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Tricks of the Trade « The Central Line

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The Cunningham Shoulder Reduction: Awake and Painless

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!

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Being an LGBT-Friendly Physician

If you weren’t aware, today is National Coming Out Day, and especially in the wake of the multiple gay teen suicides recently and 9 teenagers and young men torturing 3 men for being gay, I’d like to at least do my part to educate my fellow emergency physicians. This is a post I wrote several years ago, when I was still a wee, doe-eyed, innocent medical student, but it’s still applicable today.

A couple updates:

  • Refer to a transgender patient by his or her current gender. Or better yet, ask them how they prefer to be referred to or what name they’d like to be called. My brain forces me to struggle with this sometimes, too, but if they’re male to female transgender, refer to the patient as “she” or “her.” I’m ashamed to say I’ve heard people refer to these patients to their faces as “it” or “whatever you are.” Offensive.
  • HIV is not just a gay disease. Please please please, let’s stop with the board review questions where the tip off that it’s PCP pneumonia is that the person’s gay. I’d love to read a question that has to do with a lesbian with a broken ankle or a bisexual guy with lupus.

(Note: most of these other tips are taken from The ABCs of Sexual Health, in the BMJ, and Creating a Safe Clinical Environment for Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Patients, an excellent guide (pdf) free from GLMA.) These are not monumental, folks. It’s the little stuff that counts. Trust me.

Above all, listen, don’t make assumptions, and always be respectful.

Creating a Welcoming Environment:

  • Lesbian, gay, bisexual, transgender, and intersex (LGBTI) patients often “scan” an office for clues to help them determine what information they feel comfortable sharing with their health care provider.
  • Post a visible non-descrimination policy.
  • Put up a small rainbow or pink triangle. (I know, I hate them too, but seriously, a little goes a long way for LGBT patients.)
  • On the intake form, try “partner” instead of “spouse.” And include choices on the “Sex” category besides just “M” and “F.”

On Interviewing:

  • Try using gender-neutral words. “Are you currently in a relationship?” as opposed to “Are you married?”
  • “Do you have a girlfriend or a boyfriend?”
  • “Is there another parent?” as opposed to “Is there a father?”
  • If a patient comes out to you, recognize that you are glad they felt comfortable mentioning it, and that it’s not an easy thing to do.
  • Assess how the process is going–you may be the first person they’ve ever told.
  • Again, listen. Follow the patient’s lead.
  • Ask about sexual history honestly and openly. If you’re unsure on what or how to ask, try to let the patient explain–and let them know about your ignorance.
  • Just because someone is in a same-sex relationship doesn’t mean violence doesn’t happen.

On Counseling:

  • Be honest with yourself; if you are uncomfortable with gay people refer the patient to someone else.
  • If an adolescent is confused about his or her sexuality try to help the patient to adjust.
  • Do not have preconceived ideas.
  • If you don’t know the answer to a question, find out for the patient.
  • Know what LGBT resources are available in your area.

If you have questions or comments, please post them here; it’d be great to have an open forum to figure these issues out if you’re unsure about them.

Update: Two more great resources from AMSA: Do Ask, Do Tell, and the June 2001 issues of the AJPH.

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One-Liners to Convince Patients

Looking for the wisdom of the crowd for the best one-liners that convince your patients of things. I’ve heard a couple recently that I like:

