Old School

A few of my readers have commented on how they enjoy practice pearls, so I thought I would go ahead and share a simple one. This particular pearl is not just for medical people, it will work quite well for those of you who are not in the medical profession. In the medical profession, a lot of time is spent training people in the latest, greatest technology- the newest medication, the latest technique, the wow factor, but sometimes, it is the old school method that works best. I recently had the chance to teach a young doctor this exact lesson.

Lacerations

We had a woman that entered the emergency room who had cut off the last quarter inch or so of the tip of her finger with a pair of scissors while attempting to cut open an Amazon package, of all things. In so doing, she had also managed to nick the artery, and blood was pulsing out of the end of her finger. She had the presence of mind to bring in what she thought was the tip of the finger (what she brought in wasn’t the finger) and she was attempting to control the bleeding herself, but wasn’t succeeding.

The doctor looked at it and suggested we perform a digital block and attempt to stitch off the artery and suture the wound closed. That was going to be a bear to do. Instead, I suggested that we try something a bit more old school. I took a large emesis basin, filled it with ice, a little water water, and a bottle of Providone. I told the woman to place her finger in the basin and keep it there until the cold became painful. This concoction does three things:

• The ice numbs the area
• the Providone cleans the wound (there is a risk of infection if you don’t)
• the ice also constricts blood vessels and is great at controlling bleeding

She spent about 15 minutes with her hand in that basin, and this stopped about 80% of the bleeding. I pulled her hand out, cleaned the finger with a couple of gauze pads (4×4), then had her hold one against the tip of her finger using her thumb. After about 5 minutes of that, we still had some bleeding, so I soaked a gauze pad with tranexamic acid (TXA) and placed it against the wound. That stopped the rest of the bleeding. I dressed the wound, and we sent her home.

Esophageal Varices

Just as you can get varicose veins in your legs, you can get them in your esophagus as a result of cirrhosis of the liver and the resulting portal hypertension. I was working in the ED one night when a patient began vomiting large amounts of blood. I’m not talking about what most people would think are large amounts of blood, but what a nurse who works in the ED thinks are large amounts of blood. It looked like this:

We were under the gun: if this bleeding didn’t stop, we were looking at a dead patient. I inserted an NG tube to suction out the blood, and the doctor and I came up with a plan. Using a piston syringe, I would push about 100 ml of ice water into the tube, let it sit for about 30 seconds, then suction it back out. I repeated this about 5 or 6 times, and each time, the amount of blood that came out with it was less. I was forced to stop after that 5th or 6th time, because the cold must have been irritating to her heart, as evidenced by the fact that she began having short runs of ventricular tachycardia. For that reason, anyone trying this, I would recommend placing the patient on a cardiac monitor and keeping a close eye on on their heart rhythm while doing this.

Ice- it’s quite useful in emergency medicine, but it isn’t used much any more in emergency medicine because it doesn’t have the sexy feel of the latest, greatest advances in medical technology, but it is still damned effective. Sometimes old school is still the best way to go.