What is the coolest procedure?

[stud247]

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Like is there some procedure in EM that you do (at least once a month) that you find really enjoyable or interesting to be performing? That you're looking forward to be doing again?

 

[dchristismi]

This is going to sound really silly, but I LOVE reducing nursemaid's elbows. LOVE IT.

One minute you have a toddler refusing to move his arm, the next, he's fixed! It's quick, a purely clinical diagnosis, a quick procedure, and the problem is resolved.

And you're a hero in the parent's eyes.
It's the perfect procedure.

Of course, that's just me. I love 'em.

 

[deleted109597]

Starting my engine on the way home?

 

[Rendar5]

dropping a transvenous pacer.

though I did see a painless (no screaming, no pain meds, no sedation) shoulder relocation once which was pretty cool. a DO did it some way I hadn't seen before, so maybe OMM was involved...?

 

[willow18]

Thoracotomy, by far. Done at least once per ER shift uhh I mean episode.

 

[Doctor Bob]

I did see a painless (no screaming, no pain meds, no sedation) shoulder relocation once which was pretty cool. a DO did it some way I hadn't seen before.

To do the no screaming, no pain meds, no sedation shoulder relocation follow these steps.

First assess the cranial rhythmic impulse and assess the strain pattern on the sphenobasilar synchondrosis. Using the second vault hold, apply a counter nutation force to decompress the SBS, and pop! The shoulder is back in place.

For the DOs in the room, this is hilarious. For the MDs, this makes absolutely no sense. After a few moments, the DOs will realize its a load of crap also.


But on a serious note, when I was a tech before going to medical school I saw one of the DO ED attendings do this to a patient and it was one of the things which made me seriously consider DO school. Although osteopathic stuff is rarely if ever used in the ED, anything extra you can learn in school is just another tool in your arsenal. And once in a while you can apply it in ways that AT Still never intended and actually come up with something useful... like a less forceful shoulder reduction.

 

[lucky_deadman]

though I did see a painless (no screaming, no pain meds, no sedation) shoulder relocation once which was pretty cool. a DO did it some way I hadn't seen before, so maybe OMM was involved...?

I've done this before. NO OMM was involved. It requires the right situation and right patient.

 

[EM2BE]

dropping a transvenous pacer.

though I did see a painless (no screaming, no pain meds, no sedation) shoulder relocation once which was pretty cool. a DO did it some way I hadn't seen before, so maybe OMM was involved...?

Legg Maneuver

This is probably what you saw. Proud to say it was one of my professors that came up with it.

 

[Apollyon]

Legg Maneuver

This is probably what you saw. Proud to say it was one of my professors that came up with it.

Hmm...similar to the external rotation/internal rotation method...

...although the Legg method requires an osteopathic physician to perform it! (According to the article.)

 

[Midwest Medic]

Seems just like the maneuvers that I do for a reduction, but under sedation.
Interesting from the article that the doctor on the right in the pictures was my advisor while I was at UHS (now KCUMB) and the patient in the pictures was one of my old classmates. Dr. Legg was a funny old guy, probably the dryest sense of humor ever, but he really had a bunch of one liners when you got him going...

 

[roja]

Shoulder reduction.

 

[docB]

G tube replacement. I had a gorked out quad yesterday who was transferred from the nursing home at 3 am for the emergent, life saving, highly technical insertion of a new foley into the tract. I as the Emergency Physician supervised one of our specially trained ED nurses for the completion of this critical procedure. Once it was in we all breathed a big sigh of relief. Our swift and decisive actions saved the nursing home nurse from the inconvenience of getting off her ass and working. Thank God we were there!

The invigorating adrenalin rush I got from interveneing in that situation was only surpassed by the suprapubic tube I got to replace the week before.

 

[kungfufishing]

wow what a riveting tale! I bought the whole seat, but I only used the edge.

Would you believe that in our ED this is a physician only procedure? No idea.

 

[DOrk]

Reduction of TM joint dislocation

Not something I get to do often, but kinda cool when it pops back in-I got to do it on the same pt 2 days in a row last week.

 

[Arcan57]

For sheer satisfaction after it's done, I'd have to go with hip relocation <clunk>. Follow closely by draining a Bartholin's gland abscess <gush>.

 

[Jeff698]

For sheer satisfaction after it's done, I'd have to go with hip relocation <clunk>. Follow closely by draining a Bartholin's gland abscess <gush>.

1. Yep, way cool!
2. Yuck!

Although I like draining pus as much as the next guy, something about Bartholin's make me urp just a bit.

I like finger dislocations, too. "Hmm, let me take a closer look at that fin...YANK...ger. There ya go, all better."

Take care,
Jeff

 

[12R34Y]

By far my favorite procedure is writing the word "discharge" on the orders page.

It still makes my heart flutter just thinking about it.

 

[AlSomaliMD]

I think the coolest i have done was a chest tube, knowing that i am a med student.
but i cant wait to do a retrograde intubation lol.. 🙂

 

[DrQuinn]

Maybe not really a procedure per se, but I always enjoy giving adenosine for SVT. Always kind of sphincter tightening for everyone (though it gets a little easier now that I am an attending).

