Robert D. Glatter, MD: A large part of being an emergency medicine physician is being a problem solver, being innovative and resourceful, and trying to make the best of a challenging clinical situation—often with the lack of complete information or equipment. The spirit of what we do on a daily basis is reflected in the character of a popular TV series, MacGyver, which aired decades ago but was rebooted in 2016. Dr Amy Ho fits the bill of a problem solver, so much so that she came up with the concept of what a character such as MacGyver would do if he didn't have exactly what he needed to solve a problem—a topic of one of her past ACEP [American College of Emergency Physicians] talks. Dr Ho is a recent graduate of the University of Chicago Emergency Medicine residency and is newly clinical faculty and associate medical director at John Peter Smith Hospital, a level-1 trauma center in Fort Worth, Texas. Welcome, Dr Ho. Amy Faith Ho, MD: Hello. Thank you so much for having me, Dr Glatter. Black Tea Bags for Dental Extraction Bleeds Glatter: Let's dive right in. First up are tea bags. Can you tell us about something as simple as a tea bag and how you could use that in a pinch? Ho: I have never worked in a hospital that doesn't have tea bags for patients or family members. They are actually really great for mucous membrane bleeding. Here, I have a routine hospital tea bag. It can be any brand, such as Lipton black tea. The black tea has tannic acid in it, which is a vasoconstrictor, which means that you can use it for topical application of anything from dental extractions to hemorrhoidectomies. This is very well documented in the literature.[1,2,3] [One of my favorite tricks is using tea bags following dental extractions.] I open up a tea bag, wet it, put it in the patient's mouth, and tell them to bite down on it for about 20 minutes. That pressure plus the vasoconstriction almost always stops these dental extraction bleeds, even if they are on anticoagulation. Glatter: That is really novel. In my experience, I've used TXA [tranexamic acid], which might not be readily available. This is an incredible approach. How do your patients respond to this? Ho: They love it. They think it is so novel. It is a great thing to educate patients on for when they go home. You always worry about re-bleeding. I just tell them, "Hey, before you come to the hospital, you can try a tea bag at home." They love that. You can't send them home with TXA. You can't send them home with topical cocaine. This is a great thing that means they don't have to come back. Glatter: Do you use warm water when you use the tea bag approach? Does the temperature matter in terms of any hemostasis? Ho: The temperature doesn't usually matter. I tend to use cold water, but it doesn't make a difference. Glatter: Can you use any variety of tea or is this limited to a certain kind of tea? Ho: It has to be black tea. You want to have any tea with tannic acid. I couldn't speak to Earl Grey or any of those, but all black teas have tannic acid in it. Speculum for Peritonsillar Abscess Drainages Glatter: Let's move on to the next one, which is speculum for drainage of a peritonsillar abscess. Ho: Also one of my favorite things—I used to work somewhere where we did not have ENT. We did all of our own peritonsillar abscess drainages. I used to open up an airway cart and pull out the Mac blade because it is perfect to put in the mouth, depress the tongue, and provide some light. We noticed that there's usually a lot of paperwork involved with opening the airway cart, so we moved away from that. What I have here is a routine speculum, a pelvic speculum. You can actually remove the top part, which now becomes your tongue depressor. A lot of the speculums have a light in them. Now you are ready to visualize the oropharynx. All I do for a peritonsillar drainage is have the patient sit up, I give the speculum to the patient, and I have them open their mouth. The speculum both depresses the tongue and opens up the mouth. The patient controls the gag reflex, which helps give me better access and provides light. Then, all I have to do is poke with a needle or a scalpel. Glatter: That is really novel. Having the patient dictate how much pressure is really so key, as you describe. Ho: If they say it's advancing too far, no problem—they can pull it back. I let them completely control it. Glatter: Have you tried this in the younger age groups or is it more for an adult? Ho: Also for younger kids. When you get to the very young kids, the ones that aren't coachable, pre-teenage, it is difficult no matter what. I think a lot of people use a little bit of Versed (midazolam) or something to calm them down. For adults and teenagers, I think it's great. Makeshift Eye cannula Glatter: We will move on to our next topic, which is using nasal cannula for eye irrigation. Certainly, we are all familiar with the Morgan Lens approach, which may be costly in many hospitals. This might be something up everyone's alley. Ho: Yes, especially if you don't have a Morgan Lens, which was our problem. A