Thursday, August 23, 2007

Fast Relief, and Simple

In response to my recent "Pain in the Ass" post, in which the subject was a simple procedure bringing rapid and dramatic relief, commenters have mentioned other similar interventions. Seems like a fun topic. Here's a list I can think of (a couple of which are those mentioned in the comments, by readers.) Anyone want to chime in with others?

  • Giving "Narcan" to an overdose patient: within seconds a moribund and blue, pin-point-pupilled addict is transformed to a yelling and screaming maniac.
  • Similarly: Dextrose IV for hypoglycemia rapidly raises from unconsciousness to lucidity.
  • Relieving a subungual hematoma with the red-hot tip of a straightened and heated paper clip. FZZZT, and the patient is happy!
  • Draining any sort of painful abscess under local: pilonidal, perianal. The patient has arrived in abject pain, hardly able to walk, and leaves smiling and light on his feet.
  • Releasing a tension pneumothorax with a needle. FZZZT, and the patient is happy!
  • Reducing a dislocated shoulder: the water-bucket trick is rewardingly direct, low-tech, and effective. Pop >>> ahhh!
  • Pulling back a too-far inserted endotracheal tube. The oximeter tone rises steadily.
  • Untwisting a sigmoid volvulus with a scope. Stand back, or let someone else do it. Dramatic to all senses.
  • Cricothyroidotomy. Too scary to be fun, it certainly qualifies as dramatic and effective, especially when done with nothing but a large IV catheter.
  • Sticking a finger onto a major bleeding artery, the kind you can hear. It doesn't solve the problem but it sure as hell is a relief for the moment. When the natural instinct is to turn the head away, which some in the assemblage might do, it seems sort of heroic.
  • Squeezing bags of fluid or blood with both hands, and seeing the blood pressure rise and pulse fall within moments.
  • Carotid sinus massage: I actually did it once, for atrial flutter with syncope, absent readily available meds. I kept thinking I'd cause a stroke, and never had to do it again. Still, it's a nice maneuver based on medical school knowledge of cardiovascular physiology.
  • Opening a chest and pericardium, of course, and poking a finger into a heart wound. Been there, done that. Not so simple, but uber-dramatic. Relieving pressure in a pericardium by whatever means can resurrect a person in an instant.
  • Quickly accessing the subclavian vein. Simple. But often tricky enough that when you pop in the needle and get a nice flashback of blood in a couple of seconds, it feels pretty good.
  • Inserting a suprapubic bladder catheter when you can't get a foley to pass.
  • Apocryphal, perhaps? Everyone says it happened in their ER: giving sux to a hopelessly combative patient. Calms them right down.
  • Administering valium for status epilepticus.
  • Anyone perform/experience others?


scalpel said...

Giving benadryl for a dystonic reaction.

Successful defibrillation (beep....beep....beep!)

Applying Alcaine drops to someone with a corneal abrasion.

Jeffrey Parks MD FACS said...

Lap appy at 6am, sending them home, essentially pain free later the same day.

Butt pus!

Opening a wound infection at bedside.

NG tube for acute gastric distention or bowel obstruction

Sid Schwab said...

Good ones! Yeah, a pinkie in an incision...
Stopped using outpatient reglan after a couple of dystonias, but the benadryl was indeed dramatic.

Dr. Rob said...

IV Glucagon for meat impaction (usually works, doesn't it ED Docs?)
Prednisone for Polymyalgia Rheumatica - they call the next day feeling tons better (you can tell I am an internist).
Reduction of Nursemaid's elbow.
Ritalin for ADHD (seriously).
GI Cocktail for Chest/Abdominal pain

Good subject Dr. Sid

Eric, AKA The Pragmatic Caregiver said...

Mag Citrate. 'nuff said

Anonymous said...

Getting that microscopic (but feels gigantic) bit of dust out of my eye before I need the alcaine for a corneal abrasion.


Anonymous said...

Giving Neostigmine to a patient overdosed with anticholinergics. From psychotic to psychopathic within seconds.

Toni Brayer, MD said...

Shaving a foot corn - pain instantly gone. Not as dramatic as tension pneumothorax but happy patient anyway.

Removal of thrombosed hemorrhoid - immediate relief of pain.

Great post, thanks.

Sam Blackman said...

