Author: Charlotte Davies / Codes: / Published: 01/01/2019

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Happy 2019! Your RCEMLearning blog team is so excited that 2019 is finally here, and as we couldn’t control our excitement, we’ve released an extra early blog to celebrate. Here is an emergency medicine quiz, just for you. All the questions are based on things we think Emergency Clinicians are more likely to know how to deal with than their non emergency colleagues. There’s bound to be topics we could have included – let us know in the comments, or on twitter – #RCEMNYE. Of course, if you’re allowed 10 minutes off between 2355 and 0005, why not run it as a departmental quiz?

The Questions
1. What’s the difference between a stuffer and a packer?

2. How do you remove taser barbs?

3. How should you drain a paronychia?

4. Your next door neighbour’s son has got his foreskin stuck in his zip. How do you manage that?

5. How do you unblock an NJ tube?

6. How do you cope with crowding?

7. How do you remove a tungsten ring?

8. What’s the best thing to do for a bleeding fistula?

9a. You’re at a New Year’s Eve Party. It’s 2330 and your friend’s spawn comes running down the stairs, proudly announcing they’ve just put a bead up their nose. Is new year’s eve ruined?

9b. Your friend was so excited that you saved New Year that they eagerly pick their three year old up by their arms and spin them round. The child screams, and refuses to use their left arm – but is quite happy playing with their new toys. Is New Year’s eve ruined after all?

10. A young, and healthy patient develops a “necrotic ulcer” as per the picture, about four hours after wearing their smart shoes at work. Can you provide them any relief?

Print friendly version here.

The Answers

1. What’s the difference between a stuffer and a packer? 

RCEM has got fantastic guidance on packers and stuffers, (updated in 2020, and discussed in an RCEMLearning podcast) summarised in the infographic from EDTimeStories above. Simplistically, packers spent time prepping drugs, stuffers just rammed them in. Body Packers usually swallow a number of well manufactured packages in order to smuggle drugs across borders or into prison. Body stuffers swallow small amounts of poorly wrapped drug usually at the point of arrest to avoid detection. Both have the potential for severe toxicity.

 

2. How do you remove taser barbs?
A Taser is two weighted barbs attached to long insulated wires. They fire at 180 feet / second and deliver 50 000 volts of electricity, in pulses. To remove the barbs, stretch the surrounding skin, and tug sharply. If it’s difficult, anaesthetise the area at the site of attachment possibly using an insulin syringe. Then insert an 18 gauge needle along the side of the barb with the bevel of the needle facing the barb. Advance the needle about half a centimetre. Pull out the needle and the barb together at the same time. If this doesn’t work, use a scalpel.
As long as your patient is asymptomatic, you don’t need to do anything else. No routine ECGs. No troponins. Nothing!

Don’t taze me
BMJ
They tased me
Taser

 

 

3. How should you drain a paronychia?

A paronychia is when pus, erythema and swelling develop between the nail and nail fold causing pain and discomfort. The most common cause is trauma to the cuticle or nail fold, innoculating staph aureus. Cases can be related to antiretroviral therapy, and from sucking fingers. Strep pyrogenes, pseudomonas pyocyanea and proteus vulgaris have also been seen. There is normally a rapid onset of symptoms.

Drainage is the best way of managing a paronychia:
Provide adequate analgesia. Most people consider the skin around the paronychia to be dead, so no analgesia needed. Some patients may need a digital nerve block, or analgesic gas.
You should be able to separate the cuticle from the underlying nail, exposing the potential space that is filled with pus by pushing gently against the nail edge. The skin is not actually incised – a bonus for any diabetics.

Hot soaks may improve things in just 20 minutes.
Home with advice to soak in saline and wash regularly +elevation. Should be asymptomatic in 3- 5 days!
Give antibiotics only if tracking cellulitis.

Chronic Paronychia is a multifactorial inflammatory reaction of the proximal nail fold to irritants and allergens or repeated paronychial infections.
Herpetic Whitlow is a paronychia mimic in adolescents and adults (may be associated with genital HSV) and adults (medical professionals who get inoculated by patients).
They start with pain + tingling, then swelling and redness, constitutional symptoms. Then you get 1 or more vesicles that enlarge. Remain for 7 – 10 days, then crust over. Peeling occurs in a week.
Treatment: check other mucous membranes for vesicles, don’t incise, pain management, dry dressings, needle aspiration of larger tense vesicles, aciclovir – controversial evidence.

Other mimics include:
• Squamous cell carcinoma
• Malignant melanoma
• Malignant tumors
• Eczema or psoriasis
• Reiter’s syndrome
There’s a great review on all things paronychia at St Emlyns here.

