The "Syringe Hickey": An Alternative Skin Marking Method for Lumbar Puncture.

BACKGROUND: Lumbar puncture is a procedure that is commonly performed in emergency departments. Despite their absence from procedure kits, emergency physicians often use skin markers to delineate landmarks for a lumbar puncture. We prefer to create a temporary indentation in the skin using the suction of a syringe. This "syringe hickey" eliminates the need for a skin marker. DISCUSSION: We created a photo demonstration comparing the syringe hickey to a skin marker for site marking. The syringe hickey was created using a 10-mL syringe aspirated to 5 mL on the forearm for 1 min. The syringe hickey lasted over 30 min on a range of skin tones across the Fitzpatrick Scale. The skin marker faded but the syringe hickey maintained its definition after application of ultrasound gel and sterilization with either chlorhexidine or betadine. CONCLUSIONS: The syringe hickey is a simple skin marking technique that is resistant to antiseptic agents and ultrasound gel. The syringe hickey may be useful for other procedures that require puncture site marking.

Arterial Line Placement Pitfalls Can Be Demonstrated and Visualized With an Inexpensive, Wearable Trainer.

BACKGROUND: Radial arterial line placement is commonly performed in various clinical settings, including the emergency department. However, learners are successful on the first attempt only half of the time. Simulation can provide learners with procedure practice opportunities outside of clinical practice to increase confidence and chances of success. OBJECTIVES: We set out to build an arterial line trainer that would be inexpensive and reusable, wearable, anatomically realistic, and echogenic to allow for ultrasound use. We also hoped to devise a clear option that would allow for demonstration of procedure pitfalls. DISCUSSION: The arterial line trainer requires 4 hours of assembly time and costs $160. This includes enough material to make 48 tissue pads. The ballistics gel pad is echogenic; it can be customized with clear gel for direct anatomic visualization or dyed gel for more realism. The trainer also has a pulsatile artery for practice using anatomic landmarks. Visualization of the following important arterial line placement pitfalls is possible: suboptimal angle of approach, inadequate advancement of the catheter, and through-and-through vessel puncture. CONCLUSIONS: Our inexpensive trainer can help physicians and physicians in training conceptualize, practice, and troubleshoot the pitfalls of arterial line placement. Training programs looking to help learners understand the mechanics of arterial line placement may find it a useful tool.

Emergency Department Thoracotomy: A Cost-Effective Model for Simulation Training.

BACKGROUND: Simulation provides a safe learning environment where high-stakes, low-frequency procedures can be practiced without the fear of being unsuccessful or causing harm. Emergency department thoracotomy (EDT) is one such procedure. Realistic thoracotomy models are expensive and not readily available. OBJECTIVE: Our objective is to describe a cost-effective, realistic, reproducible, and reusable thoracotomy model for simulation training. METHODS: We modified a commercially available clothes mannequin torso to expose the chest and abdominal cavity. A plastic skeleton composed of a spinal cord and ribs was placed inside the torso. Tubing was used to simulate the aorta and esophagus; both tubes were secured to the distal spine with zip ties. Commercially available lungs and heart were placed inside the chest cavity. A small rubber ball simulated the left lung to be able to maneuver the lung. The heart was covered with plastic wrap to simulate the pericardium. Thick tape was used to simulate the pleural cavity. Yoga mats were used to simulate the intercostal muscles, subcutaneous tissue, and skin. RESULTS: This model was tested with Emergency Medicine (EM) residents during a simulation session. A voluntary survey was available for residents to provide feedback. Survey results confirmed that the model provided valuable education, with overall positive feedback. CONCLUSION: This EDT model provides a valuable teaching opportunity to EM residents who otherwise might not have the opportunity to perform this procedure. Residents agreed that the model improved their confidence and is an effective method in providing the opportunity to practice this low-frequency, high-stakes procedure.

Sensitivity of a bedside reagent strip for the detection of spontaneous bacterial peritonitis in ED patients with ascites.

STUDY OBJECTIVE: To determine the sensitivity of a highly sensitive bedside leukocyte esterase reagent strip (RS) for detection of spontaneous bacterial peritonitis (SBP) in emergency department (ED) ascites patients undergoing paracentesis. METHODS: We conducted a prospective, observational cohort study of ED ascites patients undergoing paracentesis at two academic facilities. Two practitioners, blinded to each other's results, did a bedside RS analysis of the peritoneal fluid in each patient and documented the RS reading at 3-min according to manufacturer-specified colorimetric strip reading as either "negative", "trace", "small", or "large". The primary outcome measure was sensitivity of the RS strip for SBP (absolute neutrophil count ≥ 250 cells/mm3) at the "trace" threshold (positive equals trace or greater). RESULTS: There were 330 cases enrolled, with 635 fluid analyses performed. Of these, 40 fluid samples had SBP (6%). Bedside RS had a sensitivity, specificity, positive predictive value, and negative predictive value of 95% (95% CI 82%-99%), 48% (95% CI 44%-52%), 11% (95% CI 10%-11%), and 99% (95% CI 97%-99%) respectively at the "trace" threshold for the detection of SBP. CONCLUSION: Bedside use of the RS in ED ascites patients demonstrated high sensitivity for SBP. Given the wide confidence intervals, we cannot currently recommend it as a stand-alone test. We recommend further study with a larger number of SBP patients, potentially combining a negative RS result with low clinical suspicion to effectively rule out SBP without formal laboratory analysis.

An Inexpensive Conceptual Training Model for Transvenous Pacemaker Placement.

INTRODUCTION: Emergent transvenous (TV) pacemaker placement can be life-saving, but it has associated complications. Emergency medicine (EM) educators must be able to teach this infrequent procedure to trainees. METHODS: We constructed a conceptually-focused, inexpensive training model made from polyvinyl chloride pipes and connectors, vinyl tubing, and a submersible pump. Cost of the model was $51. We tested the model with a group of 15 EM residents. We then asked participants to complete a survey reporting confidence with the procedure before and after the session. Confidence was compared using a Wilcoxon matched-pairs test. RESULTS: Confidence improved after the session, with a median confidence before the session of 2 (minimally confident; interquartile range [IQR] 1-3) and a median confidence after the session of 4 (very confident; IQR 3-4, p=0.001). All residents agreed that the model helped them to understand the process of placing a TV pacemaker. CONCLUSION: Our TV pacemaker placement model was inexpensive and allowed for practice of a complex emergency procedure with direct visualization. It improved trainee confidence.