The diagnostic tool of choice is the portable Doppler. Have you noticed that these machines always seem to be lost or broken or locked in a place that no one can find? Some of them look like they were assembled during the Nixon administration, and are just as reliable. Even when they do function, it can be almost impossible to hear the faint “whoosh-whoosh” sound of a digital artery over the departmental ambience of groaning patients, overhead pages, ringing phones, and trauma alerts. Cranking up the gain only rewards you with unearthly howls of microphone feedback.

A simpler alternative is to use a pulse oximeter. Every emergency department has at least one, and sometimes there’s one attached to every monitor. Simply put it on the fingers or toes distal to the injury, and wait to see if you get a reliable waveform and pulse rate. Check it against the patient’s actual pulse rate by auscultation or a pulse check in the uninjured extremity. If you see a waveform, you’re getting a critical piece of information: There is perfusing capillary flow to the tissues distal to the site of injury (photo 3). Best of all, you don’t have to position the oximeter right over the artery or be able to hear a weak signal in a noisy environment. Keep in mind that unlike the Doppler, the oximeter cannot tell you which artery is delivering blood. Patient movement can create artifactual signals with an oximeter, just as it can with a Doppler machine, so it’s important to keep the patient still and really be sure you are seeing a sustained waveform.

Eye Irrigation

The ideal piece of equipment for flushing a chemical eye injury is a Morgan lens. There is no better alternative, although the day may come when you need to act immediately and you discover that someone forgot to restock the eye cart. In fact, that day may come more than once, often the same day when people decide to have bleach and Pine-Sol fights.

You can effectively irrigate the eyes using a nasal cannula and standard IV set. First, cut the cannula tubing fairly close to the branch point (you don’t want too much slack). Connect your IV tubing to a bag of normal saline, and then find the screw hub that would normally connect to the IV. Stuff the prong of this screw hub into the nasal cannula tubing that you just cut (photo 4). Firm this connection up with some tape – it will leak some, but you’ll still get an effective flow. Place many chucks and a bedpan under the patient’s head to catch runoff. (To many patients, this is more important than it should be. I remember one young woman with liquid detergent in her eyes who refused to be irrigated unless I could promise to keep her hair dry, because she’d just had it done. Once I pointed out that suppurating corneal ulcers might clash with her highlights, she relented.)