Archive for category Medical and Surgical Procedures
I think we’ve all experienced what I like to call “case envy.” Or even sometimes, “shift envy.” You come on and your colleague immediately starts telling you about the interesting case, or the polytrauma, or the fantastic save/diagnosis/procedure that they just completed.
“Hey, bud, I just performed an open thoracotomy, cross-clamped the aorta and threw in a central line just after performing a cric while I was watching this guy’s aorta rupture during my ultrasound of his belly during which we lost pulses. Sorry about the rest of the mess here in the ED, but those three pelvics and a disempaction might yield something interesting… Enjoy your shift!”
I sometimes hear the story and wonder what I might have done. Would I have handled things the same way? Is that the diagnostic approach I would have followed? Would I even have considered things the same way? Why don’t I ever get the cool cases…?
In residency, we had one colleague who was the perpetual “Black Cloud.” Now, they got to see a lot of cool stuff. However, you didn’t want to follow them because you knew it was going to be chaos in the ED when you arrived. And, if you came before them, you knew the last part of your shift was going to start going to pot about an hour before the end of it.
So maybe it’s not so bad being a bit of a white cloud… but still… I think we all like to have a little something that gets the juices flowing, the mind working, a bit of “yeah for me” moment… After all, that’s why we got into Emergency Medicine… at least for me… how about you?
I, sir, am a convert.
I had read about Dr. Cunningham’s technique at his website, shoulderdislocation.net. I was amazed at his videos, but honestly didn’t believe them. Painless? No pulling? And no procedural sedation? I didn’t think it was possible.
Until last week.
A 16 year-old boy came into our busy Peds ED after having been pushed, and had fallen onto the shoulder; he was neurovascularly intact but clearly out. He was in pain as I unwrapped the EMS triangle gauze wrap and placed him in a shoulder sling, but was very calm, not screaming or tearful, and I thought, today’s the day to try this. I gave him a shot of subcutaneous morphine, and by the time he was back from x-ray, he was resting comfortably. I explained my two options like this: “I have one technique that I can try right now, it will have no pain, and can try to get your shoulder back in in about 5 minutes. And if that doesn’t work, we will put in an IV, and give you some medicines to make you sleepy, and then put it in that way.” Wanting no needle for the line, he wanted to try the Cunningham technique. Literally 3 minutes later, it was reduced.
Dr. Cunningham does a much better job of explaining his technique at his site than I would, so I’ll recommend everyone to head over there and read through it, but after it worked last night, I was on Cloud 9. None of my colleagues believed me. “Painless? No sedation? No way.” (This was especially satisfying and helpful, as I was also managing a little girl with a spiral tibia fracture that needed procedural sedation for some reduction; it would have been nursing suicide to tie up two nurses for two procedural sedations. We were being triaged a good 7 patients an hour at the time.)
I do want to share several tips and suggestions on this technique:
- Read through Dr. Cunningham’s analgesic positions. There are essentially two positions in which a patient will hold their arm if it’s dislocated, and these are positions that are pain-free for the patient. More on position 1 and position 2.
- Watch the videos a couple times. They really are amazing.
- You have to have a calm, compliant patient, and they have to trust you. The technique truly is painless, but if they don’t trust that you aren’t going to hurt them, or they’re anxious or tense, it’s not going to work. I tried this technique a few weeks ago with an obese, very tense woman (despite narcotics) and it didn’t work. I had to sedate her with a tiny touch of Fentanyl/Versed, and it popped in immediately with 30 seconds of the FARES technique.
- I’ve emailed back and forth with Dr. Cunningham for some clarifications that I wanted to share with you about his technique. The most common mistakes?
Patient position – shoulder slumped forwards or to the side (abduction). You can massage all you like, the humeral head won’t slide laterally in this position. Again “sit straight up, lift your head up, chest out, shoulders back, relax as much as you can.”
Your position – sat/knelt too far forwards or to the side, pulling patient’s humerus into anterior flexion or abduction.
Traction – the more you pull, the more the patient will pull against it, stopping relocation.
Spasm at point of reduction – prep your patient that the actual relocation might feel a bit strange (whatever technique you use) and that if they feel the shoulder move and it feels strange to just relax and let it move, if they spasm at this point it might hurt and abort the reduction (OK as long as you can explain this to them, take your time and go again).
What does “shrug your shoulders” mean to him? (I described this to my patient as “When your teachers tell you you’re slouching, and they ask you to sit up straight and fix your posture.”)