  • From Keeping Up in EM, on antibiotics for URIs for kids: “I don’t think we’re going to need antibiotics this time, we need to save them so when we need them they’re really going to work.”
  • From a Peds EM attending on cough medicines for kids: “Oh, those haven’t been tested in children–and I don’t want your child to be the test!”
  • On teenagers having unprotected sex/without birth control or use it “not always”: “Oh wow, so you’re already looking to have children! Do you want a boy or a girl?” This is usually followed by a blank stare from said teen, who thinks I’m insane. “I just figured you must want kids, since it only takes one time to get pregnant.” (Teenagers require a special kind of approach, I think. Their brains don’t work right.)
  • On undifferentiated abdominal pain: “I don’t know what you had, but I’m glad I was able to make you feel better. About a third of the time we don’t know what caused people’s pain in the Emergency Department, but it’s not life-threatening and people get better. I could lie and make up a diagnosis, but I don’t think that’d help you or me.”
  • On convincing someone to get necessary testing or doing a pelvic/genital/rectal exam they don’t want or think necessary: “I know it might be uncomfortable or inconvenient, but I would be a bad doctor if I missed this or didn’t try to make sure it’s not X.”
  • Would love to hear people’s other tidbits. I still have a difficult time with some of these conversations, especially “I need a CAT scan of my head.” These obviously don’t always work, but they help translate the medicalese into words patients can understand and relate to–and show that you’re on their side.

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Apple of my eye

You have to understand- I have been a conscientious objector staging my own quiet campaign against Steve Jobs because when I was in medical school the Macintosh program, which everyone SWORE was compatible with my PowerPoint presentation over which I had labored to produce a riveting lecture for the Neurosurgery in-service on Robotics in Medicine, ate my presentation.  Grrrrrr.  I would have cheerfully strangled Mr. Jobs with a mouse cord.  Then Pixar came along with some of my favorite movies of all time, and my heart began to soften.  Macs became cuter and sexier, though they remained expensive and though I cast an occasional appreciative glance at the curves and bright colors, I remained steadfastly a PC Person.  I loved the modular quality of my PCs and usually did my own maintenance (I am still the Tech Support in our house).  Apple had iTunes, a proprietary interface that grated against my do-it-yourselfedness.  Then came the iPown- er- iPhone.  Its meteoric rise caught my attention.  Sleek, smooth, and it had all that screen real estate!  Tragically, though, it was only available on AT&T.  I didn’t want to change to a new carrier, and hacking the iPhone to use on T-Mobile seemed more trouble than it was worth.  I made due with other phones that I liked well enough, and I was happy.  Then a Sexy Beast arrived on the scene.

The name was terrible- iPad sounded like a feminine hygiene product, and it was nothing more than a glorified iTouch.  Or so I thought.  I researched and read one article after another, though took each with a healthy dollop of sodium since the reviewers were usually dazzled by shiny objects of every kind.  I heard murmurings that it would revolutionize the notebook, but I did not believe.  So one morning after a particularly rough night shift, I decided to see what all of the fuss was about.  I hadn’t gotten a decent gadget in a long time.

It was beautiful.  Smooth.  Clean.  The screen was bright, crisp, and the whole thing felt right in the hands.  Not too heavy, not too light.  Whoa.

Do you remember when the Grinch from the cartoon realized the true meaning of Christmas and his heart grew ten sizes to break open the screen that showed the shriveled thing?  The WANT did that in my brain when the sales guy showed me more than I realized was possible.  It wouldn’t replace my laptop, but it would become my constant companion.  I am not ashamed to reveal that I sleep with it.

So for those who are contemplating joining the iCult of iPad, here is a rundown of some of my current favorite apps, in no particular order:

1)    Medscape – Free- just like the iPhone version, only bigger screen. Lists drugs, interactions, diseases, and procedures.

2)    ePocrates- Free- same as every other ePocrates.  Useful drug information.

3)    MedCalc- Free- Medical calculator.  Just like it sounds.

4)    Medical Spanish- Batoul Apps- $4.99.  Very good medical Spanish app.  It talks!

5)    PubMed on Tap- Free- Easy access to PubMed.

6)    ECG Book- Free- ECG tutorial

7)    Facebook- Free- rapid access to FB, but no live chat available on the free app (there is a paid app that will do that)

8)    Pandora- Free streaming internet radio.

9)    Netflix- Free app with subscription to the service, and movies that are marked “Watch Now” can be watched on the iPad with internet connection.

10) Beat the Traffic- Free, and indispensible in Atlanta, where we have actually had a live zebra running on the interstate.  I am not making that up.  Also helpful for avoiding the bison hazards.