As a pediatrician, I'm shocked (shocked, I tell you) that you neglected reduction of a nursemaid's elbow. There's nothing like the almost instantaneous relief on a child's face once they get their arm back!

Bruce said...

Nothing in my world beats a successful crash trach.

Greg P said...

As an intern, I saw a patient with a hemiplegia, found to have a very low blood sugar, given 50% Dextrose and watched the hemiplegia melt away to nothing (had a previous hx of stroke).

Here's a slow-motion one: one of my partners saw someone in the ER in a coma, CSF obviously abnormal, CSF glucose was 0 (zero). dx: pneumococcal meningitis. Eventually left the hospital with only some minimal cognitive problems, that will probably resolve. Talk about grabbing someone away from the Grim Reaper.

Lisa said...

Hydrocortisone for Addison's disease, I swear its like rising from the dead.

ER's Mom said...

True story of residency...

34 weeks pregnant. Dissecting ascending aortic aneurysm.

Baby delivered 32 seconds after start of c/section.

Sid Schwab said...

ERs Mom: impressive. Was it a Marfan's patient?

Anonymous said...

Giving anesthesia. You get to play with adrenergic, GABA, and mu receptors. to name a few. All with fast and dramatic results. Instant gratification.

It's the most fun you can have with your clothes on.

Anonymous said...

Bipap on a gasping CHF.

Vitum Medicinus said...

"Relieving a subungual hematoma with the red-hot tip of a straightened and heated paper clip. FZZZT, and the patient is happy!"

After I had seen this done once, I always find it amusing to see patients who squirm at the sight of the red-hot poker, not realizing it actually isn't going to hurt.

Paramed said...

"giving sux to a hopelessly combative patient. Calms them right down."

Ethical, Naa. Effective, you betcha.

Dilaudid for the persistent drug seeker. I've Never seen a happier patient.

Versed for those times when you can't afford the memory.

Diprivan when you really want to mess with someone. Awake, asleep, awake, asleep..etc

Joy K. said...

What is the "water bucket trick" for a dislocated shoulder?

Sid Schwab said...

Joy: if you have a person lie face down with the affected arm dangling over the edge of a gurney, and have him/her hold a bucket which you steadily fill with water, with luck as the bucket gets full and heavy enough, it'll pop the shoulder back in. Alternatively, you put your foot in the patient's armpit, lean back, and pull. When neither works, you call the orthopedist.

Unknown said...

Laser iridotomy for angle closure glaucoma. As soon as you pop through, there's a huge gush of fluid, the anterior chamber deepens, and the patient feels so much better.

Judy said...

Crash C-section, getting handed a floppy, blue baby with no respiratory effort and a heart rate of about 40.

Neonatal resus protocol rocks.

If the baby is out in time, APGAR scores tend to be in the neighborhood of 4 and 8-9.

The OB team is always suitably impressed. They should be more impressed with themselves. Most of the battle is getting the baby out before things get ugly.

On a really good day, the baby may even end up in the full-term nursery.

Gary M. Levin said...

Instantaneous relief of pain from contact lens overwear syndrome by use of topical ophthaine

Instantaneous reduction of refractive error with lasik surgery
'the wow factor"

Annie said...

I had the opportunity to observe cardiac bypass surgery when I was a nursing student. In the OR, there was a huge display screen that showed the patient's QRS complex with, if I am recalling it correctly, an inverted T wave. After everything was hooked up (so to speak), that T wave became rounded and upright!! I can still remember feeling such awe.

Annie said...

Hmmm.......I may have mis-remembered the changes I saw to the QRS complex. As I think of it more, it may have been a depressed ST segment that returned to baseline. Sorry fans of Dr.'s been a couple dozen years and thousands of bedpans.

IcedLatte said...

Lidocaine (or similar, plus some steroid) injected for trochanteric bursitis. Patients arrive thinking (wishing) they're goiing to have a leg amputation, and skip out.

Anonymous said...

Methylene Blue for methemaglobinemia.....almost intubated to breadthing easy


Anonymous said...

IV steroids for acute adrenal insufficiency

Tacky and hypotensive to stable in minutes

ER's Mom said...

Amazingly enough, no! Just an extremely unlucky woman.

I had gotten paged stat to endoscopy, turned to my intern (who happened to be the ER rotating intern) and said "Where the f$%^ is endoscopy?" He led me there.