Shrug – I use the term shrug as the simplest way to describe to a patient what I’m actually aiming for. Most patients will be starting with the shoulder slumped forwards, this has the effect of placing the scapula in an anterior position (rotated and anteverted). In this position the humeral head has to move a long way anteriorly past the glenoid rim before it can move laterally and reduce – this basically means that it will not reduce in any of the ‘humerus in adduction’ manoeuvres (mine, Kocher’s, external rotation etc). The scapular position you are aiming for is retroversion and a posterior position (glenoid rim moves back, little anterior humeral head movement required, can just slide laterally). Possibly a better way to word this is (to patient) “sit straight up, lift your head up, chest out, shoulders back, relax as much as you can.” (Try this on yourself, you’ll feel your own back, scapulae and shoulders moving where you want them). You definitely don’t want them actively shrugging or nothing will move.
Dr. Cunningham also admits that we should always be tailoring our technique to our patient: “If you find yourself spending >5 mins on massage (and happy that patient as relaxed as can be) then the problem is almost certainly positioning, try and visualise yourself and your patient from ‘a few steps back’ to see what you can improve, or try a different technique.”
- Update: A few more pointers from Dr. Cunningham. On my obese patient I had tried it with and failed:
It can be difficult/impossible to perform Kocher’s or Cunningham manoeuvre on obese patients simply because they can’t adduct the humerus enough. This means that the articular surface of the humeral head is not opposed to the labrum (for an easy slide) and the anterior joint is under more tension. I normally prefer either a Milch or a scapular manipulation manoeuvre for the obese.
And on Analgesic Position 1:
this is the easiest way to get the patient into the position but the key is the relationship between the humeral head and the scapular glenoid rim. So in fact you can get this position with the patient on a chair, trolley or I’ve done it with patient supine – standing next to bed with one hand around mid humerus and the other holding the wrist keeping the elbow at 90 degrees and the wrist supinated. Asking the patient to put chest out and shoulders back at this point while massaging biceps does the trick. I have used this a couple of times with trauma – awake patient with a cspine collar on who you really don’t want to manipulate neck/shoulder or sedate.
A big thanks to Dr. Cunningham for his technique, for helping my patient (and of course, making me look like a total baller in the department). In the right patient, it works like a charm, and the 3 minutes you invest in talking calmly to the patient, gaining their trust, and helping them relax is worth the 20-30 minutes you save filling out sedation paperwork, hooking them up to the monitor, having the nurse draw up the meds, sedate the person, reduce the person, and then wait for them to wake up before they can get post-reduction films.
Dr. Cunningham is working on putting together some more videos shortly that provide tips and troubleshooting. I look forward to them!
Wanted to alert our readers (Hi mom and dad!) to a fantastic site that I dare say is the “Emergency Medicine Clinical Ultrasound Site to Beat,” out of Hennepin County Medical Center from our friends in Minneapolis. Boy they have some great pathology — and they capture it all on ultrasound! (Being a Midwesterner myself, I can’t believe they’re so violent there. We’re! So! Nice!)
One of my favorites: Man stabbed with cooking knife, is embedded below.
A special plug for Stephen Smith’s (yes, the ECG maven Stephen Smith) Acid-Base Disorders lecture, which is, as you might have guessed, all about Acid-Base. But it’s about as clinically relevant as you can get in the ED, very high-yield, and very clear. I’m pretty sure it’s the best Acid-Base talk I’ve ever seen, and yes, I think it’s worth an hour of your time (and worth the required Microsoft Silverlight browser plug-in).
And finally, if you weren’t aware, Vanderbilt has a bunch of also-super-high-quality and high-yield ultrasound tutorial videos. Please check out both sites, you won’t be sorry!
Web video is really revolutionizing procedure training in the emergency department: when I have a procedure I want to teach an intern, I pull up a video during a shift, have them watch it, and then have them practice it in front of me before we go see the patient. Case in point: the shoulder reduction video from the now-defunct (or on hiatus) Keeping Up in EM site from the great guys at Vanderbilt. Goes through a bunch of the techniques, super high-quality video, super instructive:
Two more plugs: Michelle Lin recently had a great tutorial on the Legg Manuever, and if you need to review your orthopedic exam, this guy at Orthopedic Assessment Methods blog has a bunch of high-quality videos as well.
Also: if you’re curious what they’re talking about in the video, it’s from this paper.
I think the first and most lasting memory we all have of medical school is cadaver lab. That is where we met our first patient and started to learn about disease processes. It’s where a lot of us experienced death up close for the first time and began our lifelong pursuit of staving it off for as long as possible. We shared the experience with our classmates – bonding us together as future physicians. So many friendships (and a few romances) were made over that cadaver.
