Skin Not Tough Enough?

Steri-strip and Suture Combo Technique for Repairing Fragile Skin   Old people.  They come with all sorts of problems and complications. Even simple lacerations are more complicated with them. Have you ever encountered a laceration in an elderly patient whose skin was just so fragile and thin that even your suture just tears right throughRead more

How deep should I place my CVC?

All the hard parts are done in the placement of your central line. You nicked the vein and NOT the artery. The wire threaded smoothly. You got confirmation on your ultrasound. Now, you just insert the triple lumen in over the wire. Inserting a central line to the right depth on your first try withoutRead more

Naloxone, for more than just opiate reversal

This week we have seen some interesting uses of naloxone in the Sinai ED, so let’s review: Naloxone for pruritis? Why yes. Several randomized controlled trials have shown Naloxone to be efficacious in all sorts of pruritic conditions – chronic urticarial, atopic dermatitis, Psoriasis Vulgaris – to name a few. The dose range is high,Read more

The Ten Commandments

Verbal de-escalation is a powerful and effective skill to help calm agitated and aggressive patients. This method is proven safe, effective and decreases the likelihood for restraints. Among properly trained physicians this process takes less than 5 minutes. Just follow these “10 Commandments.” Respect personal space. 2 arms length. Do not be provocative. Body language is important. Do not cross arms,Read more

Sugar the Rim

“Want to hear the funniest therapy that actually works?” – Dr. Ben Schnapp, former Chief Resident extraordinaire It was my first month of intern year, and I had just presented a patient with a recurrent rectal prolapse. Ben Schnapp, the senior resident, was delighted to show me what he said was the “the funniest therapy that actually works.”Read more

I hate Mondays!

Garfield had it right. Mondays are the worst.  Want proof? Well, in 2004 the CDC published a survey measuring health care utilization among US Emergency Departments over a 10 year period. The results? ED visits peaked on Monday and then decline throughout the week, and Medicare patients were more likely to visit the ED on a MondayRead more

Name that plethoric structure…

We are all familiar with the RUSH exam (see Dr. Weingart’s original article if you’re not). Since it’s been a recurring theme this week, we are going to focus on the IVC measurement of the spontaneously breathing patient. This will not be a discussion of which method of volume status measurement is superior (i.e. legRead more

The Matt Egan’s Wrist Memorial Radiology Pearl

Name that fracture, ideal imaging modality, and treatment including indication for operative repair: That would be a classic scaphoid fracture. It should ideally be imaged first with a three-view x-ray (AP, lateral, and scaphoid view – 30 deg extension, 20 deg ulnar deviation), but an MRI is the most sensitive for occult fractures. CT withRead more

DKA without the ICU

As we discussed yesterday, the treatment algorithm for DKA is fairly straightforward with a few subtleties we rarely appreciate, until now. Yesterday we focused on fluids, today we move on to the insulin. Can we offer the patient anything else beside an insulin drip? Obviously the answer is yes, or else this pearl wouldn’t exist.Read more

Diluting your sugar

Last week, we closed out the week by discussing the dischargable, ‘benign sugars,’ but what about when you have the legit ‘sugars.’ We’re talking about DKA. While the algorithm for DKA is fairly straight forward – fluids, insulin, replete lytes prn, admit / ICU consult, there are some often under appreciated subtleties we neglect inRead more