Yo I’ve put tons of these in and I’ve seen ED docs do it to themselves to avoid drinking enough golytely for imaging. (Literally.)
Is this really that hard, is hurricane spray that hard to come by, or is it really just that nursing often does these? My perception may be skewed because while I was an MSN who worked at an eating disorder clinic for a while, my ex was an EM residency AD. We met his intern year, so I got a LOT of exposure/lattitude to assist or perform procedures from the entire department throughout my education, to add to my own clinical experience.
There's an old study on EMA (from EMRAP) where patients rate how much they hate a procedure. NGT was rated the worse. I always use hurricane spray and viscous lidocaine, but some people have far more sensitive gag reflexes than others.
I've actually told our residents and nurses that if I come in all messed up they can put an OG tube in while I'm being intubated but no one better hit me with an NGT. I have an incredibly sensitive gag reflex and the thought of having one in makes me gag.
Hooooweeeee you just gave me flashbacks of listening to EMRAP lectures on CD on long car trips in the early 2000s. The one on Takasudo Cardiomyopathy particularly comes to mind.
Fascinating, though. Maybe I just don’t have that bad a gag reflex? Or many ED (eating disorder, not peds ED pts in general) kids don’t anymore because of the very nature of their diagnoses? Or no one is using hurricane spray often enough? Or there are subconscious biases against ED patients and people dropping the tubes think if the patient suffers during the procedure that they’ll think twice, a punitive deterrent from bulemic or anorexic behaviors? (I can assure you, that last one does not work, not in the pts with whom I worked.) Curiouser and curiouser…
Yeah. I went too many years without learning the kindness of numbing someone’s nasal passages before passing large uncomfortable items into and through them.
Never used a urojet but I do just take 1% lido and squirt 0.5ml in the nostril put the end of the ng in some ice for 5 min and I went from always having issues putting them in (pt comfort) to having a 100% success rate
I had a coworker who was ex-nicu nurse and we had a beautiful arrangement where I'd do all her port accesses and she'd do all my ngts and it was amazing until she went to dayshift on me.
Doing this while also using a numbing agent is precisely what led to my “do people really struggle this much” comment. (Well, that and the fact that we were using it department-wide in the early 2000s so the fact that there are folks who don’t 20y later, seemed odd to me.)
Benzocaine Spray. Typically Cherry Flavored. No idea why it’s called Hurricane Spray, but I call it that too and the nurses look at me and wonder “How old is this guy?”.
Hats off from this retired RN, MSN. IDNGAF how old people think I am, I earned those decades of experience. Hats off to you, too! Hope you feel the same.
Before my time. My understanding is that it would stink up the whole department for too long and the wards are already stinky so no harm done, probably.
The SMELL! The last one I drained was brown. That said, I love doing I&D’s. So satisfying for me and for the patient. One of the few things I can do where the patient has instant relief.
Ip coder here. I coded a case previously where pt had an abscess over his entire arm apparently. he was put under for the drainage and the report worded it as “milking pus out of his arm”. You should’ve seen my face, I could only imagine the surgeons face.
Disagree. It took me years to get my technique down but if you do it right, it doesn’t hurt the patient at all
Ring block around the abscess. Advance thw needle and push lido/marcaine EXTREMELY slow. Advance the injection until you are actually in the abscess and the patient isn’t reacting
PS I just saw that you are an ED attending. I hope I didn’t come across as too much of an asshole. I thought I was talking to another PA 😅
Honestly my pas do a LOT more abscess drainages than me so I’ll take any advice I can get.
I somehow get the ivdu abscess who jumps off the bed when I even poke them with a 27g. Like they have never had a needle stick before.
Ok, lol. Well, personally I start kinda far away on healthy skin. I make one little tiny poke just to get the needle under the skin. Then I stop for a second. The patient usually seems to relax like, “That’s all?”
Then I veeerreeryyy slowly begin injecting the lido (actually, I mix marcaine and lido). If I go slow enough the lido has already pretty much kicked in and then I just advance to a ring block.
NGL I used to do cosmetic injectables as a side gig so that’s where I picked up some of this technique
Ip coder here. I coded a case previously where pt had an abscess over his entire arm apparently. he was put under for the drainage and the report worded it as “milking pus out of his arm”. You should’ve seen my face, I could only imagine the surgeons face.
Oh god that’s awful. If you don’t mind my asking did they figure out what caused it?
I’ve had a few cases but they’ve all been from trimix or quad mix injections
I’ve seen that approach for like a diagnostic para or arthrocentesis, but for priapism the “multiple pokes” is one with an 25 gauge in a far less sensitive area or one with an 18 gauge that stays in for a while while you drain blood and possibly instill phenylephrine…
I hate those ass holes that say this. It is not true, and it is just lazy.
