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Keeping Up With Your Literature

I’ve talked a lot about how important (and easy) it is to keep up with the literature in your field. Doing this is critical to staying at the top of your game. I’m posting the link to my short video on how to do this using current technology to make it as easy as possible. 

There are three categories of sources that you should be looking at:

  • Core sources – these contain articles that almost always relate to your area of interest. I read 8 core journals each month.
  • Non-core sources – these journals occasionally contain articles important to your field. I read 15 non-core journals monthly.
  • WTF sources – Yes, WTF! (World TaeKwonDo Federation for those of you who actually don’t know what this means). These are things that are totally off topic, but interesting. They sometimes give you a kick in the head and get you thinking about things that could be important in your field. These are very important! I read 18 WTF sources, most of which are updated daily.

You can download what Scott Weingart calls “show notes” by clicking here. It summarizes and gives some specific recommendations for things discussed in the video. 

If you want to see the full list of what I read every day, click here.

Please feel free to comment and share how you keep up in your field!

(Source: https://www.youtube.com/)
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The Two-Sheet Trauma Trick

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Hypothermia is always a concern in trauma patients. Even the simple act of completely exposing your patient in the trauma room facilitates it. How do trauma professionals balance the need to see everything with the equally important need to keep the patient warm?

The natural reaction is to cover them up. Sheets and warm blankets are the usual tools. But I always marvel that, as soon as the blanket goes on, there’s always a need to examine something or do some procedure. Look at a wound. Insert a urinary catheter. And every time this happens, the blanket comes off.

Here’s a clever way to deal with this problem. Don’t use just one sheet or blanket. Use two! Fold each one in half, so they are each half-length. Place one on the top half of the patient, the other at the bottom, overlapping slightly at the waist. If you need to look at an extremity, fold the blanket that covers it over from right to left (or left to right) to uncover just the area of interest. To insert a urinary catheter, just open the area at the waist, moving the top sheet up a little, the bottom down a little.

Bottom line: Keep your patient toasty! Use the two-sheet (or warm blanket) trick to avoid hypothermia. Remember, patient temperature begins to drop as soon as the clothes come off! And I don’t recommend the use of one-piece inflatable warming blankets (e.g. Bair Hugger) until the work in the ED is complete, because the whole thing has to be removed every time you need meaningful access to the patient.

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Best Of How To: Stop Scalp Bleeding

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Bleeding from scalp wounds may seem like a trivial problem, but I have personally seen someone die from unrecognized hemorrhage over time from one. All too often, these are covered up with a crude dressing when the patient arrives in the ED and is not looked at for some time.

Here are some tips to stop scalp bleeding:

  • Use direct pressure. This seems obvious but is frequently done incorrectly. Direct pressure involves a small diameter piece of gauze (stack of 2x2s or double folded 4×4) and only one or two fingers. Larger dressings or the palm of the hand do not provide enough pressure to stop all the bleeding. Direct pressure for 5 minutes (no peeking) will stop all bleeding that doesn’t need more advanced techniques.
  • Inject local anesthetic with epinephrine. This increases vasoconstriction and helps the direct pressure work even better. Be cautious if there is a large skin flap that does not have a nice pink color. Degloved skin has been crushed and small vessel vascular injury has occurred. Further reducing blood flow with epinephrine may kill the skin flap in this type of injury.
  • Apply Raney clips. Neurosurgeons use these to stop scalp bleeding during brain procedures. Caution! Only apply to unconscious patients, and only to the scalp (not face)! These hurt!
    Raney clips
  • Oversew the scalp. Use a large silk or nylon suture and insert a large running stitch to close the wound. This will stop all bleeding from the skin edges. However, any arterial bleeders underneath will continue to be a problem.
  • Ligate individual bleeders. Use a small absorbable suture and attack each small arterial bleeder with a figure of 8 stitch. Don’t suture large chunks of tissue; make sure that you are attacking just the artery and not any adjacent nerves.
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How To: Retrograde Urethrogram

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One of the hallmarks of urethral injury is blood and the meatus in males. The standard answer to the question “how do you evaluate for it?” is “retrograde urethrogram.” Unfortunately, too few people know how to perform this test, and not all radiologists are familiar. Many times it falls to the urologist, who may not be immediately available.

The technique is simple. The following items are needed:

  • A urine specimen cup
  • A tube of KY jelly (not the little unit dose packs)
  • A bottle of renografin or ultravist contrast
  • A 50-60 cc Toomey syringe (slip-tip)
  • A fluoroscopy suite

Pour 25cc of contrast and 25cc of KY jelly in the specimen cup, cap it and shake well. Draw the contrast jelly up into the syringe. Under fluoro, insert the tip of the syringe into the penis and pull the penis toward yourself, pinching the meatus around the tip of the syringe. Slowly inject all the contrast, watching the contrast column on the fluoro screen. Once there is easy flow into the bladder, you can stop the study. If you see extravasation into the soft tissues, stop the study and call Urology.

The advantages to using this technique are:

  • The contrast/jelly mix creates a contrast gel that is less likely to leak from the meatus when injected
  • The jelly makes it easy to insert the catheter if no urethral injury is detected

Normal urethrogram:

Normal urethrogram

Abnormal urethrogram:

Abnormal urethrogram