Herpetic whitlow don’t cut it
Herpetic whitlow
4. Your next door neighbour’s son has got his foreskin trapped in his zip. How do you manage that?
Provide adequate analgesia. The patient is likely to need intranasal analgesia, or analgesic gas to enable you to proceed further. Once the patient will let you look, local infiltration of lignocaine, or a penile nerve block will be useful.
Once you’ve done this, you might be able to roll the zip back – and simply undo it, like you would to retrieve a trapped scarf or something.b) Cut the trousers off, leaving only the zip. If they’re really really precious trousers you might be able to just cut the stitches keeping the zip in place.Look at where the foreskin is trapped. If it’s trapped in the teeth of the zip, cut the bottom of the zipper, and gently seperate the teeth freeing the foreskin.If the foreskin is trapped in the zip mechanism, this is trickier! At this point you need some pliers to snip the median bar off of the zip itself.If this fails, you’re going to need urology assistance to remove the trapped tissue – this may lead to an emergency circumcision.litfl.com zany-zipper
sljch.sljol.info

 

5. How do you unblock an naso-jejunal tube?

A blocked nasojejunal tube is likely to be blocked with undigested food products. Any enzyme that breaks this down will be useful – clogzapper, sodium bicarbonate or creon can be used. Fizzy drinks used to be recommended – but they shouldn’t, because they make the contents more acidic, and less likely to work. They also may end up dissolving the tube itself.

 

6. How do you cope with crowding?

If you find out the answer to this, do let us know! We’ve got two podcasts (1 and 2) on this. Our strategies:

  • Focus on what you can change, and only what you can change
  • Front load investigations and treatment
  • Use “fit to sit” as much as possible
  • Don’t alter your admission criteria.

 

 

7. How do you remove a tungsten ring?

How many departments have ring cutters nowadays? Even if you can find them, they won’t even scratch a tungsten ring. I think the easiest way of removing rings is to do it quickly, before the digit is so swollen you can’t get it off! Here are a few alternatives:
Use oxygen tubing: see video
Use a mole wrench
Tourniquet wrap
Of course, if the ring is not on a patient’s finger, be extra careful as it may be a sensitive area.

Hair tourniquets sound easy to remove, but are actually very tricky. The hair wraps itself round and round a finger, compromising blood flow. This causes oedema – so even seeing the hair is difficult. Prompt removal makes it easy – think about using depilatory cream, and a cutting needle. If all else fails, you may need assistance from your local friendly plastic surgeon – they’ve got fantastic operating skills.

 

8. What’s the best thing to do for a bleeding fistula?

Ok, this seems an easy one. But it’s serious. A patient bleeding from their fistula could easily die. These are crackingly high pressure bleeds. Pressure application is important. Not just “put a bandage on and see what happens”. Invert a drinks lid, place it on the bleeding bit, and bandage it on *really* tight. Then get the patient to a vascular surgeon ASAP.

There’s full guidelines available from the British Renal Society.

 

 

9. You’re at a New Year’s Eve party. It’s 2330, and your friend’s spawn comes down the stairs, proudly confessing that they’ve just put a bead up their nose. Is new year’s eve ruined with a trip to ED?
You can save New Year’s Eve! A “mother’s kiss” may mean the foreign body will come out all by itself! Check out our foreign bodies blog for more details.

 

9b. Your friend was so excited that you saved New Year, that they eagerly pick their three year old up by their arms, and spin them round. Their child starts screaming, and refuses to use their left arm. Is New Years Eve ruined after all?
You can save New Year for the second time! Your friend’s child has probably given themselves a “pulled elbow” or “nursemaid’s elbow”.  This is a subluxation of the radial head in the annular ligament. There are lots of ways to correct the subluxation – pronation and flexion is more likely to be successful, according to a twitter poll.
Be careful though – sometimes supracondylar fractures also have this mechanism of injury!

 

 

10. A young, and healthy patient develops a “necrotic ulcer” about four hours after wearing their smart shoes at work. How do you manage it?

How likely is it that a patient has a necrotic ulcer after four hours? If you look at the picture, you can see there appears to be a tense swelling, surrounding the necrotic area. It’s unusual for necrotic ulcers to be so raised.
Immediate management would be to check whether the ulcer is really necrotic – or whether the “ulcer” is full of fluid and blood. De-roofing the blister, like you’d do for a burn, is ideal.

After debriding the ulcer, you notice it’s just a fluid filled blister.

Hopefully you enjoyed our random quiz questions. How well did you do? Let us know on twitter #rcemnye. Or why not post your own quiz questions?

Happy 2019!