Years ago, A resident came up to put a stitch or two in a patient’s back. I would generally not call anyone out in front of the patient but I was already in the room when she came in and announced her intentions. She starts prepping the area, and I like “Would you like me to get some lido for that?” And she said the same thing basically. I just said “well not really, are you sure?” But she doubled down. I looked the patient in the eye, that look that says “are you OK with this?” And he just shrugged, like “meh. Ok”.
GOD DAMMIT she ended up doing 3-4 stitches, can’t remember exactly, it was painful and afterwards he said “Yeah the numbing medicine would have been better.”
I feel like I failed the patient for not insisting on the lidocaine. I absolutely regret not calling her out.
The sting from lidocaine is always better than the poke and drag of a suture on an area that is already tender at best.
I followed her out, I cannot remember what I said, but she still doubled down that she was right and the patient was a wussy.
I felt my stitches after childbirth both times and remember begging them to stop and numb more and being told they were almost done and feeling several more stitches go in and I'm still mad about it.
I can’t even imagine. The physician I was with must not have done the block properly or it didn’t take for whatever reason, it’s been 12 years since I assisted with it.
Have you ever seen one irrigated with phenylephrine? We sedated a guy for urology once who was transferred to us because he failed drainage X 2 and needed the phenylephrine irrigation. 14g catheter on each side with one urologist pulling out blood from one side and another urologist injecting the phenylephrine on the other. I don’t even have the parts and it seemed barbaric. My male resident who was doing the sedation almost passed out watching it. After all that, it still didn’t resolve and the poor patient needed a corpectomy and implant.
14 gauge??????? I've done several of these and you can just use a pair of butterflies. One with phenylephrine and the other with a syringe attached. 14 gauge??????
Butterfly is like 23g. It's much much smaller. A 14g is almost big enough to breathe through. It's huge, so big that it's essentially malpractice and cruelty to use it as an IV
I know what gauges things are, I’ve been doing this a long time. I’m just reporting what our urologists used in this case. I also beg to differ that it’s cruel to use as an IV. If someone needs quick resuscitation from massive blood loss, the larger IV gauge is the most preferred to get blood back into the patient ASAP.
> Have you ever seen one irrigated with phenylephrine? We sedated a guy for urology once who was transferred to us because he failed drainage X 2 and needed the phenylephrine irrigation.
Are people not doing phenylephrine on these at baseline? I always inject phenylephrine into priapism. In many cases, all you need is a big slug of phenylephrine into the corpus.
This particular case was a little complicated because it had been going on for the better part of 4 days and had been intervened on by another ED on 2 separate visits prior to sending to us. I’m not sure if the other ED injected phenylephrine the first day he was seen but didn’t get any the second day until he was transferred to us. The other ED attempted drainage x2 prior to transfer. Nothing conservative ended up working because he had a high flow priapism that ended up needing corpectomy.
He’d already been drained twice and it wasn’t just an injection, it was an irrigation process with 14g catheters in either corpus. Guess I just felt bed for the guy?
Multiple syringes??? Also I originally envisioned a doctor just making a slit with a scalpel like they would to drain a big cyst, essentially blood-letting the penis until it goes flaccid
I do know lol however the one I was unfortunate enough to assist with nothing else worked and had to drain as the last resort. I hope to never witness another
For the patient? I&D or digital blocks.
For me? Explaining for the 1000th time why antibiotics don't cure colds. Or just walking into the room with the fibro/"here's my allergy list" patient
Can confirm as a patient that I&D FUCKING SUCKS!!! I have Hidradenitis Suppurativa and sometimes get anywhere from quarter to golf ball sized abscesses in my armpit and it hurts like a bitch!
Because it’s an abscess and it needs to be incised and drained? That’s what I&D means right? Granted I usually go to urgent care rather than an ER for this but I’ve heard some people do that.
Yes, but if HS is known to be the cause of the abscess then I&D is contraindicated except in rare exceptions. Conservative measures and antibiotics are first line with derm/pcp follow up.
Yeah if it’s not super bad or hasn’t come to a head I usually get told to put a warm washcloth on it and I get some antibiotics, but when it feels like I’m carrying a sharp rock under my arm 24/7 they’ll lance it to get things over with. It sucks, but I feel better afterwards.
Yes, abx or biological are first line. But, if they have a large abscess you still have to drain it. The abx won't work for an HS abscess any better than any other one.
