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Macgyver Fixes In Rural Medicine
Dr Martha Riesberry MD CCFPRural and Remote 2019Halifax, Nova Scotia
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Who am I?
• Rural family physician locum and surgical assistant
• I have worked in Northern Ontario and South Western Ontario
• OR assist, Emergency, Clinics and Cardiac Rehab• Based in Kitchener , Ontario• I have no declarations• Mom of 2, James and Elizabeth
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Objectives
1. Share techniques used by other rural and urban physicians with limited resources
2. Discuss techniques used by attendees3. Try some of these techniques
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Topics
• Tubes and catheters• Containers large and small• Warming and cooling • Dental procedures• Closures/securing techniques• Uses of tape• Other techniques• Resources outside the Emergency Department
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Tubes, IVs and Catheters
Foley Catheter• Place in gunshot/ stab wound and inflate balloon or fill with saline to adjust pressure.
• Also apply under clavicle to apply pressure with stab wounds. Fill with saline to tamponade bleeding
• Suction ET tubes or newborn oropharynx• Umbilical catheter• Nose bleeds
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Tubes, IVs and Catheters
14‐16 gage IV for spike tracheotomy• Attach 20ml syringe with no plunger.
• Place endotrachial tube in synringe and seal with balloon.
• Hard to ventilate.
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Tube to bag adapter of a 7 ET tube fits 3 ml syringe with plunger removed.
IV bag spikehttps://www.youtube.com/watch?v=oIn245TPzAI&authuser=0
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Other uses of tubes
• Fold IV tubing to set off alarm on pump to attract nursing attention when bed side buzzer not working.
• (very affective according to one unnamed patient / doctor)
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Containers Large and Small
• Aerochambers• Chest tube reservoirs• Irrigation protection
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Aerochambers
• Styrofoam or paper cups– Opening to face and inhaler in base– Adjustable to face size and shape
• Pop bottle– Cut a hole in the base and mouth around the opening
– Place thin wire around the opening of the inhaler and warm to melt into the bottle a perfect fit.
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Aerochambers
• https://www.youtube.com/watch?v=NBszxJvczYM
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Chest tube
• Place free end of tube (possibly a foley with fenestrations cut into it used as a chest tube) into a pop bottle full of water.
• Tape the tube with large amounts of tape to keep it in place.
• Condome with a hole in the tip for a one way valve on a chest tube. – Cover with vaseline/muco– A pen can be used for tube
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Other
• Medicine cups with a hole in the bottom big enough to place a 20 cc suringe.
creates protection from irrigation
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Warming and Cooling
• No incubator or warming cupboard? Warm blankets in the dryer
• Bucket of warm water boiled in kettle. Check temperature and top up with further water. – Place bags of saline in water to warm
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Dental Procedures
Coverage for broken teeth• Bone wax or cheese wax• Tissue glue• Blue tacSplint• Bendy metal nose piece from mask. • Secure to replaced tooth and 2 adjacent teeth with skin glue.
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Securing Techniques
• IO stabilizer to hold the endotracheal tube in place if you’ve criched someone — fits 5.5F very nicely.
• 3.O suture through chest tube and patients skin..and tie in position
• Use ceiling cross bars to hang IV bags
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More secure than direct on skin.Wider tape used
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Securing
• Tie hair in knots to bring skin edges together after winding several strands together– 2 hand tie easier than instrument tie, but wet hair helps
• Can do the same with short strands, but glue after twisting.
• Add friars balsam for further seal, but will need to be cut.
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Other Techniques
• Tongue depressor clamp for epistaxis.– 6 tongue depressors and wrap half inch tape at the bottom to tape all 6 together then apply another wrap leaving about a half inch between.
– Apply to a bleeding nose rather than using ones fingers (that run out of ATP) and you have a simple and cheap way of managing minor epistaxis. Leave on for 20 minutes
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Other uses for tongue depressors
• Place in teeth and ask the patient to bite down. Flick tongue depressor. If not pain, jaw not likely broken
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Splints
• Long card board box• Birch bark • Sticks• Real beer can for splinting position
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Ring Removal
• . https://youtu.be/kGGwX2lY4rc
• Use wrist block rather than ring block to reduce distortion and swelling from fluid
• Use dental tape instead of the suture material• Squeeze to exsanguinate the finger• Wrap distal to proximal
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Light Sources
• Head lamp: useful to have in the car• Torch feature on cell phone.• Small pen light taped to tongue depressor
– Or ask patient or parent to hold the light.
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Tape
• Can be used to remove small items such as nettles, slivers, stingers etc.
• Cheap version to remove hair after shaving• Treatment for over grown skin on toe nails
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Other Techniques
• Use a straw or pen lid to mark skin before preparing for techniques. This is not washed off with prep.
• Bed sheet pelvic binders• Plastic sheet stretcher• Gauze wrapped with tape for mouth block. • Make a loop in a splint to pass a cord/rope through so it can be hung on bed post at night
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Other Techniques
• Bone Rongeurs for cutting thick toe nails• Drop your IUD plunger? No problem
– Tape 2 q tips together with steri strips and remove cotton buds. Just long enough.
– ? Would the longer C & S swab work?– Careful strings don’t get caught in appliance
• 4‐5 mm punch biopsy needle as a skin currette
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Medications
• Chew amox‐clav if no iv antibiotics in awake septic patient and long transport time
• IV dex and acyclovir in juice for children• Dexamethasone to reduce dental abscess pain. Can drink IV formula
Learn• Dental blocks and regional blocks
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Warming Blanket
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Warming Blanket
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Warming Blanket
• Recommended only for use for short cases• Leaves arms free• Cannot place items on top as no sections for air. Warn surgeon
• Can place a blanket underneath to protect from colapses
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Umbilical bandages
• For use when bandage placed over a gap• May cause negative pressure
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Resources outside the ER
• Does your hospital have a dremel?• Vice in maintenance room to secure bolt
– Fiberglass blade from cast room to cut with saline drip to keep cool
• Finger in a metal plate with a hole in it.– Called in local man with shop who came to cut plate
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Other resources outside the ER
• Water and warm body– Burns/scalds in camp placed patient in water for almost an hour. Other person kept patient warm from behind. Changed shirts to keep upper body warm.
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Seasonal variation out of ER
• Eggs for vagal maneuver– Pin hole in top and bottom of eggs– Blow egg content out. – Can decorate egg afterwards
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Other Suggestions?
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April 23‐25, 2020