very senior nurse showed this to me. You can take some normal IV tubing—here's the spike and here's the end—and you can connect it to a nasal cannula. [With the nasal cannula, you put this part] that usually goes up the nose across the bridge of the nose, and then that dribbles water straight into the patient. I take the nasal cannula and cut it before it bifurcates. Once you have it cut, you just have a small hole, which is the perfect shape for the end of the IV tubing to go into. Let me grab my IV tubing and I'll show you what I mean. Glatter: Can you generate enough ocular pressure with this technique as compared with a Morgan Lens? Ho: You absolutely can. You can put it on a pressure bag. All you do is take the nasal cannula, [which has been cut at the end]. This is the end of the IV tubing, and it snuggly fits right in there. You can add a little bit of tape, if you want, for security. Now, this is all continuous tubing. You can spike a saline bag, and then you can pressure-bag that in. [You take the nasal cannula and put it right around the face]. You can cinch it down behind the head and you can just tape it so that it goes right over the bridge of the nose into the eyes. The whole end, if you follow the tubing back, goes all the way down to the spiking. You can stick that right into your nasal saline bag, put it on a pressure bag, and you're good to go. You can pretty quickly drop a whole liter of irrigation into them. Glatter: It seems like it might even be faster than with a Morgan Lens, just based on the physics of the tubing. Ho: I think the fastest thing about it is you don't have to wait for someone to find the Morgan Lens. I find that patients tolerate this really well, too, because they understand conceptually what's going on. You can have them help hold the nasal cannula exactly where it needs to go and they'll tell you when it's no longer flowing. Glatter: I love how you involve the patients because that's so important. Patients are often intimidated, but when you involve them, it seems to put them at ease. I like that a lot. Dental Floss for Stubborn Rings Glatter: The next one is dental floss for ring removal, which is always a favorite of ours. It's an alternative to getting the bow cutters, calling the fire department, getting the ring cutters out, and all that noise. Ho: And asking for vice grips and cutting someone's brand-new engagement ring. I am totally with you. This is another great thing, which is pretty well documented. You can do this technique with dental floss or any string. A suture or anything like that works also. If you start with a patient who has a ring—this one's a little snug on me, but it's a little tough to get over the knuckle—you can take normal household dental floss; pull a nice, long string of it out. Glatter: Does it need to be coated dental floss? Ho: It doesn't matter. You just have to be able to slip it under the ring at one side. I'm cutting off a generous amount of dental floss. You start with a ring, then you take the dental floss and slide it under the ring. Usually this is pretty easy because your constriction points are almost always the knuckles. If you're below the knuckles or below whatever traumatic area, that usually does the trick. I have it strung under the ring. You're trying to constrict and wrap that dental floss as tight as you can, especially over the fattest area. For me, that is almost always the knuckle or the area that's swelling. The tighter you go, the better it is. Now, you have the dental floss under the ring and constriction [of the finger] using the dental floss. From there, you have someone hold pressure on one end. As you unwrap the proximal end, the ring slides off. It slides up as you're going, because as you're unwrapping, it's also pushing it up. By the end of it, you get right over the knuckle. Glatter: Are there any situations where you would not use this method? Say, the ring had been on for 4 days and there's an infection. There's cellulitis that you see—any compromised skin or any ulcerative lesions. Would that be a contraindication? Ho: If there's an open fracture at the distal tip, I wouldn't because you can't safely constrict it. Everything else, the ring has got to come off. I have a pretty low threshold to do it, especially because for men, they have so many of those new metals that you can't cut. The first time I see a trauma with a ring on, that ring needs to come off. We'll go straight to the floss or the suture ASAP to get it off before the swelling gets worse. The only time I've seen it not work is if the patient has too much pain to allow you to wrap that suture or floss around their finger. In those cases, I do a digital block, so it still works after I provide a little bit of pain control. Milk... It Does a Body Good! Glatter: Really nice. Let's move on to the next topic, which is capsaicin exposures—chili peppers, pepper spray. That's always a favorite of ours. I understand that you have a little concoction. Ho: We do. We get so many patients who got pepper-sprayed by the cops—they're protesting, or something like that. If you irrigate it with normal saline, it still burns. We actually use full-fat hospital milk. The reason it works is that capsaicin is fat-soluble; it's a hydrophilic hydrocarbon.