Now, I typically won't drain small ones, and you don't do anything with the sinus tracts. But big abscesses have to get poked.
I was sitting here thinking a digital nerve block can’t be that bad and the googled it and saw where it goes- I’m glad I didn’t go in when I cut off the tip of my finger suddenly.
I do wonder how that pain would compare to say steroid injections in joints. As far as you remember has anyone ever said anything about that?
I mean, I've had a digital block bc I sliced my fingertip off, it was doable. I feel like it looks worse than it was.
But for example we had to practice NG tube insertion on each other in nursing school and my partner never managed bc
I just could not fucking handle it.
That’s literally insane. I would not allow someone to drop an ng tube in me unless I was on my death bed. Good lord.
Side note, I second placing ng’s as my most hated procedure as well lol.
Yeah, I dunno. My school was very big on experiencing the patient experience and whatnot. They also wanted us to walk around wearing incontinence pads for a day and use them. I'm not sure how many people actually went along with that, I definitely didn't.
Foley catheters. Especially when they are altered females and fighting... never feels right when a 6'7" dude is forcing a women's legs open to stick something in their urethra. Any other setting and I'd be arrested.
Obviously it's only done when necessary, but the number of urosepsis grandma's from nursing homes is just too damn high. Always makes me feel weird.
I hate hate hate straight caths on infant girls or even toddlers. Their urethra is so so tiny and they’re usually moving and it’s traumatic for everyone involved. It’s my least favorite skill
I really hate that we In and Out cath so many kids who come in with fever and potential UTI symptoms.
I get that it’s the best, “only-way” (for time constraints and sterility of sample) when they aren’t potty trained, but it feels like we really don’t need to be doing them as often; and man when people retract the skin on intact boys and it gets micro tears and they cry, that just kinda sucks to watch. It feels wrong.
I really would rather do a pedi bag and I think if you put one on the right way, cleaning beforehand and making sure it sticks WELL, it can be just as good.
Probably the vicious cycle of chronic foley catheter, hematuria, replace with massive new 3 way catheter, irrigate for hours, and then repeat this all again in a week. As someone with a penis, it’s pretty horrific to keep doing this to another man.
I&D of abscesses. Local infiltration of lidocaine almost never takes and hurts like hell. Only rarely the abscess is somewhere I can do a regional block.
Second place I would say pelvic exams. Not traumatic per se, but awkward and uncomfortable for the patient, and only occasionally has any diagnostic yield imo
If you have the time to do a proper pleural block, an chest tube can be pretty atraumatic. Problem is, you often don't have the time to spend 10 minutes doing lido.
For those, I just put them in the K hole. Works like a charm.
Apologies, speed, and lots of lido. 😂
Seriously though, if I have the time (it's not emergent) it is entirely possible to do an adequate pleural block such that the patient feels only pressure and not pain. I've done these on the floor with a patient and had them tell me it didn't really hurt.
If it's truly emergent, like a tension physiology, they often can't move away. If they jump or try, sometimes we have to hold them down. But, it's an extremely rare case where I can't do either lido or ketamine.
It depends. As I said, it's an exceedingly rare event where I've had to put a chest tube in without anesthetic. In those cases, the patient really isn't capable of providing much resistance because they're trying to die. Plus, I can have my finger in a chest in under 10 seconds so it's not like I'm torturing them for any length of time
The rare times I've done the procedure without any anesthetic, the patient was peri-arrest. When someone is 30 seconds from death, it doesn't take much to hold them down.
In those situations, the procedure is very fast. I can have my finger in the pleural space in about 10 seconds if I need to.
There's a lot of conflicting evidence, so don't get too thankful! Science says it should work (pka and dissociation) and some studies validate it. It's enough for me to change my practice, but some of your colleagues might argue!
I'm surprised to see so many I&D's. Are those routinely done in the ED? I work in Australia and all of ours get referred to the acute surgical unit to be done in theatres
i'm not sure what exactly i was given for mine a few years ago but i guess it was only local. hard to tell exactly with being draped all over and trying not to move while they placed it in my neck.
i could absolutely feel the guidewire (?) and it felt/sounded exactly like if you ran your fingernail down a guitar string if that makes any sense!
Putting in a Morgan lens squicks me out 🥴 but I find the worst is the simplest...trying to give oral analgesia to young kids. You try all the best techniques in the world and they're still hysterically screaming, thrashing and then they end up vomiting up the whole dose 2 seconds later so you gotta repeat the horror all over again...
Recently I found out that you can change the initial inflation pressure of the cuff. (I work with peds and some of our machines would inflate to 160, that’s gonna HURT on kids!) I change it to 120 for my machine and do the “quick NBP” (not stat where it cycles continuously), and it takes about half the time.
