adding an anxiolytic, such as morphine or valium, especially if the patient is very anxious or uncomfortable. This is painful.
  • Anesthetize the eye prior to taking the pressure. Use two to four drops of proparacaine hydrochloride ophthalmic solution 0.5%; that should be enough to anesthetize the eye surface for about five minutes, depending on how much your patient is crying. Have the patient hold a tissue against his cheek while you drop in the medication.
  • Tell the patient he will initially feel a burning sensation, then relief, and then more burning.
  • Always put the condom cover on the tonopen before using it.
  • Calibrate the pen if required after applying the condom cover.
  • Wait about 60-90 seconds before taking a pressure. If you wait for more than five minutes, the numbing agent will start to wear off.
  • Tap the transducer on the anesthetized cornea. The tonopen tip should be perpendicular to the cornea.
  • Use light, quick touches. You will hear the tonopen make a clicking sound to ensure it is reading the taps as it calculates the pressure.
  • Keep the transducer head as flat and direct on the cornea as possible. Do not press into the eye.
  • Do not hold the patient's eye in any way. You may rest your hand on his forehead or nasal bridge, but holding the eye will give you a false high reading. Don't pull down the lower lid or pull up on the upper lid if at all possible.
  • If you have to assist a patient with keeping his eye open, hold onto his eyelashes instead of the lids themselves.
  • You will have to touch the cornea 10 times. The machine takes an average of these 10 taps and displays the pressure as a single reading on the window.
  • The statistical calculator indicator is the small number (usually) on the window. It is usually in the 90 percent range on readings done correctly. If it is lower than that, consider rechecking the pressures.
  • It is suggested you check the pressure in both eyes and compare the values.
  • Some tonopens show the message "Or Err," and you should consider this a true concerning pressure that is very high. If you are using the pen correctly and receive this message, it is not because the pen is broken. It is more likely the patient has a severely high pressure and it cannot be measured.

Treatment While Awaiting Consult

Clinicians should provide immediate treatment to reduce intraocular pressure if an ophthalmologist is not available within an hour to confirm the diagnosis and the patient has a significant decline in vision (cannot read text or count fingers). Try to decrease the pressure by instilling cholinergic drops. This results in miosis.

Give one drop of timolol 0.5% to the affected eye, wait one minute, and then give one drop of apraclonidine 1% to the affected eye. Wait another minute, and then give one drop of pilocarpine 2% to the affected eye. Wait one more minute, and then give 500 mg IV acetazolamide (give by mouth if IV is unavailable). (UpToDate. 2018.)

  • Recheck the pressures every 30 minutes.
  • Systemic medications other than acetazolamide (such as IV mannitol) should be administered under the guidance of an ophthalmologist because angle closure should be confirmed before they are given.
  • Ophthalmologists will consider additional treatments like iridotomy to open the angles if pressures are higher than 40 mm Hg. This is a laser procedure and the preferred method of treatment. It can also be used as a preventive treatment for patients at high risk or with borderline pressures.
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"Or Err" means the pressure is extremely high. Don't be fooled by this reading. Photo by Martha Roberts.


Several medications can increase intraocular pressure by narrowing the angle. Medications that block acetylcholine may increase the risk for narrow angle closure.

Medical Concern                Medications that May

or Diagnosis                       Increase Intraocular Pressure*

Anxiety, depression             SSRIs such as Prozac and Paxil; Vistaril

Nausea and vomiting          Phenergan

Muscle spasms                   Norflex, Artane, Cyclobenzaprine

Asthma, COPD                   Any steroid (prednisone, Decadron), Atrovent,

                                           or Spiriva

GERD                                 H2 blockers, Tagamet, Zantac, Detrol

Incontinence                       Detrol, Ditropan

Other                                  OTC decongestants, ephedrine, Benadryl,

                                           sulfa-based drugs (Bactrim, Topamax),

                                           many antipsychotics

*Incomplete list.

  • Advanced age, female gender, hyperopia (farsightedness), and family history of angle closure and narrow angle glaucoma may increase the risk for closure.
  • Ocular and systemic steroids can increase intraocular pressure. Eye pressure should be checked in patients on long-term steroids and those who need steroids for more than 10 days.
  • Other reasons to check the intraocular pressure include trauma from blunt force or significant corneal abrasions.
  • Consider possible contraindications to medications for treating increased intraocular pressure (i.e., beta blocker contraindicated with severe bronchospasm, second- or third-degree atrioventricular block, uncompensated heart failure).
  • Consider higher doses of Zofran for nausea such as 8 mg. (UpToDate. 2018.) Do not give Phenergan if at all possible.
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Watch a video of Dr. Denis Dollard demonstrating how to use a tonopen.

