People are clumsy, especially with their medications. How many times have we met patients who dropped their brand-new bottle of Xanax down the sink? Or sat in a puddle at the bus stop and dissolved all their Percocets? It’s almost like the universe has a cosmic vendetta against fun medications. These terrible accidents never seem to happen to lactulose.

Albuterol Spacer

One exception to the rule is our old friend the albuterol metered-dose inhaler (MDI). While this is definitely not a fun medication, many patients lack the physical coordination to use the inhaler correctly. Whether it’s a young child with chubby fingers or an elderly patient with arthritic hands, some patients simply can’t manipulate the MDI and end up spraying their ear, eye, chin, or the entire emergency department, while their bronchi continue to squeeze shut. These patients need a spacer to facilitate controlled inhalation of albuterol to benefit from it.

Even though spacers look like cheap plastic toys, they can be expensive (I saw one on “sale” for $60 once). Patients often balk at purchasing them, or can’t pick one up until their designated pharmacy opens. In these cases, you can build your own spacer out of two standard albuterol nebulizer kits.

Open up both kits, and take out one of the T-pieces. On both ends of the T-piece, put on a section of the ribbed blue tubing – depending on your kit, you may have to squish the tubing a little to get a fit on both sides. This leaves one opening left in the T-piece, which you should cover with tape (photo 1).

Next, take the mouthpiece from one kit and stuff it into the end of one section of ribbed tubing. On the opposite end, push in the albuterol MDI. Poke a few holes in the tubing near the MDI with an 18-gauge needle, and it’s ready to go. Spray two puffs of albuterol into the tubing, and have the patient inhale slowly through the mouthpiece (photo 2). Try not to think of similar devices you made in your friend’s basement in high school, and be sure to emphasize that the patient needs to obtain a “real” spacer as soon as possible.

Doppler Alternative

There is a tried and true tradition of inebriation and power tool usage – in particular, malt liquor seems to mix quite often with table saws, snow blowers, belt sanders, reciprocating blades, boat winches, and industrial mixers. Some of the associated hand injuries we can fix ourselves, and some of the really horrendous ones require a surgeon’s intervention. As soon as the initial assessment is done, the most immediate question is whether or not there is blood flow to the digits distal to the injury.

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.)

Next, place the prongs of the nasal cannula on the bridge of the patient’s nose, taping in place if necessary, and open up the flow from the IV bag. Fluid will flow through the IV tubing and into the nasal cannula, irrigating both eyes (photo 5). One notable disadvantage is that it’s not easy to irrigate only one eye with this method, and it should be used only as a bridge until a Morgan lens becomes available. Until it does, though, it is far better to obtain moderate success through improvisation rather than complete failure in the pursuit of perfection.

Dr. Fisher is an emergency medicine attending at Westerly (R.I.) Hospital. Have a nifty idea you’d like to see in Tricks of the Trade? E-mail it to him at fisherwhit@gmail.com (he promises to give you credit).