Cardiology looked pale because of the pregnancy. As soon as I heard the story, I turned pale because the heart is kinda important.

She got cut midline by me and went to CICU for the night because they wanted the placental site to heal before hitting her with an obscene amount of heparin. Next day, her sternum was cracked so she was literally cut from pubis to clavicle! But she walked out of the hospital a week later and the baby did well in the NICU and left in 11 days.

I remember just shaking afterwards...we had the whole chest-cracking instruments opened and did the c/section in the heart room with the heart team's scrub (on the theory that if something went wrong, it's far more important for the CT surgeon to have his team there). My intern, the ER guy, was pratically salivating at the thought of needing to crack her chest.

Macha said...

on a multip, reducing an anterior lip (or even a little more) and instantaneously the head descends to the perineum and you say to the nurse, "she's fully"

make mine trauma said...

Chronic, painful AC joint (acromioclavicular) from overuse and early arthritic changes. Sought treatment after five or six aggravating months. The INSTANT the methylpred was injected, the pain was gone. Ahhhhh


Knowing not to suction away at (a gushing) aortic tear during a node dissection......priceless.

The speed of benedryl at reversing anaphylaxis

ERnursey said...

The B52. Raging psychotic turned into sleeping baby.

IV narcotics for kidney stones. Take a pale, diaphoretic, writhing, puking patient and relieve their agony. They think you are the queen.

Diprivan for ventilated patients....night night and don't remember a thing.

Cardioversion for unstable tachyarrhytmias....ZAP and they go from half dead to pink, warm and dry.

And the most amazing drug of all, Adenosine! It keeps us from having to zap a good number of people.

Anonymous said...

KevinMD, great blog.. my first time contributing..

For Fast Relief,and Simple, here are my top THREE from the wonderful world of urology:

(#3) Foley

(#2) Priapism (prolonged painful erection). If it can be brought down with a quick penile injection, it's amazing how quick it is relieved.

(#1) Manually reducing a PARAPHIMOSIS. Paraphimosis is when the foreskin of the penis gets trapped behind the glans, it gets edematous and swollen, which makes it even tighter, and more trapped. Very painful and looks scary (see pic). Sometimes, with gradual constant squeezing pressure and pushing the glans, it can be popped back in and reduced. Instant relief, and at the same time squeezes out the edema, so it looks immediately better! The manual reduction procedure itself looks (& sometimes sounds) like something from the Spanish Inquisition, but once finished, the patient is amazed and infinitely grateful.

Gory photo link:


Anonymous said...

I think the only one I've seen was Valium for the ongoing seizure. I was pretty impressed with how quickly the seizures stopped and then how quickly they would return if the Valium started wearing off.

codeblog said...

Awesome post.

I third the Propofol. Takes them from thrashing to zzzzzzzz.

I've never personally seen it, but I'm assuming TPA for strokes/heart attack would fit.

And from personal experience, I'd have to say the epidural that was placed during transition was an otherworldly experience. What else could take you from out-of-control 10/10 pain to blissful relief?

(I'm tellin ya - Pitocin was invented by the devil.)

Anonymous said...

Laser iridotomy is not an easy procedure with immediate relief, as said above.
The procedure is painful and absolutely scary for the patient.
The success rate is only 43%.
The adverse effects are important:
double vision, glare, a white horizontal line, uncontrollable IOP, uveitis and significant vision loss.
More than 50% of the patients lose their job. Life changes completely after this surgery.

Sid Schwab said...

anonymous: from what (little) I know, you may be confusing "elective" iridotomy with when it's done for acute angle closure. For acute angle closure, it can be dramatic. And whereas I don't know if it's true that 50% lose their jobs, it is true that it works only half the time or less when done electively; that would suggest that if people really lose their jobs it might be the ones that aren't helped.

Anonymous said...

sid schwab,

50% of those who have undergone a preventative iridotomy lose their job because of the side effects of the iridotomy, not because of the after effects of a glaucoma attack.
Doctors underestimate the adverse effects of iridotomies! This surgery should never be done preventatively, it's a vision-threatening procedure!
I read the FDA has started to do an investigation into this surgery and its adverse effects.
I have had iridotomies in both my eyes, I know what I am writing about! I lost almost all my vision.


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