11) iSpy- Free webcam app for those of us with voyeuristic tendencies.  Nothing too racy here, but beautiful views from webcams of Red Square, Lyon, Tokyo, etc.

12) Various news outlets, all free, including WSJ, AP, USA Today, Newsy, NewsPro (Reuters), Bloomberg, BBC News, etc.

13) StarWalk for iPad – $4.99- My favorite astronomy program.  Hold overhead and it will switch to a live view of the skies.

14) iBooks and Free Books- both free, but Free Books is ALL free, and iBooks is a free reader for books that you purchase.

15) The Elements- $13.99- Totally worth it for the song alone, but brings the periodic table to life in an eye-popping display.  This above all others shows the potential of textbooks on the iPad.

16) Pocket Pond- Free- Koi pond.  Weird, but cool.

There are hundreds more, and I am sure you will find your own personal favorites (let me know amattke@aol.com).  None of these programs include movies (available for rent or own, for a fee, of course) or Podcasts, which have become my new guilty pleasure.  My current favorite is Skeptoid, a skeptical look at pop culture.  ACEP, EM:Rap, and Annals of Emergency Medicine have podcasts, as do many of the specialist societies.  QuackCast deals with medical matters in a gratifyingly snarky fashion.  There are many choices, and your mileage may vary.

These are but a few of my favorite things.  iPad does all the usual email, pictures, web browsing, and contacts, and it does them beautifully.  It doesn’t do Flash video, so some web pages won’t look right.  Another of my favorite things is that my calendar automatically pushes with a subscription to Mobile Me.  I can change my schedule on the iPad and it updates my online “cloud”, which then automatically updates my PCs.  Yes, I still have them.  Still a PC person at heart, I still have room for other loves.  And you can have my iPad when you pry it out of my sleep-deprived hands.

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What The Heck Is Your Private Blog Like?

A video introduction. Sorry for the mumbling.

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Best Pediatric Sedation Technique Ever

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.)

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How I E-Learn E-M

via flickr's 8bitjoystick

Yes, dorks, I’m back, and with a “Now, More Nerdy Than Ever!” post.

So I’ve realized recently that a lot of people don’t know about all the ways you can learn a ton of emergency medicine online, for free. I really enjoy learning this way, partially because there’s so many different ways to learn online that it keeps it from getting too boring, and keeps you keeping on. We’ll start with the quickest bites of knowledge, via email.

The University of Maryland Emergency Medicine Residency puts out little pearls every day, but did you know you can get them sent to you via email? Sign-up here, and you’ll  get a little bit of knowledge every day in your inbox. (I can’t count the number of times I read one of these and within a week I’m searching my inbox to remember what exactly it said. Always pertinent and always good.)

Next up: the blogs. I’ve previously listed my favorites, but I’m going to highlight the most high-yield educational ones that I love:

  • Top of that list would be Life in the Fast Lane, which literally posts so much content I can’t keep up. Take the Antidote Challenge, for example, which lists a ton of poisons and you have to go through and remember all the antidotes. High-yield, fast, great learning. I don’t know how they post so much.
  • I really like the Emergency Medicine Forum. The poster summarizes a recent case she had, what the pitfalls and critical actions of the case were in her opinion, how she managed the case, with some references at the end.
  • My Emergency Medicine Blog is kind of like the UMEM Pearls. The author takes something he learned from his shift and posts it to the blog with a reference. “Name the 4 indications for non-medical management of a Stanford B dissection,” for example.
  • I can’t leave out my friend Michelle Lin’s Paucis Verbis cards. An index card summarizing what she thinks she needs to know about any number of problems in Emergency Medicine. You can’t get more high-yield.

How do I read all my blogs, by the way? I use Google Reader. It allows you to subscribe to RSS feeds of blogs (and journals and newspapers, and anything else that offers an RSS feed) so you can read all the content in one place. (An RSS feed is a way that sites can share their content with you without you having to visit their website.)

