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Tactical Medicine News

Trick of the Trade: Persistent Paracentesis Leakage 2.0

by Carmen Estrada
Oct 20, 2021
You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leaka...
Tactical Medicine News

Trick of the Trade: Tibial Intraosseous Line Stabilization in an Agitated Patient

With the advent of commercial intraosseous (IO) needles for vascular access, administering IV medications for patients in extremis has been made mu...
Tactical Medicine News

Simulation Trick of the Trade: Bleeding Cricothyroidotomy Model

One advantage of simulation as an educational tool is the re-creation of cognitive and emotional stresses in caring for patients. Doing this for a ...
Tactical Medicine News

Trick of the Trade: EMLA for Lumbar Punctures

A 9 year-old patient presents with a headache and fever after swimming, along with subjective neck stiffness. Meningitis was of concern especially ...
Tactical Medicine News

Ultrasound-Guided Pericardiocentesis

All the years of ultrasound training in residency has paid off. You found the large pericardial effusion in the hypotensive patient who is still a...
Tactical Medicine News

Trick of the Trade: The PIPP for deep peripheral IVs in obese patients

The Case A 500-pound morbidly obese male presents to your ED complaining of mild shortness of breath and palpitations. A quick ECG shows SVT with ...
Tactical Medicine News

Trick of the Trade: Less traumatic nasopharyngoscopy

A fiberoptic nasopharyngoscope is a handy tool to check patients for suspected foreign bodies (e.g. fishbone stuck in throat) or laryngeal edema. D...
Tactical Medicine News

Trick of the Trade: Stimson technique using wrist restraints

A patient presents with an anterior shoulder dislocation on x-ray. Your ED just received 5 new patients via ambulance and you are trying to priorit...
Tactical Medicine News

Trick of the Trade: Got a shoulder dislocation? Park it

Myriad techniques exist to reduce shoulder dislocations, which includes scapular rotation, Hennepin, Snowbird, Cunningham, and Legg maneuvers. The...
Tactical Medicine News

Trick of the Trade: Making the NG and NP procedures less painful

When doing nasogastric (NG) tubes and fiberoptic nasopharyngoscopy (NP) procedures, there many approaches in how patients can be locally anestheti...
Tactical Medicine News

Trick of the Trade: External jugular tourniquet

Paitents can be a challenge when trying to obtain peripheral IV access. The vein may be collapsed from dehydration or scarred because of IV drug u...
Tactical Medicine News

Trick of the Trade: Use the angiocatheter for central lines

Central lines come packed with a long introducer needle (pink arrow) to feed the guidewire through AND a long angiocatheter (yellow arrow). Most pe...
Tactical Medicine News

Trick of Trade: Umbilical foreign body removal

Emergency physicians are constantly challenged with fishing foreign bodies out of various orifices such as ears, as shown here in an earlier Trick...
Tactical Medicine News

Trick of Trade: Needle foreign body removal

  An IV drug user accidentally breaks off a 25-gauge needle in his/her forearm and presents to your ED for needle foreign body removal. How can you...
Tactical Medicine News

Trick of Trade: Incision and loop drainage using tourniquet

The technique for abscess drainage traditionally is incision and drainage (I&D). In August 2012, I wrote about incision and loop drainage (I&a...
Tactical Medicine News

Trick of the Trade: Reducing the metacarpal neck fracture

General principles of fracture reduction involve axially distracting or pulling on a fracture fragment and pushing the piece back into anatomical ...
Tactical Medicine News

The mystique of direct laryngoscopy: Learning and teaching the procedure

This post is about an editorial comment by Dr. Richard Levitan on an article (1) about pulmonary critical care doctors performing intubations in t...
Tactical Medicine News

Trick of the Trade: Persistent paracentesis leakage

Dr. Matt Borloz (Carilion Clinic) recently emailed me his recent trick in fixing a persistently leaking paracentesis site. Read about his experienc...
Tactical Medicine News

Trick of the Trade: Avoiding a straight-needle needlestick injury

You are finishing up a successful subclavian line procedure. You insert the straight-needle suture needle through the skin to secure the line. When...
Tactical Medicine News

Trick of the Trade: High volume irrigation of abscesses

Large-sized abscess often have pus trapped in deep crevices and pockets. Irrigation can help express the pus. How can you set up a high-volume irri...
Tactical Medicine News

Trick of the Trade: Don’t miss the pneumothorax in needle thoracostomy

A patient arrives in PEA arrest and you note that her left chest has no breath sounds or lung sliding on bedside ultrasound. You suspect a tension...
Tactical Medicine News

Trick of the Trade: Safer guidewire disposal

Have you ever accidentally flicked a drop of blood while disposing a straight guidewire into a rectangular sharps bin? The bins just don’t quite f...
Tactical Medicine News

Trick of the Trade: A flexible pediatric ear curette

Having you had trouble seeing a pediatric patient’s tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid cur...
Tactical Medicine News

Paucis Verbis: Delayed sequence intubation

A 40 y/o man presents with significant agitation and severe respiratory distress from a COPD exacerbation. His oxygen saturation is 75% on room air...
Tactical Medicine News