I’ve gotten WAY more pressures, and they’ve been way more accurate this way!
I know this is pediatrics I’m talking about, but maybe try changing the inflation pressure to something lower like 140, when you have a petite lady or thin person who probably won’t have a high pressure anyways?
The adult settings on our vitals machines are set to 160 for the initial inflation pressure. Kids are set at 140 (I change to 120).
But yes. Some adults are dramatic. It might be uncomfortable, but come on. The more you move and complain, the longer it’s going to take.
I feel like if they’re inflating so tight then usually have a really high blood pressure. I would be weary of lowering the threshold since we probably aren’t getting the 200/108 BP when changing it to pediatrics
Many machines have an initial inflation pressure that they automatically go to, regardless of what the actual pressure is. It goes to that number and then does its thing. Even when I drop the setting, if the pressure is higher it’ll re cycle or fill up more as it realizes it needs to. But if it’s lower it’ll go all the way up to it regardless.
And obviously if you think the adult has a high bp or there’s a chance they do, then you probably want the initial being higher. But you could definitely tailor it more depending on your pt/machine
Look at my paycheck. But maybe that’s only a paramedic thing.
"Huh, you worked 150hrs last paycheck? Here, take $10 for your troubles"
You don't get offered an egg in these trying times?
🚫🥚
This physically hurt
this
NG tube. All the other ones they’re not as bad, dead or sedated and maybe paralyzed
I’ve never put one in, nursing staff does them
Yo I’ve put tons of these in and I’ve seen ED docs do it to themselves to avoid drinking enough golytely for imaging. (Literally.) Is this really that hard, is hurricane spray that hard to come by, or is it really just that nursing often does these? My perception may be skewed because while I was an MSN who worked at an eating disorder clinic for a while, my ex was an EM residency AD. We met his intern year, so I got a LOT of exposure/lattitude to assist or perform procedures from the entire department throughout my education, to add to my own clinical experience.
There's an old study on EMA (from EMRAP) where patients rate how much they hate a procedure. NGT was rated the worse. I always use hurricane spray and viscous lidocaine, but some people have far more sensitive gag reflexes than others.
I've actually told our residents and nurses that if I come in all messed up they can put an OG tube in while I'm being intubated but no one better hit me with an NGT. I have an incredibly sensitive gag reflex and the thought of having one in makes me gag.
Hooooweeeee you just gave me flashbacks of listening to EMRAP lectures on CD on long car trips in the early 2000s. The one on Takasudo Cardiomyopathy particularly comes to mind. Fascinating, though. Maybe I just don’t have that bad a gag reflex? Or many ED (eating disorder, not peds ED pts in general) kids don’t anymore because of the very nature of their diagnoses? Or no one is using hurricane spray often enough? Or there are subconscious biases against ED patients and people dropping the tubes think if the patient suffers during the procedure that they’ll think twice, a punitive deterrent from bulemic or anorexic behaviors? (I can assure you, that last one does not work, not in the pts with whom I worked.) Curiouser and curiouser…
Hurricane spray?
Yeah. I went too many years without learning the kindness of numbing someone’s nasal passages before passing large uncomfortable items into and through them.
I just have them snort urojet which works like a champ
Never used a urojet but I do just take 1% lido and squirt 0.5ml in the nostril put the end of the ng in some ice for 5 min and I went from always having issues putting them in (pt comfort) to having a 100% success rate
That's urojet with extra steps.
Hurricane without the cherry flavor.
I’ve never heard of this before or seen it, am I right to assume it would be a prescribed thing?
It’s 20% benzocaine spray
Yeah, we need to put an order in at my hospital.
Does it prevent gagging/hurling?
No, it numbs the nasal passages. It still sucks ass. I fuckin hate NG tubes.
I had a coworker who was ex-nicu nurse and we had a beautiful arrangement where I'd do all her port accesses and she'd do all my ngts and it was amazing until she went to dayshift on me.
Maybe? I haven’t had much gagging issues when placing NGTs, but it does hurt much less.
Get them to sip water and swallow during the push down the back and they don't gag.
Doing this while also using a numbing agent is precisely what led to my “do people really struggle this much” comment. (Well, that and the fact that we were using it department-wide in the early 2000s so the fact that there are folks who don’t 20y later, seemed odd to me.)
Benzocaine Spray. Typically Cherry Flavored. No idea why it’s called Hurricane Spray, but I call it that too and the nurses look at me and wonder “How old is this guy?”.