I still always kind of like the rush of:
Getting a nice thread for a central line. I do my "happy thread, happy thread, happy thread" chant as I push the guidewire through.... and when it slides in easily that is always very satisfying...
And just endotracheal intubation. Sliding it through the cords, pulling out teh stylet, and bagging with nice yellow to the ETCO2 detector, that still is a nice relieving feeling.

I guess I Just like feeling relieved more than excited nowadays.

I delivered a turd about the width of a tennis ball a few days ago from a nursing home patient, by the way. Almost as exciting as docb's G tube replacement....

Q

 

[leviathan]

I've done this before. NO OMM was involved. It requires the right situation and right patient.

I've seen an attending do this before with nitrous oxide and a nice, calm, soothing voice. Worked like a charm.

 

[Tiger26]

Honestly, just doing a really thorough history and physical and then writing an outstanding progress note the next morning is probably the coolest procedure that I could think of . . .

 

[FLTDOC1]

I like pushing D50 - on a cold, sweaty dead appearing person GCS of 3 and a glucose of 10 and watching them magically come to life

 

[Greenbbs]

i know it's not a procedure, but clinically diagnosing a hot appy by a good physical exam, then having the surgeon compliment you on a job well done is extremely satisfying.

 

[willow18]

i know it's not a procedure, but clinically diagnosing a hot appy by a good physical exam, then having the surgeon compliment you on a job well done is extremely satisfying.

But did you get the CT after the good physical exam?

 

[overthebars]

But did you get the CT after the good physical exam?

And a pelvic US?

 

[kungfufishing]

defibrillation with immediate return to oriented mental status. I've only gotten to do this twice, and oddly enough both were patients that cards wasnt sure they wanted to cath who promptly coded while the cardiologist was in the ED. It is a satisfying feeling to push a button and have a dead person wake up and ask "can someone please get me some ice chips?"

 

[TysonCook]

for stable patients in SVT doing a vagal manouver and having them go from sweaty palpitations and feeling like death, to sinus, all by "bearing down like your trying to take a big $hit" Patients love it.

 

[Greenbbs]

But did you get the CT after the good physical exam?

Actually, nope. The attending surgeon was a very good non malignant surgeon, and I know him pretty well, so he took my word for it. She ended up having a 18mm dilated, fluid filled necrotic appendix, which he had to convert her to open to remove.

 

[It'sElectric]

I've only been working in an ER for a few months now, but the coolest thing I've seen is a cardioversion.

Merely an MS3, but cardioversion is very cool and instantly satisfying. Watching the monitor go from A-flutter to sinus in a matter of seconds is beautiful.

 

[Static Line]

Clocking out is a great procedure.

 

[southerndoc]

Merely and MS3, but cardioversion is very cool and instantly satisfying. Watching the monitor go from A-flutter to sinus in a matter of seconds is beautiful.

I love to cardiovert patients. Give 'em the juice!

 

[McPoyle]

I love to cardiovert patients. Give 'em the juice!

This has to be one of my favorites, mostly because I can often see an immediate and tangible change in the pt's status (improved mental status mainly). Really anything that gives me instant gratification is pretty cool (I was trying to find that scene from bringing out the dead when Nicholas Cage pushes the narcan on that kid but I can't find it).

D50 and Adenosine I like for the same reason...

 

[Apollyon]

I have to go with the adenosine, too. I've only defibrillated patients to consciousness twice, and they were both on the ambulance - once was 1993, and the other on New Year's Day, 1999.

Before the adenosine, I tell the patients that I can't tell them what they will feel beyond it being "the weirdest thing you have ever felt in your life", which is funny, because that is what I hear, verbatim, after they get it.

Ibutilide chemical cardioversion is getting there, too - right at the moment the AFib converts.

 

[gutonc]

I have to go with the adenosine, too. I've only defibrillated patients to consciousness twice, and they were both on the ambulance - once was 1993, and the other on New Year's Day, 1999.

Before the adenosine, I tell the patients that I can't tell them what they will feel beyond it being "the weirdest thing you have ever felt in your life", which is funny, because that is what I hear, verbatim, after they get it.

At the VA, "getting kicked in the chest by a donkey" elicits more understanding that you might imagine.

 

[McPoyle]

I enjoy Adenosine, pushing it seems to elicit a very predictable sequence of events:
1.) Pt. begins by appearing anxious, scared, c/o CP maybe SOB, diaphoretic, maybe slightly altered.
2.) Adenosine is pushed and the anxiety seems to peak with a "WTF" kinda look on the pt's face followed shortly by a lil panic and one bout of emesis as the pt. struggles to comprehend the events that have recently transpired.
3.) HR and other vital signs return to normal parameters. The anxiety almost immediately melts away, skin color improves, no longer altered. Also, the pt is generally grateful because the symptoms have subsided and conversive while we transport them to see you nice folks!

I've only done a couple of cardioversions but I can't help but to smile when I see the immediate effects... although it looks like it hurts-a lot-but I guess thats what the versed is for huh? Can't hurt if you don't remember it...

 

[Jeff698]

I love to cardiovert patients. Give 'em the juice!

