February 2008

Contributed by readers/Edited by Donald B. Middleton, MD

Puncture Prep
If you think a lumbar puncture will be necessary, put some lidocaine-prolocaine cream on the testing area. While other exams, like computed tomography, are being performed, the skin over the spine will become anesthetized. For the patient, this means that the needle stick will be less painful, and no time will be wasted waiting for the anesthesia to take effect. Thanks to Dr. Anand Swaminathan in New York City for the tip.

Dry Tap
When Dr. James Nelson of San Diego, California, has trouble collecting cerebrospinal fluid (CSF) in a nonemergent patient, he determines whether dehydration might be the problem. If so, he administers two liters of normal saline and tries again, often successfully. If the clinical situation permits, Dr. Nelson prefers to give intravenous fluid regardless of the patient’s hydration status, in order to optimize CSF volume.

Soothing Words
Soothing Words Dr. Gus Garmel in Santa Clara, California, reminds us to keep the patient involved during the physical examination. State what you are doing: “I’m looking in your eyes and can see your nerves. They look fine.” Or, “Your blood pressure is normal at 115 over 70.” Talking to patients during the examination allays a great deal of anxiety and reaffirms your expertise.

Lidocaine Lollipop
To anesthetize the soft palate, Dr. Dan Firestone in San Diego, California, makes a lidocaine “lollipop” out of a tongue blade and a dab of 5% lidocaine ointment. The patient holds the medicated end against the side of the soft palate to be aspirated for 5 to 10 minutes. If the patient swallows the ointment, a new dab is applied. Although benzocaine spray generally provides quicker anesthesia, it can be ineffective or short-lived. It may still be used in small amounts after lidocaine application, but keep in mind that excessive benzocaine use can lead to methemoglobinemia. Alternatives may be safer.

Hammerscope
Dr. Thomas Crawford from Santa Clara, California, doesn’t worry when his reflex hammer goes missing. He just turns to the rubber-coated edge of his stethoscope head to examine the patient. The flexible tubing of the neck gives the head a good bounce off the tendons. Thanks to Dr. Crawford for the suggestion.