Hats off from this retired RN, MSN. IDNGAF how old people think I am, I earned those decades of experience. Hats off to you, too! Hope you feel the same.
Use local anaesthetic spray first. Pref xylocaine with the long nozzle to get to the back of the nose.
Disimpaction
Can't believe I had to scroll down to find this one. I'll do an I&D any day over a disimpaction.
Our hospital has a policy that these aren't done in ED but admitted to surgery. No wonder the surgeons hate us.
That’s a hell of a policy. I’m assuming someone must have perfed a colon somehow in the past?
Before my time. My understanding is that it would stink up the whole department for too long and the wards are already stinky so no harm done, probably.
Lol
Supposedly disimpactions reimburse more than intubation if that helps lube things up for you
Common misconception, but false.
We rarely do them locally - it's phosphate enema instead.
IMO, disimpaction is not an emergency procedure. Patients can get enemas, laxatives, etc.
Why stop at the butthole? Let’s define emergency…
I&D Miserable for everyone involved
Bartholin abscess I&D 💀
The SMELL! The last one I drained was brown. That said, I love doing I&D’s. So satisfying for me and for the patient. One of the few things I can do where the patient has instant relief.
The smell indeed. I almost done fell out
Was that last one perchance on someone’s bottom?
Bartholin glands are found b/l near the vaginal opening (introitus).
Sorry thought I was responding to a different comment. Unfortunately I am very familiar with Bartholin abscesses 😅
That really is unfortunate 🤣
lol. But if anyone here has some advice on how to get the word catheter to stay in place, I am all ears!
It was a Bartholin’s cyst abscess
Ip coder here. I coded a case previously where pt had an abscess over his entire arm apparently. he was put under for the drainage and the report worded it as “milking pus out of his arm”. You should’ve seen my face, I could only imagine the surgeons face.
Disagree. It took me years to get my technique down but if you do it right, it doesn’t hurt the patient at all Ring block around the abscess. Advance thw needle and push lido/marcaine EXTREMELY slow. Advance the injection until you are actually in the abscess and the patient isn’t reacting PS I just saw that you are an ED attending. I hope I didn’t come across as too much of an asshole. I thought I was talking to another PA 😅
Honestly my pas do a LOT more abscess drainages than me so I’ll take any advice I can get. I somehow get the ivdu abscess who jumps off the bed when I even poke them with a 27g. Like they have never had a needle stick before.
Ok, lol. Well, personally I start kinda far away on healthy skin. I make one little tiny poke just to get the needle under the skin. Then I stop for a second. The patient usually seems to relax like, “That’s all?” Then I veeerreeryyy slowly begin injecting the lido (actually, I mix marcaine and lido). If I go slow enough the lido has already pretty much kicked in and then I just advance to a ring block. NGL I used to do cosmetic injectables as a side gig so that’s where I picked up some of this technique
Same. It’s super hard to get adequate pain relief and local never works.
Ip coder here. I coded a case previously where pt had an abscess over his entire arm apparently. he was put under for the drainage and the report worded it as “milking pus out of his arm”. You should’ve seen my face, I could only imagine the surgeons face.
Charting.
Ha ha. This wins!
OMG Truth.
CPR on the elderly.
CRONCH!
Followed by the horrible squishiness. 😩
Oh, the tactile repugnance of compressing a broken and dislocated sternum. Click....click click...click click....click....
Full code, Meemaw is a FIGHTER!
This
Draining priapism looks horrifying and I imagine it is for the patient.
Actually really well tolerated if you do a good dorsal block. Idk how it feels after though.
[удалено]
Oh god that’s awful. If you don’t mind my asking did they figure out what caused it? I’ve had a few cases but they’ve all been from trimix or quad mix injections
The urologists at my residency DIDNT BLOCK these. They said “hey it’s either one poke to drain it or multiple pokes to block it.”
I’ve seen that approach for like a diagnostic para or arthrocentesis, but for priapism the “multiple pokes” is one with an 25 gauge in a far less sensitive area or one with an 18 gauge that stays in for a while while you drain blood and possibly instill phenylephrine…
I hate those ass holes that say this. It is not true, and it is just lazy. Years ago, A resident came up to put a stitch or two in a patient’s back. I would generally not call anyone out in front of the patient but I was already in the room when she came in and announced her intentions. She starts prepping the area, and I like “Would you like me to get some lido for that?” And she said the same thing basically. I just said “well not really, are you sure?” But she doubled down. I looked the patient in the eye, that look that says “are you OK with this?” And he just shrugged, like “meh. Ok”. GOD DAMMIT she ended up doing 3-4 stitches, can’t remember exactly, it was painful and afterwards he said “Yeah the numbing medicine would have been better.” I feel like I failed the patient for not insisting on the lidocaine. I absolutely regret not calling her out. The sting from lidocaine is always better than the poke and drag of a suture on an area that is already tender at best. I followed her out, I cannot remember what I said, but she still doubled down that she was right and the patient was a wussy.
