Clinical Pearl- Paronychia, splints, and diabetes

During my shadowing shift I got the opportunity to see X-rays of a tibia fracture and of an ulna fracture. The resident I was with taught me to splint the tibia and ulna and let me assist him. First the resident measured the plaster on the patient and then I counted out and folded 10 layers of the plaster. From there the medical student soaked the plaster in warm water and then it was ready to place on the patient.The split done for the tibia fracture was a posterior ankle and stirrup splint and for the ulna we did a sugar tong splint. Dr. Chhabra explained that splints are usually done in the ED in order to allow blood flow and inflammation which would otherwise be restricted with a cast. In both cases the patients were coming back to the ortho clinic and most likely will not need surgery.

Another patient we saw was a diabetic with a swollen finger draining pus. The resident performed a paronychia which required a lidocaine nerve block on the patients middle finger in order to numb. After waiting about a minute the resident took his blade and went in under the nail bed. Immediately after the pus began to drain along with some blood. This patient happened to be diabetic and had a blood sugar level of 500+ which was concerning to the resident so he order labs on him and also started an IV. The resident was concerned that he could go into diabetic ketoacidosis which is a condition where the body does not have enough insulin and produces excess ketones.

Lastly, Dr. Chhabra took me to see one of his patients that was diabetic and came in because of a nail puncture on the bottom of his foot. They ordered him a tetanus shot immediately. Then Dr. Chhabra showed me two places on the foot where he could take the pulse as well as the red swollen area that was warm to the touch. This patients case of cellulitis was not too bad but he was put on two different antibiotics which should help him recover. The concerning factor was if he were to get a fever or if the area of redness and inflammation grew bigger. The patient was discharged with antibiotics and should be doing better over the next couple days.

Use of Tonopen due to Ocular Trauma

When I was shadowing Dr. Chhabra, we met a patient that suffered from ocular trauma due to an altercation. Dr. Chhabra explained that one concern for this patient would be that they are suffering from a build-up of ocular blood. This condition left untreated could eventually lead to very serious consequences such as blindness. In order to check whether or not the patient was suffering from this condition, they used a Tonometer TonoPen which would check the intraocular pressure. If the pressure reading of the eye that suffered from the trauma was much higher than the pressure reading of the other normal eye, this would indicate an ocular issue. In this case, a bedside procedure called a lateral canthotomy would be performed in order to relieve ocular pressure. Luckily, this was not the case for the patient.

Confirming an Intrauterine Pregnancy (IUP)

Q: How can the location of a patient’s pregnancy and the fetal heart rate be detected? How can we rule out an ectopic pregnancy?

A: A type of pelvic ultrasound, called a transabdominal ultrasound, is conducted in order to scan the lower abdomen. This less invasive method allows the physician to examine the bladder (appears as a large black circle), the uterus with endometrium thickening, the cervix, fallopian tubes, and ovaries (appear as chocolate chip cookies). This ultrasound can also show bowel movements and usually detects a fetal heart rate. An intrauterine pregnancy (IUP) can be confirmed with a gestation sac located within the uterus and a fetal heart rate, but the patient must be at least 6 weeks pregnant. Physicians are most concerned with the presence of fluid, which can denote an ectopic pregnancy. An ectopic pregnancy is when the fetus develops outside of the uterus, typically in the fallopian tube, and can cause extensive internal bleeding by rupturing the fallopian tube. This condition puts both the mother and the fetus at risk, thus it must be diagnosed and treated rapidly.

Case: A patient at 10 weeks gestation presented in the Yellow Team with slight pelvic pain. A transabdominal ultrasound was conducted to verify an intrauterine pregnancy (IUP). The ultrasound image showed a yolk sac within the uterus which is typical at 10 weeks gestation. However, a fetal heart rate wasn’t detected. There was no fluid present that could point towards an ectopic pregnancy. The ultrasound was also unable to locate the ovaries, so another proper ultrasound was ordered to confirm an IUP.

Clinical Pearl- C. diff

A fellow Sr.R.A. and I were able to conduct a Gun Violence survey with a patient who was also being tested for C.diff. C. diff stands for Clostridium difficile. The infection is a bacterium that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. It typically occurs after the use of antibiotic medication.

In order to see the patient, the Sr.R.A and I had to dress in yellow gowns prior to entering her room. The nurses advised us to not have any contact with the patient in order to prevent the infection from spreading.



Discrimination Towards Minority Patients in Hospitals

During my time enrolling patients in the ED and the Trauma Room, I have always wondered whether minority patients experiences discrimination during their hospital visits.


Natalia Neha Khosla, a medical student at UChicago, has developed a research project that helps to address the issues of the situation. Apparently there have been numerous studies that show that black patients have received poor health care and outcomes in the U.S. The student states that the reason clinicians saw black patients as less likely to improve is because they saw those patients as less personally responsible for their health than white patients. She stated, “… that the reason clinicians saw black patients as less likely to improve is because they saw those patients as less personally responsible for their health than white patients. She also did this study with paitents in French hospitals, and she saw that there was no racial bias. This is possibly due to the fact that the French government does not request the racial identity of their citizens.

Science and medicine are not invulnerable to the effects of racism, because we are humans and are shaped by our environment. This is why it would not be wise to separate medicine from race. This is imperative to understand in order to treat patients without bias.

Clincal Pearl – Thoracentisis

During my Shadowing shift, I was able to experience a procedure called a Thoracentesis. This is an invasive procedure to remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A hollow needle was carefully inserted into the thorax after local anesthesia was administered. A yellow-like color was seen when the needle was withdrawing the fluid from the pleura.

The patient was experiencing difficulty in breathing whilst she was laying down. This would cause her to sit upright more often so that she can breathe better. This diffuclty in breathing arose due to the build of pressure in her lungs. This pressure stemmed from the patient’s ovarian cancer condition. The ER doctor made a call to do this procedure because the patient was not going to be operated on until the morning. The doctor wanted the patient to have a restful sleep throughout the night.