I remember the nervousness as we decided who would make the first cut. We started our dissection on the upper extremities, and that first incision to expose the flexor muscles of the arm seemed so impossible. Who were we to cut into another person? Shaking scalpel aside, we made our way through.
Today I was faculty at my final cadaver lab of my residency teaching the junior residents advanced procedures such as venous cutdowns and thoracotomies. There was no hesitation in their hands as we identified landmarks and dissected out veins. Everyone reached for the scalpel in anticipation of making the thoractomy incision. Eager hands reached in to find and cross-clamp the aorta. No nervousness here. Everyone was eager to cut and learn.
As I count down the final several weeks of my residency and look to my future as an Emergency Medicine attending, I find myself thinking back more and more on my training. Days like today take me back to where I started; scared, unsure, wondering if I would be able to pick up that scalpel. Now I can see where those first tentative days have led me to. And, I thank all of those patients who gave of themselves along the way so that I could continue the promise I made to that first patient so many years ago… ”Rage, rage against the dying of the light…”
In my short Pediatric Emergency Medicine career, I have successfully:
- burrito-wrapped my fair share of pediatric laceration patients;
- debrided 3rd degree burns with IM ketamine;
- removed cockroaches from ears, and
- sutured a sleeping child.
But never, ever in my career have I sutured a child without them screaming bloody murder. Until today, ladies and gents.
God bless you, Spongebob Distractionpants. For the low price of $1.99 (and your iPhone service plan, of course) you can download an episode from iTunes and totally distract a kid — without any respiratory depression or squirming!
It did absolutely nothing when I tried to distract the kid during the lidocaine injection, but once he was numb, I was suturing up his lip, dragging suture material along his face and waving suture instruments near his mouth and eyes without an ounce of fear — or even interest. He was totally, absolutely, completely fixated on my iPhone showing the SpongeBob episode. (And works faster and more reliably than PO versed.) Thank you, inherent distractability of the immature mind!
(The febrile 2 year-old tonight with otitis would have none of it, despite me going for a Yo Gabba Gabba episode, in case you’re wondering.)
My name is Scott Weingart. I’m an emergency physician intensivist from New York. For the past ten years, I have been hosting a webtext on ED critical care at EMCrit.org. Over the past year, this has flowed into the free EMCrit blog and podcast on all things ED Critical Care.
Both these efforts have been devoted to bringing Upstairs Care, Downstairs. What I mean by this is that geography alone should not determine the aggressiveness of treatment. monitoring, and comfort-giving in critically ill patients. If the care makes sense and is based on good evidence in the ICU, it should be started the moment the patient rolls through the ED bay doors. Some might consider this far-fetched, but we’ve been trying to make it work for a few years now with some notable successes (and a few set-backs.)
I am pleased to now be able to post my podcasts and show notes here at the Central Line Blog. To start it all off, here are the top 3 posts from 2009:
Sympathetic-surge Crashing Acute Pulmonary Edema – When a patient gets wheeled in with crackles up to their clavicles and a BP of 280/190, the problem is NOT volume overload. These patients need afterload reduction. And if you need to intubate them, it is on some levels a failure [Read More & Listen to the podcast]
Intubating the Critical GI-Bleeder – Nothing is as sphincter-tightening as having to tube a variceal bleed with a belly full of blood. As in so many things, proper planning prevents poor performance. [Read More & Listen to the podcast]
Non-traumatic Subarachnoid Bleeds - A ton of things need to be done in a very short time in these critically ill SAH patients.
[Read More & Listen to the podcast]
I would love to hear your comments and any suggestions for future topics.
You are about to endotracheally intubate a patient. As you struggle to elevate the laryngoscope more anteriorly, has your left hand ever trembled while trying to see the vocal cords? Before you say, “I think the cords are too anterior, hand me the [insert your favorite backup airway adjunct]“, let’s focus on some basics.
How can you gain significantly more laryngoscope lift strength? You can do more left arm bicep/tricep exercises, or…
Trick of the Trade
Hold the laryngoscope handle as close to the blade as possible.
Grabbing part of the blade helps to stabilize against the “waggling” of the handle. Furthermore, it is easier to pull exactly along the long-axis of the handle at this grip point. I would avoid holding the laryngoscope handle as shown in the image above. Is the physician intubating or holding a fragile cup of tea?
The most stabilizing larngyoscope grip
which provides maximal lift strength.
For other airway Tricks of the Trade, take a look an older post.