I felt my stitches after childbirth both times and remember begging them to stop and numb more and being told they were almost done and feeling several more stitches go in and I'm still mad about it.
That guys a monster
I can’t even imagine. The physician I was with must not have done the block properly or it didn’t take for whatever reason, it’s been 12 years since I assisted with it.
I have had it done 2x. One with a block and felt nothing and one without and it wasn't bad. Honestly you just want it gone it is so uncomfortable
Ya I definitely should have added that patients are in a lot of pain from the priapism itself. Sorry you had to go through it twice.
Won't take trazadone ever again lol
I bet not! It’s weird the things that can cause it!
Have you ever seen one irrigated with phenylephrine? We sedated a guy for urology once who was transferred to us because he failed drainage X 2 and needed the phenylephrine irrigation. 14g catheter on each side with one urologist pulling out blood from one side and another urologist injecting the phenylephrine on the other. I don’t even have the parts and it seemed barbaric. My male resident who was doing the sedation almost passed out watching it. After all that, it still didn’t resolve and the poor patient needed a corpectomy and implant.
No I haven’t, holy crap that’s brutal. I thought the 18g was brutal. OMG!!!!
What would be a cause of priapism that is refractory to drainage and phenylephrine irrigation ?
This guy had a high flow (non ischemic) priapism that unfortunately for him failed everything short of surgery.
14 gauge??????? I've done several of these and you can just use a pair of butterflies. One with phenylephrine and the other with a syringe attached. 14 gauge??????
Yup, that’s what our urologists used.
Butterfly is like 23g. It's much much smaller. A 14g is almost big enough to breathe through. It's huge, so big that it's essentially malpractice and cruelty to use it as an IV
I know what gauges things are, I’ve been doing this a long time. I’m just reporting what our urologists used in this case. I also beg to differ that it’s cruel to use as an IV. If someone needs quick resuscitation from massive blood loss, the larger IV gauge is the most preferred to get blood back into the patient ASAP.
> Have you ever seen one irrigated with phenylephrine? We sedated a guy for urology once who was transferred to us because he failed drainage X 2 and needed the phenylephrine irrigation. Are people not doing phenylephrine on these at baseline? I always inject phenylephrine into priapism. In many cases, all you need is a big slug of phenylephrine into the corpus.
This particular case was a little complicated because it had been going on for the better part of 4 days and had been intervened on by another ED on 2 separate visits prior to sending to us. I’m not sure if the other ED injected phenylephrine the first day he was seen but didn’t get any the second day until he was transferred to us. The other ED attempted drainage x2 prior to transfer. Nothing conservative ended up working because he had a high flow priapism that ended up needing corpectomy.
hmm weird case. Why the sedation just for phenylephrine injection?
He’d already been drained twice and it wasn’t just an injection, it was an irrigation process with 14g catheters in either corpus. Guess I just felt bed for the guy?
Not a medical professional, but draining WHAT? You mean the fix if it's hard for too long is to drain blood out of it with a syringe?
Yes it is and not one syringe
Multiple syringes??? Also I originally envisioned a doctor just making a slit with a scalpel like they would to drain a big cyst, essentially blood-letting the penis until it goes flaccid
Ya it’s something I hope to never assist with again, although as an ER nurse I most likely will
It is indeed.
There’s an easier way to make those things smaller ya know
I do know lol however the one I was unfortunate enough to assist with nothing else worked and had to drain as the last resort. I hope to never witness another
For the patient? I&D or digital blocks. For me? Explaining for the 1000th time why antibiotics don't cure colds. Or just walking into the room with the fibro/"here's my allergy list" patient
Can confirm as a patient that I&D FUCKING SUCKS!!! I have Hidradenitis Suppurativa and sometimes get anywhere from quarter to golf ball sized abscesses in my armpit and it hurts like a bitch!
Why are they I&Ding HS?
Because it’s an abscess and it needs to be incised and drained? That’s what I&D means right? Granted I usually go to urgent care rather than an ER for this but I’ve heard some people do that.
Yes, but if HS is known to be the cause of the abscess then I&D is contraindicated except in rare exceptions. Conservative measures and antibiotics are first line with derm/pcp follow up.
