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Category: Bedside Procedures

HOW TO DIAGNOSE SEPTIC ARTHRITIS

HOW TO DIAGNOSE SEPTIC ARTHRITIS

The biggest challenge in diagnosing septic arthritis is to think of it. Once you think of it, there is a diagnostic process that you activate. The second biggest challenge is that that diagnostic process we learn in training is flawed. We have no alternatives right now, so I will share with you my thoughts on how we should use our judgment as clinicians.   Triggers to consider septic arthritis essentially are the same triggers as infection anywhere. Celsus’ cardinal signs…

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SOFT TISSUE FOREIGN BODY: PAIN WITH MANIPULATION

SOFT TISSUE FOREIGN BODY: PAIN WITH MANIPULATION

A patient presents with redness and swelling. There had been a wound there 2 weeks before and the patient is worried about retained foreign body. Xrays are negative for foreign body. The student tells the patient “Good news! The xrays show there is no foreign body there!”   You wince a bit. Every mature clinician must know the limitations of the tools they use. I want to take a divining rod to the beach and see if it knows which…

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REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

REAPPROXIMATING MID FOREARM FRACTURES THROUGH ANGULATION

A patient presents with a mid forearm fracture. Reduction is tough because it is 100% displaced. Unlike distal fractures, you can not grab the bone as it is surrounded by muscle. It is hard to pull enough traction to reapproximate. Now what?   Try angling more during your reduction, exaggerating the angulation. Now it is slack enough you can put the distal piece on the proximal piece. Use your other hand to guide it on manually. Once the two pieces…

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AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.   A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the…

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INDIRECT LARYNGOSCOPY

INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?   Dental mirror – they are cheap, have your ED stock them   Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to…

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FINGER TEST FOR NECROTIZING FASCIITIS

FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.   Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make…

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BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?   In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The…

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JAW THRUST MASK GRIP

JAW THRUST MASK GRIP

You are intubating a critically ill patient. The first intubation attempt fails and the patient experiences rapid oxygen desaturation. The respiratory therapist tries to ventilate the patient but air leaks out around the mask with each breath, spraying bloody froth on those nearby. The chest does not rise and the saturation is dropping. You want to help. Let’s address some questions that come up on this topic:   What is the problem when air leaks in face mask ventilation? When…

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UNLOCKING SHOULDER DISLOCATIONS

UNLOCKING SHOULDER DISLOCATIONS

A patient presents with a recurrent anterior shoulder dislocation. Milch fails but Spaso works. The next month she is back and the procedure feels different, with more resistance. This time Spaso fails and Milch works. Same shoulder, so what is different? Why did the efficacy reverse?   Milch’s 1938 article started with a question: why do some reductions seem impossible and then under general anesthesia they become very easy, almost going in spontaneously? It was the muscle and tendon opposition,…

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KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

KOCHER INTENDED FOR SUBCORACOID DISLOCATIONS, NOT SUBGLENOID

The Kocher technique, one of the oldest and most popular techniques, was developed for the subcoracoid anterior dislocation. Review Neil Cunningham’s resources at shoulderdislocation.net for insight on this, as well as his translation of the original Kocher article.   The goal of Kocher’s method, which was worked out on cadavers in 1870, is to roll the greater trochanter of the humeral head on the glenoid rim. It might have been named the “shoulder rim roll.” Here are the steps:  …

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