Trick of the Trade: Alternative to Word catheter for Bartholin abscess

Bartholin abscesses are challenging to manage, partly because of Word catheter insertion. Sometimes, the space is not large enough (unable to fit t...
Tactical Medicine News

Trick of the Trade: Incision and loop drainage of abscesses

Why are we still teaching the traditional incision and drainage approach to simple abscess drainage? They require frequent, painful packing changes...
Tactical Medicine News

Trick of the Trade: Ring removal using oxygen mask strap

  Creative emergency physicians exist worldwide. Check out this nifty trick on ring removal by Dr. Simon Carley (Centre For Evidence Based Emergenc...
Tactical Medicine News

Trick of the Trade: Massaging a mandibular dislocation back in

Continuing the theme of mandibular dislocation tricks (protecting your thumbs, post-reduction stabilization), Dr. Daniel Gromis from Advocate Chris...
Tactical Medicine News

Trick of the Trade: Removing a Tungsten Ring Stuck on Your Finger

A patient presents with a tungsten ring on their injured finger and is unable to remove the ring. Tungsten rings are unique in that ring cutters c...
Tactical Medicine News

Trick of the Trade: Unblocking the obstructed IV line

 A patient’s PICC line becomes obstructed and presents to your ED for care. She is using it for chronic antibiotics for osteomyelitis. You are unab...
Tactical Medicine News

Tricks of the Trade: Valsalva maneuver by using a 10 cc syringe

Last week, Dr. David Johnson shared his trick to elicit a Valsalva maneuver out of his patient. Here’s another trick that I saw one of our EM resi...
Tactical Medicine News

Trick of the Trade: Valsalva maneuver by pressing on the abdomen

A patient presents to triage in rapid SVT rhythm. While you are trying to get an IV in the patient and drawing up adenosine, you have the patient ...
Tactical Medicine News

Trick of the Trade: "Punch out" the foreign body

A patient re-presents to the Emergency Department with a foreign body sensation in his heel after stepping on a broken window. Despite a negative x...
Tactical Medicine News

Trick of the Trade: Hair tourniquet release

A 3 month old baby presents with distal erythema and swelling of one of her toes. A hair tourniquet is identified. Typically one can try manually ...
Tactical Medicine News

Trick of the Trade: Mark your sites with a Sharpie

 Marking the surface anatomy for procedures can significantly increase your chances for success, such as for lumbar punctures and central lines. I...
Tactical Medicine News

Trick of the Trade: Ear foreign body

Sometimes classic techniques need to be revisited, especially when I get new photos from the collective readership. Let’s review a painless way to ...
Tactical Medicine News

Trick of the Trade: Bend the IV angiocatheter

You identify a great external jugular (EJ) vein to cannulate for IV access. You are having a hard time keeping the angle of the angiocatheter aime...
Tactical Medicine News

Trick of the Trade: Seldinger chest tube technique using bougie

A 40 year-old man presents with a traumatic hemopneumothorax. He weighs 400 pounds. Chest tubes can sometimes be challenge, especially for those wi...
Tactical Medicine News

Trick of the Trade: Protecting your thumbs in mandible relocations

Does anyone think that this is generally a bad idea when closed-reducing mandible dislocations? Yes, it's easiest to apply downward pressure on the...
Tactical Medicine News

Trick of the Trade: Peritonsillar abscess aspiration technique using IV tubing

A few weeks ago, I gave a Tricks of the Trade talk for the Stanford-Kaiser Emergency Medicine residents and faculty. I was overwhelmed by the gre...
Tactical Medicine News

Trick of the Trade: Pelvic speculum for peritonsillar abscess

Peritonsillar abscess drainage in the ED continues to be one of my favorite procedures to perform. There are several tricks to increase your chance...
Tactical Medicine News

Video: Khan Academy and digital whiteboards

Dr. Rob Rogers (University of Maryland) is at it again with another brilliant installment of his Medical Education Videos. This 10-minute video co...
Tactical Medicine News

Trick of the Trade: Irrigation fluid is key – but not in your eye!

High pressure irrigation of wounds is critical in reducing the rate of wound infection. There are a variety of commercial irrigation kits which inc...
Tactical Medicine News

Trick of the Trade: Another magnet trick for metallic FB removal

Last week, I talked about the use of Rare Earth Magnets for removing metallic foreign bodies. Sometimes a straight magnet though isn’t quite stron...
Tactical Medicine News

Trick of the Trade: Rare earth magnets for metallic FB removal

A child presents to your Emergency Department with a small button battery up her nose. Your usual tricks fail: Occluding the other nostril and ha...
Tactical Medicine News

Trick of the Trade: Difficult intubation — making lemonade out of lemons

  In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough t...
Tactical Medicine News

Trick of the Trade: Minimizing propofol injection pain

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz… As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient e...
Tactical Medicine News

Trick of the Trade: Dental Avulsion and Subluxation

It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of...
Tactical Medicine News

Trick of the Trade: A removable guidewire

An essential skill of any innovative troubleshooter in the Emergency Department is the ability to recognize when one piece of equipment may be used...
Tactical Medicine News

Trick of the Trade: Hip dislocation Part II

As a followup to the blog on the Captain Morgan technique for hip dislocations, I’d like to throw out another similar technique that also does NOT ...
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