One of our cardiologists refers to the sedation/cardioversion as "stone n' spark".

He also refers to AICDs as "soul catchers". I always picture an indian dream catcher dragging an elated soul back into an emaciated body.

Take care,
Jeff

 

[DrWBD]

I always thought the "dump to Medicine" was the most enjoyed ER procedure, since it happens pretty much every day.

 

[gutonc]

I always thought the "dump to Medicine" was the most enjoyed ER procedure, since it happens pretty much every day.

That's actually Ortho's favorite procedure. It's #2 on the Neurosurg list.

 

[southerndoc]

Over the past week, I've had 3 ankle fracture/dislocations. The first 2 I did myself (one was a fairly bad fracture, but came together nicely after reduction). The third was open with the foot completely off the ankle mortise. The thing looked horrible, and surprisingly the patient had a pulse. Needless to say he went to the OR emergently.

 

[MasterintuBater]

As much as I despise Dental pain, I bucked up and did an inferior alveolar block on a guy that was screaming in miserable pain. I hadn't even pulled the needle out of his mouth when he started thanking me and hugged me when it was done. He left without asking for Vicodin. THAT was a gratifying procedure.

 

[Apollyon]

Starting my engine on the way home?

By far my favorite procedure is writing the word "discharge" on the orders page.

It still makes my heart flutter just thinking about it.

Honestly, just doing a really thorough history and physical and then writing an outstanding progress note the next morning is probably the coolest procedure that I could think of . . .

Clocking out is a great procedure.

I always thought the "dump to Medicine" was the most enjoyed ER procedure, since it happens pretty much every day.

Lame, lame, lame. Our job is cool and fun. Even as weak attempts at humor, if this is your favorite, most exciting procedure, maybe you should re-examine your career choice (except for the ever-present slam from the IM flea, a student in this case). Just because you say you want to be, or are an EM doc, doesn't mean you should be one.

Now, granted, a few of these are from our EM friends that have posted affirmatively to the opposite on many other occasions, but, given the chance to tube another patient, and drop in a central line, and shock another, and relocate a joint, and go home, I'm staying a little extra time and doing the procedure.

 

[Hard24Get]

I love a big, juicy, multi-level laceration always makes me smile. But nothing beats a big, cellulitic, loculated abscess in need of I&D 😍 I've only done one chest tube but I loved it. Ooh, and LPs - that moment when you remove the needle and CSF comes out!..And then there's foreign body removal, you never now what you're gonna get!

I guess I just like procedures...😳

 

[deleted109597]

Over the past week, I've had 3 ankle fracture/dislocations. The first 2 I did myself (one was a fairly bad fracture, but came together nicely after reduction). The third was open with the foot completely off the ankle mortise. The thing looked horrible, and surprisingly the patient had a pulse. Needless to say he went to the OR emergently.

I will admit, I do like pulling those back on. You're standing there, skiing, someone is pulling the skin out of the hole, and clunk.

 

[Kubed]

Getting interosseous access with an Illinois needle is pretty awesome. In the middle of a code, adrenaline is pumping, getting scared that you can’t get IV access. “Having a problem with that vein? No worries…. THUNK! Access granted.”

 

[colforbinMD]

I can't believe in 44 replies nobody else seconded the 1st reply..... I LOVE nursemaid's elbows.... I will lie cheat and steal to get them from the waiting room and fix them before they even hit the department.


I also love adenosine.

 

[Jeff698]

Nursemaid's are pretty cool, I agree.

I also like shoulders, hips and, most especially, patella dislocations. "Thunk" is a really cool sound/feel.

I&Ds of big, juicy, pus-bubbling abscesses is still pretty rewarding. I cut one that literally hit the ceiling in residency. That was cool.

For me, though, good old fashioned intubation is probably still my favorite.

Take care,
Jeff

 

[kungfufishing]

I also like cardioverting nursemaid's elbows. The looks on the faces of the parents and nursing staff and hospital admin and jury are priceless.

seriously, I love those too as well as alveolar blocks for toothaches at 2 AM.

Anyone else like art lines? I think I'm the only guy in our group who does them, but I'm glad I have maintained this skill since residency. Sometimes they are really useful.

 

[Apollyon]

Anyone else like art lines? I think I'm the only guy in our group who does them, but I'm glad I have maintained this skill since residency. Sometimes they are really useful.

Me too - no one else does them in our group. Either you get it in 1 second, or you're probing. I get a chuckle out of stealing this procedure from a resident, too.

 

[Hawkeye Kid]

Me too - no one else does them in our group. Either you get it in 1 second, or you're probing. I get a chuckle out of stealing this procedure from a resident, too.

Agree on the art line...while not the coolest, you either get it right away or it takes forever. I give myself < 5 min before I walk away and come back later; can't count the number of times I've stuck multiple times without luck and come back 30 min later and gotten it right away. Same thing with LPs for me--it either comes easily or it's a huge pain.

Also agree with Jeff...nothing more relieving than getting the tough tube on the third or fourth look (luckily we have some attendings that give us that many attempts).

 

[kungfufishing]

I find that it is usually right where I thought it was the first time, I just went too fast and went through it and caused a spasm and a teeny tiny target.