Jim Weighs In

  • You should be checking pressures in any painful, angry red eye.
  • Put your tonopen back in the same spot every time.
  • Consult ophthalmology immediately if a patient has an elevated pressure. Very high ocular pressures are generally between 40 to 70 mm Hg (normal is approximately 8 to 21 mm Hg).

Martha Weighs In

  • Does your patient have a corneal abrasion? Give him one 5 mg tablet of PO diazepam to go. Let him get a restful night's sleep so the eye has adequate time to heal.
  • Never use the same condom twice and change it between eyes.
  • Never check someone's eyes without wearing gloves. You can transfer nasty germs into the eyes even after handwashing, so glove up.
  • The American Academy of Ophthalmology has some absolutely awesome information:

Disclaimer: No financial compensation or other compensation was provided by Reichert in the making and publication of this blog.

Saturday, September 29, 2018

It's a good idea to find the ring cutter in your department before you need it. Know where it is, what the box looks like, and if it's electric or manual. Some departments may even keep it in the PIXIS or medication dispensary machine. You will also want to know where you keep your vice grips, wire cutters, and spreaders.

A patient with a hand injury must have his ring removed immediately. Lacerations, crush injuries, burns, degloving injuries, fractures, and even hand or finger contusions require prompt removal of any constrictive device. Swelling in the distal extremity can occur around the injury. The space in the hand, especially the joint space, is small and unforgiving. You must act fast and remove the ring because it can cause diminished blood flow, incarceration, or necrosis to digits rapidly.

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Using a manual ring cutter: Set up and act quickly. Photo by Martha Roberts.

Removing a ring from a finger can be tedious and troublesome. Occasionally, rings can be removed by using a lubricant such as petroleum jelly. Other rings may slip off if soaked in icy or soapy water. When those fail, the string method may work. (This technique will be discussed in a future post). For time's sake and to minimize trauma, a manual or electric ring cutter may be used to promptly and safely remove constricting metal, silver, and gold bands.

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Don't let this degloving injury scare you; this ring can be easily removed. You must anesthetize this finger before attempting removal because any contact with this area will be extremely painful. Photo by Martha Roberts.

What happens if your patient is wearing a Tungsten ring instead of a silver, gold, or metal one? Tungsten cannot be cut off or removed using a manual or electric ring cutter. You will need a Vise-Grip or some kind of locking pliers that can apply continuous and mounting pressure. These pliers crack off Tungsten rings instead of cutting. The cracking technique requires mounting pressure, and may need to be done several times before the Tungsten breaks. Simply place the Vise-Grip around the ring and squeeze. It will shatter. Check out this technique at

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Vice-Grip pliers are great for snapping off Tungsten rings. Photo by Creative Commons.

Sometimes you can get a ring cutter to gnaw off most of the ring, but that last little bit causes trouble. You can use a pair of mini wire cutters to snap through the last piece of the ring. Simply wedge the wire cutters into the space where you have been cutting and squeeze.

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Watch a video showing a ring removal with bonus footage of a degloving injury.

Ring Cutting Pearls

  • Anesthetizing the finger is necessary to allow proper placement of the ring cutter and to reduce anxiety and pain.
  • Electric or rotary ring cutters need a good, sharp blade. Swap out the blade if you aren't making progress.
  • A ring fully embedded in the skin cannot be removed without destroying it. Be sure to tell your patient that is going to happen.
  • Give your patient the pieces. Tungsten rings are usually guaranteed for life. The manufacturer will most likely replace it if it breaks (even on purpose).
  • If you're taking off a Tungsten, metal, silver, or gold ring, don't slide the pieces off the finger. Carefully peel back or pop off the layers of the ring or it will cut and damage the skin further.
  • Bee stings, animal bites, and even scratches to the hand or foot require immediate ring removal, even if swelling isn't initially present.
  • Double hemostats will also work if you don't have a spreader. See this demonstrated in the video.
  • Check with your maintenance department if you can't find the right tools. They will know exactly what you need.
  • Ring cutters are also useful for toe or penile rings.
  • Hand, finger, toe, and penile swelling aren't just related to trauma. Make sure you tell patients who are fluid overloaded, septic, and preparing for admission or surgery that they need to take off their rings as soon as possible.