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…

Read More Read More

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…

Read More Read More

LUNG AUSCULTATION: HEARING CRACKLES

LUNG AUSCULTATION: HEARING CRACKLES

You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?   Sit up and take a deep breath might be bad advice?   Increase signal Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful…

Read More Read More

PNEUMONIA: CLINICAL VS RADIOGRAPHIC DIAGNOSIS

PNEUMONIA: CLINICAL VS RADIOGRAPHIC DIAGNOSIS

An elderly patient presents with cough and shortness of breath. The resident says the lung examination is normal and the chest x-ray is negative and wants to send the patient home. But you hear crackles posteriorly at the right base. And the oxygen saturation is 94%. And the patient looks ill. What do you do?   If your practice is to use chest radiograph as the gold standard for pneumonia (following IDSA guidelines – Mandell 2007) then you might be…

Read More Read More

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…

Read More Read More

DE-ESCALATING VIOLENT PSYCHOSIS: TELL A STORY

DE-ESCALATING VIOLENT PSYCHOSIS: TELL A STORY

A patient presents to the emergency department on a 5150 hold. He is yelling and straining against police restraints. Of course you will use medications but also want to try calming him down through bedside interaction.   The human mind, unhinged by disease and drugs and high emotions, needs simple, calm communication that is easy to understand. Talk to the patient in a story format. Introduce the characters and organize it chronologically (past, present, future). Make it very clear that…

Read More Read More

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,…

Read More Read More

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:  …

Read More Read More

DENIAL? IT’S ABOUT HOPE

DENIAL? IT’S ABOUT HOPE

A patient presents with a scalp hematoma from a remote fall. When you press on it, it feels very soft but is not swollen. You are confused, and order a CT, which shows complete lysis of the bone,. Further workup suggests metastatic renal cell carcinoma. The patient is avoidant on history and keeps explaining away the findings and concerns. Hours later, while he is awaiting a bed upstairs, he reveals that a year ago his doctor suspected renal cell carcinoma…

Read More Read More

DON’T CALL IT A SEIZURE…

DON’T CALL IT A SEIZURE…

Anecdote 1:Don’t call it a seizure, start CPR Resident: Hey, remember that patient in room 7 with the heart attack? Now he’s having a seizure! You: That is not a seizure, let’s start CPR! (the patient survives, and receives emergent catheterization opening a blocked vessel)   Cardiac arrest is often accompanied by jerking movements. The cartoons of the 1940s understood this. Bugs Bunny would typically do a few good jerking leg kicks prior to faking death with Elmer Fudd, Yosemite…

Read More Read More