Next up: Podcasts/Videos.

  • EMRAP is probably the most well-known (and is free for EMRA members!). But did you know there’s also a totally free video podcast version at EMRAP.tv? The Mel Herbert Empire also includes some free lectures from the All LA Conference and others.
  • The EMCrit Podcast is both awesome and free, and I’ve learned a ton from it. (And Scott Weingart also posts here. So it must be good, right?) And a secret tip: if you search Google for pages on emcrit (type “site:emcrit.org” and then your search criteria, you’re bound to find something useful. For example, I found the “PAILS” mnemonic for reciprocal changes on this page.
  • I’ve also just recently started listening to Keeping Up in Emergency Medicine, by the Vanderbilt EM gurus. It’s a quick, 30-minute podcast summarizing EM-relevant journal articles where Clay Smith and Jim Fiechtl give criticism and a summary of the findings.
  • Secret tip: You can watch live USC Grand Rounds on Thursday mornings (California time) as well.
  • Hennepin County EM has a bunch of great ultrasound and procedure videos on their YouTube channel.
  • Run out of Hemocult developer? Need to irrigate someone’s eyes and don’t have a Morgan lens? Procedurettes by my absolutely fantastic attending Whit Fisher will save your butt every time.

Finally, Journal Articles. This only kinda-counts, but here’s a bunch of great online resources:

  • EBMedicine. Insanely great, evidence-based diagnostic and management summaries on almost every EM topic by now.
  • I heart The Emergency Medicine Clinics of North America. Shorter than EBMedicine but provide a great overview of many topics, and each issue focuses on a certain theme. You can access them as well if you’re a member of mdconsult.
  • ACEP also provides its Critical Decisions in Emergency Medicine series, which are probably the shortest of all these options, but pretty good as well.

So, you’re asking yourself, how do I keep track of all of this? A private blog, of course. Whenever I read a good article or find something useful that I don’t want to forget, I summarize everything on the private blog and link or upload the PDF of the article I read it in. This way, I can always have access to the information as long as I have an internet connection. If I tried to store it all away in a notebook, it’d either get lost, fall apart, or I’d just forget it at home and be none the wiser.

(And one final tip, you can now save PDFs that you’re viewing with Google’s PDF reader to your Google Docs account.)

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Academic Library Proxy Bookmarklet


This post is probably geared mostly toward residents and academics who have access to a university library for their researchin’ and journal readin’ (and especially nerdy residents and academics). I’ve made a little tool to hopefully help a few people find accessing journal articles from home a little easier. It’s called a bookmarklet.

What does it do? Well, if your university or hospital library has a proxy server (now we’re getting reallly nerdy), you can use it to try to auto-access journal articles on the web, without the hassle of going to your library’s website, logging in, finding the journal you want, then the article you want, then opening the PDF. It’s probably easier explained in the accompanying video, below.

Visit this page to get the bookmarklet.

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A Means To An End

… was my initial, no-pun-intended explanation about why I needed to disimpact my patient; luckily his sense of humor (and the 10 of valium I gave him) helped. After the fact (and washing my hands), also inappropriate would have been:

  • It stinks that you’re constipated.
  • Can I log this procedure?
  • It’s hard to get it all.
  • What a crappy job.
  • So this is Brownian motion.

See also: Whit Fisher’s Rectal Regrets Procedurette on how to gown up appropriately.

(Side note: An attending once told me the most awkward thing he’d heard during a disimpaction was his patient, saying, “What, you aren’t going to take me out to dinner and a movie first?”)

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Brush up on your Ultrasound skills with the iPhone Sonosite app

Sonosite has released a FREE iPhone app that will help improve their ultrasound skills.

The videos are amazing! Containing many tips, pointers on techniques, great sample cases, image gallery.

The app even has an abbreviated manuel for the Sonosite.  The app also contains the latest news concerning sonosite machines.

Here are some screen shots:

For a sample video click here

If you do not like the app, you are out time but not money.

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