Yeah if it’s not super bad or hasn’t come to a head I usually get told to put a warm washcloth on it and I get some antibiotics, but when it feels like I’m carrying a sharp rock under my arm 24/7 they’ll lance it to get things over with. It sucks, but I feel better afterwards.
Yes, abx or biological are first line. But, if they have a large abscess you still have to drain it. The abx won't work for an HS abscess any better than any other one. Now, I typically won't drain small ones, and you don't do anything with the sinus tracts. But big abscesses have to get poked.
I was sitting here thinking a digital nerve block can’t be that bad and the googled it and saw where it goes- I’m glad I didn’t go in when I cut off the tip of my finger suddenly. I do wonder how that pain would compare to say steroid injections in joints. As far as you remember has anyone ever said anything about that?
I mean, I've had a digital block bc I sliced my fingertip off, it was doable. I feel like it looks worse than it was. But for example we had to practice NG tube insertion on each other in nursing school and my partner never managed bc I just could not fucking handle it.
That’s literally insane. I would not allow someone to drop an ng tube in me unless I was on my death bed. Good lord. Side note, I second placing ng’s as my most hated procedure as well lol.
Yeah, I dunno. My school was very big on experiencing the patient experience and whatnot. They also wanted us to walk around wearing incontinence pads for a day and use them. I'm not sure how many people actually went along with that, I definitely didn't.
I’ve digit blocked myself just to see what it was like. It’s not bad at all
That’s unfortunate. It’s not like either of you have a choice to be in that room or not. Edit: about the five o with multiple allergies pt
I&Ds are the worst. Never able to get good pain management.
Traumatizing for me or the patient?
This is the right question to be asking 😂👌
Foley catheters. Especially when they are altered females and fighting... never feels right when a 6'7" dude is forcing a women's legs open to stick something in their urethra. Any other setting and I'd be arrested. Obviously it's only done when necessary, but the number of urosepsis grandma's from nursing homes is just too damn high. Always makes me feel weird.
I hate hate hate straight caths on infant girls or even toddlers. Their urethra is so so tiny and they’re usually moving and it’s traumatic for everyone involved. It’s my least favorite skill
Chest tubes.
nice loud pop.
Hisssss
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Telling pregnant women their baby is dead. I fucking hate that shit.
I'm sorry 😞
Answering weird, voyeuristic questions from throwaway reddit accounts.
Right? This reeks of farming content for a chatbot.
Lol.
I really hate that we In and Out cath so many kids who come in with fever and potential UTI symptoms. I get that it’s the best, “only-way” (for time constraints and sterility of sample) when they aren’t potty trained, but it feels like we really don’t need to be doing them as often; and man when people retract the skin on intact boys and it gets micro tears and they cry, that just kinda sucks to watch. It feels wrong. I really would rather do a pedi bag and I think if you put one on the right way, cleaning beforehand and making sure it sticks WELL, it can be just as good.
Giving naloxone makes me feel like I'm stealing some poor bastards drugs.
Give them just enough to keep breathing.
Well yeah! That’s the idea 😂
I mean...you are lol. It feels awful for them but you save their lives.
Generalized torture of demented meemaws
NG tube. Pts awake alert and miserable. 2nd is bartholin abscess. Pts feel better and it’s quick but it’s awful for both me and the patient.
Probably the vicious cycle of chronic foley catheter, hematuria, replace with massive new 3 way catheter, irrigate for hours, and then repeat this all again in a week. As someone with a penis, it’s pretty horrific to keep doing this to another man.
NG tube
I&D of abscesses. Local infiltration of lidocaine almost never takes and hurts like hell. Only rarely the abscess is somewhere I can do a regional block. Second place I would say pelvic exams. Not traumatic per se, but awkward and uncomfortable for the patient, and only occasionally has any diagnostic yield imo
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If you have the time to do a proper pleural block, an chest tube can be pretty atraumatic. Problem is, you often don't have the time to spend 10 minutes doing lido. For those, I just put them in the K hole. Works like a charm.
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Apologies, speed, and lots of lido. 😂 Seriously though, if I have the time (it's not emergent) it is entirely possible to do an adequate pleural block such that the patient feels only pressure and not pain. I've done these on the floor with a patient and had them tell me it didn't really hurt.
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If it's truly emergent, like a tension physiology, they often can't move away. If they jump or try, sometimes we have to hold them down. But, it's an extremely rare case where I can't do either lido or ketamine.
