Category Archives: How to

How To: Retrograde Urethrogram

I’ve gotten a number of recent requests to repost this easy, DIY guide to the retrograde urethrogram. Enjoy!

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. This is my variation on the standard technique. 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

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Submental Intubation – The Video!

Yesterday, I described a technique for providing a secure yet short-term airway tailored to patients who can’t have a tube in their mouth or nose. Patients undergoing multiple facial fracture repair are probably the best candidates for this procedure.

A picture may be worth a thousand words, but a video is even better. Please note that it is explicit and shows the blow by blow surgical procedure. Of note, it is a quick and relatively simple advanced airway technique.

Related post:

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Help! My Consultant Won’t Come In To See A Patient!

Consultants provide very important services to trauma patients in the ED and inpatient settings. The trauma professionals managing those patients can’t know everything (although we sometimes think we do). But occasionally our patients present issues that require evaluation by other experts in order to guarantee excellent care.

Sometimes our consultants want to do too much, or make recommendations that are not really in their area of expertise (e.g. a cardiologist evaluating a cardiac contusion). See the related post link below for tips on this situation.

But sometimes you know what the patient needs, but the consultant doesn’t agree or doesn’t do what you expect. Or they don’t want to come in when called. What to do?

Here are some tips:

The patient is in the ED and the consultant won’t come in to see the patient.

  • Are they right? Does that problem really need to be dealt with in the ED in the middle of the night? Many simple fractures and wounds do not need immediate attention. They can be dressed/splinted, the patient reassured, and instructed to see the consultant in the clinic the next day.
  • Is your knowledge of current management of the condition correct? Perhaps it has evolved, and it is now commonplace to temporize and deal with the problem as an outpatient during business hours. Make sure you are up on the current literature.

The patient is in the ED and the consultant won’t come in to see the patient, and you are sure that they should! Now what?

  • Call them personally (not a resident, midlevel provider, or any other intermediary) and clearly and concisely explain the situation, and your assessment of why the problem needs their immediate attention.
  • Listen to or elicit their rationale for not seeing the patient. If legitimate, this may help educate you and modify your future management of similar patients. If the rationale is not legitimate, inform them (tactfully) that this is at odds with your education/training/experience with other providers. Ask them to further explain, if they can.

If they still won’t come in despite what you think is a legitimate need, then you must calculate a quick risk:benefit ratio. Will any patient harm occur if the consultant does not see the patient? And what is the professional damage that you will incur if you move on to the next steps. If you believe that harm will occur, here are your options, from least to most damaging to your professional status at the hospital:

  • Contact another consultant in the same or overlapping specialty (if there is one). Apologize for the fact that you know they are not on call, and explain the situation.
  • Appeal to a higher authority. Contact the trauma medical director, service chief, or hospital administrator and see if they can intervene.
  • Explain to the consultant that you truly believe that harm will occur, and you will have to document that fact in the medical record as well as their failure to respond. In some cases, this will shake them loose, but they will certainly be pissed.
  • If all else fails, see if you can find a service that will help you by accepting the patient as an admission so they can be managed appropriately the next day. But then follow through by reporting the event to appropriate people including chief of staff, chief medical officer, VPMA, hospital quality department, and risk management. This is the nuclear option, so be prepared for the fallout.

Bottom line: This is not a fun situation to find yourself in. Good luck!

Related post:

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Retained Foreign Objects After Penetrating Injury

A Chinese man was in the news a few years back after having a four inch knife blade removed from his head. It had been there for four years!  The knife blade broke off after he had been stabbed under the chin. Unfortunately, he was unaware that any part of the knife had been retained. It remained partly within the nasopharynx and the tip came to rest behind his left eye. His symptoms included headaches, stuffy nose and bad breath. The picture below shows the badly corroded blade in front of some of his radiographic images.

See the video at the bottom of this post for more details and images.

knife-in-head

What is the best way to deal with a problem like this? Here are some practical tips:

First, get in the habit of imaging any body part with a penetrating injury. Retained objects can be as simple as gravel or as complicated as the knife blade above. And remember, some patients who have been stabbed present with a simple laceration but don’t want to tell you how they got it. Image before you close it!

Next, don’t remove it. This is common knowledge, but innocent looking objects (pencils, nails) can penetrate arteries and keep them from bleeding while embedded. Unpleasant and sometimes fatal bleeding can ensue if pulled out.

If you do not have specialists versed in the body regions involved in the injury, transfer immediately with the object secured in place. For objects penetrating minimally complex areas like the extremities, surgeons may opt to carefully remove it in the emergency department, or may elect to do so in the operating room.

Injuries to complex areas should undergo high resolution CT scanning so that 3D reconstruction can be performed if needed. The surgical specialists can then plan the operative approach. This is dictated by the anatomy of the area(s) involved and the architecture of the object (think about hooks and barbs). For objects located near critical areas, an operative exposure must be selected that provides access to all portions of it, and allows for rapid vascular control if needed.

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How To: Secure An Endotracheal Tube To… Nothing!

Several decades ago I took care of a patient who posed an interesting challenge. He had been involved in an industrial explosion and had sustained severe trauma to his face. Although he was able to speak and breathe, he had a moderate amount of bleeding and was having some trouble keeping his airway clear.

Everyone frets about getting an airway in patients who have severe facial trauma. However, I find it’s usually easier because the bones and soft tissue move out of your way. Or are already gone. As long as you can keep ahead of the bleeding to see your landmarks, things will go fine.

In this case, the intubation was easy. The epiglottis was visible while standing above the patient’s head, so a laryngoscope was practically unnecessary! But now, how do we secure the tube so it won’t fall out? Sure, there are tube-tamer type securing devices available, but what if they are not available to you? Or this happened in the field? Or their face was missing or falling off? Or it was in the 1980’s and it hadn’t been invented, like this case?

The answer is, create your own “skin” to secure the tube. Take a Kerlix-type stretchable gauze roll and wrap it tightly around their face, and their head if needed. Remember, they are sedated already and they can breathe through the tube. This also serves to further slow any bleeding from soft tissue. Once you have “mummified” the head with the gauze roll, tape the tube in place like you normally would, using the surface of the gauze as the “skin.”

Be generous with the tape, because the tube is your patient’s life-line. Now it’s time for the surgeons to surgically stabilize this airway, usually by converting to a tracheostomy.

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