[4] If you use whole-fat milk, it has caseins, which are lipophilic and act as a detergent. You literally take whatever was exposed—and I'll do this for eyes included—pour a whole carton of whole-fat milk over it, and that completely does the trick. Anything fatty works. We've used hospital-grade mayonnaise also for skin exposures, and it immediately cuts the burn. It's such a nice thing for patients. Again, it's something you can counsel them to do at home if it happens again. It's clean, it's cheap, it's easy, and it's a quick discharge. Glatter: If someone has terrible eye burning, other than tetracaine or some topical anesthetic, would this apply? Ho: Absolutely. I just lay them flat and I pour milk right over them. Sometimes I'll do the nasal cannula/IV tubing Morgan Lens trick and pour milk straight into that. What's really fascinating is that as you are pouring, you can actually see these little fatty-looking things, that look like oil, come out with the milk. It's an absolute detergent. It's safe for the eye. You irrigate them with a little bit of normal saline after and it completely does the trick. Glatter: That's really novel. I really have never known that you can do that for an ocular exposure. That's really incredible. Hot Sauce for Cannabinoid Hyperemesis Glatter: One of the last topics is for those who overuse cannabinoids and have intractable vomiting. How would you approach this type of patient typically in your ED? Ho: I treat a lot of these hyperemesis syndromes similarly because—unless they're a diabetic—you don't really know if it's pot and sometimes they won't tell you. My question for these hyperemesis patients is whether hot showers help. If they do, I will go immediately to this capsaicin trick. It's pretty well documented that for cannabinoid hyperemesis, there is a TRPV1 receptor, which is a vanilloid receptor that responds to both scalding water and capsaicin.[5,6] I've tried multiple times to order capsaicin cream, but it's never come to me in the hospitals I've worked at. We've [started] using hot sauce. The literature is pretty well documented that capsaicin 0.025%-0.075% works really well as a cream for this syndrome.[5,6] The problem is that hot sauces [don't have capsaicin percentages on the labels], so we have to figure out what to do. Hot sauces are graded in Scoville units.[7] If you look at the Scoville units and convert that to percentage of capsaicin, you're looking at 4000-12,000 Scoville units, which includes hot sauces that are fairly mild to moderate. A hot sauce we frequently have is Crystal, with tabasco and habaneros in there. All you do is put a generous amount on the abdomen. You can cover it with a Tegaderm so that none of your staff members touch it. The only side effect to this is that patients can feel a little bit of burning, as you would expect. If that happens, just wipe it off. You can put a little milk on it. No harm, no foul, usually. Also put [the hot sauce] on the back of the arms. Glatter: Is there any toxicity to this? I've read anecdotally that in a certain milligram-per-kilogram ratio, there could be toxicity or even lethality. Ho: The main issue isn't so much toxicity. The main issue is that topical application can cause severe burns, which is why this conversion of [hot sauce Scoville units to the percentage of capsaicin] matters. Don't throw ghost peppers on anyone. This mild-to-moderate range is really what you're looking for. For any patient who says hot showers work, even if they don't smoke pot, I try it. There are case reports in the literature that are pretty well done. There are bigger and bigger studies that have reported this working as well. In my practice, [this has not worked for maybe one or two patients]. Glatter: [Do you think this should be first line] before you give someone droperidol or Ativan (lorazepam)? Ho: I do. I totally do. I always offer it to them. I tell them, "It might make your stomach burn and you'll smell like hot sauce." They usually go for it. The problem with these patients is that they've taken so much Zofran (ondansetron) and everything else at home that their QT [interval] is already in the 500s. I feel pretty nervous giving them droperidol, haloperidol, etc. We have a patient that we routinely use hot sauce on. Sometimes she gets a little skin irritation. We put mayonnaise on her, too, to get rid of the capsaicin. She is always joking that she smells like Buffalo Wild Wings when she goes home. Glatter: That is incredible. Using the kitchen to our advantage—what an amazing thing. I bet your administrators love [the cost savings]. Ho: Oh, yes. The breakroom hot sauce is missing a lot. Glatter: Thank you again. This has been incredibly educational. I look forward to further conversations about some of your other tricks of the trade. Ho: Absolutely. Thank you so much for having me. This has been a lot of fun. Source