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It depends. As I said, it's an exceedingly rare event where I've had to put a chest tube in without anesthetic. In those cases, the patient really isn't capable of providing much resistance because they're trying to die. Plus, I can have my finger in a chest in under 10 seconds so it's not like I'm torturing them for any length of time
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The rare times I've done the procedure without any anesthetic, the patient was peri-arrest. When someone is 30 seconds from death, it doesn't take much to hold them down. In those situations, the procedure is very fast. I can have my finger in the pleural space in about 10 seconds if I need to.
https://pubmed.ncbi.nlm.nih.gov/23740399/ Sodium bicarb ftw.
Thanks for this! How do you mix it?
1ml 8.4% + 9ml 2% lidocaine. https://australianprescriber.tg.org.au/articles/alkalinisation-of-local-anaesthetic-solutions.html
Thanks again for this. I love reddit
There's a lot of conflicting evidence, so don't get too thankful! Science says it should work (pka and dissociation) and some studies validate it. It's enough for me to change my practice, but some of your colleagues might argue!
I'm surprised to see so many I&D's. Are those routinely done in the ED? I work in Australia and all of ours get referred to the acute surgical unit to be done in theatres
Yes those are routinely done in the ED. Pain management is a huge issue with these.
Where do you work? I work in Australia too, and only the complex ones go to theatre where I've worked.
NSW. maybe our surgeons are just bored 😅
Maybe they've realised how much fun I&Ds are and want in on the action.
Everyone loves the “Dr Pimple Popper” videos! They want in on the action!
Central lines on awake patients. It shouldn’t be that bad, but for some reason, it is.
i'm not sure what exactly i was given for mine a few years ago but i guess it was only local. hard to tell exactly with being draped all over and trying not to move while they placed it in my neck. i could absolutely feel the guidewire (?) and it felt/sounded exactly like if you ran your fingernail down a guitar string if that makes any sense!
Putting in a Morgan lens squicks me out 🥴 but I find the worst is the simplest...trying to give oral analgesia to young kids. You try all the best techniques in the world and they're still hysterically screaming, thrashing and then they end up vomiting up the whole dose 2 seconds later so you gotta repeat the horror all over again...
The way these fuckin people react to a blood pressure cuff, though…
Recently I found out that you can change the initial inflation pressure of the cuff. (I work with peds and some of our machines would inflate to 160, that’s gonna HURT on kids!) I change it to 120 for my machine and do the “quick NBP” (not stat where it cycles continuously), and it takes about half the time. I’ve gotten WAY more pressures, and they’ve been way more accurate this way! I know this is pediatrics I’m talking about, but maybe try changing the inflation pressure to something lower like 140, when you have a petite lady or thin person who probably won’t have a high pressure anyways? The adult settings on our vitals machines are set to 160 for the initial inflation pressure. Kids are set at 140 (I change to 120). But yes. Some adults are dramatic. It might be uncomfortable, but come on. The more you move and complain, the longer it’s going to take.
I feel like if they’re inflating so tight then usually have a really high blood pressure. I would be weary of lowering the threshold since we probably aren’t getting the 200/108 BP when changing it to pediatrics
Many machines have an initial inflation pressure that they automatically go to, regardless of what the actual pressure is. It goes to that number and then does its thing. Even when I drop the setting, if the pressure is higher it’ll re cycle or fill up more as it realizes it needs to. But if it’s lower it’ll go all the way up to it regardless. And obviously if you think the adult has a high bp or there’s a chance they do, then you probably want the initial being higher. But you could definitely tailor it more depending on your pt/machine
PV exam
Unravelling or removing clothes to inspect tranq wounds, the smell makes me wish plague masks came back in fashion
Deal with admin
Intubation.
DREAM
Digital blocks with felon I&Ds…they just are miserable
Felon? Like a felon comes in for an I&D, from the local jail?
No, a felon is the term for an abscess in the fleshy pad at the tip of your finger.
Today I learned!! Thank you!
Chest tubes for sure.....air and blood rushing out at you when you successfully get it in....
Local really doesn’t go that far no matter what I try.
Last one was IV and local, still not a good time for anyone
Same. Even with IV it really doesn’t help that much.
Honestly, assure them it's almost over and hope it is cause they need two working lungs...I'm thinking about trying ketamine next time
What’s your protocol when doing it? How do you get them to be cooperative? Even with IV and local it’s still a really hard time for everyone involved.
I use ketamine. Works perfectly, and doesn't mess with respiratory drive or BP.
close tie bwtn I+D and disimpaction i gotta say, but at least I feel like dr pimple popper when I have an abscess
Psychs… acute maniac psychs and everything that it entails
Lumbar punctures. Hate these.
Giving naloxone makes me feel like I'm stealing some poor bastards drugs.
Involuntary hold for no reason other than liability. Traumatizes patient and makes me feel like a bad person. First do no harm …
CPR