Since emergency physicians are the MacGyvers of medicine – mullet not included – we asked our readers to send in their best stories of improvising on the fly. What did you do when you were fighting against the clock and couldn’t find the supplies you needed? Here are our four winning entries, with comments by Ken Iserson, MD, author of Improvised Medicine.
[Part of a series – Click the link to read Adapt & Adopt: When You Improvise, Use All the Tools in Your Toolbox]
I was getting ready to go on a long-awaited dive trip to the great barrier reef. The week before the trip, I was flossing and popped out an amalgam which hit the roof of my mouth and then disappeared. Being an ER doc, I immediately suspected that it had wound up in my lung. I went to my ED radiologist and asked him to take a single view AP X-ray to confirm my suspicions. He assured me that I would be coughing if I had inhaled such an object, but he humored me and had his tech take the film anyway. Sure enough, there was a small, dense radiopaque foreign body in my left lower lung field on X-ray.
I called my friendly pulmonologist and set up my bronchoscopy, bummed by the thought that having him mess with my lung might cause me to reconsider diving the next week in Australia. On day two, after the untimely aspiration, and the day before the scheduled bronchoscopy I had my MacGyver moment. I thought to myself, “Small diameter, heavy object, let me see if I can avoid the bronchoscopy”.
So I did a handstand up against the wall, pumped up and down a few times to jiggle my body. All of a sudden I felt something hit the underside of my larynx. I shook my head and out came the lost filling into my mouth.
I spat it out and returned to my ED radiologist to confirm my success and then called the pulmonologist to cancel my procedure.
Iserson: Smart move. While asking most adult EM patients to do a handstand is unrealistic, this acrobatic modification of a pediatric maneuver could also be achieved by keeping a patient’s pelvis and legs on the bed while draping the chest and head over the side, allowing gravity to assist with FB removal.
At around 7pm one evening I had a 19 year-old male, tall, thin, smoker who had spontaneous chest pain and shortness of breath while baling hay. Textbook case of a spontaneous pneumothorax, which was confirmed on CXR, and if I remember correctly, estimated at around 20%. The facility was a small rural ED with limited on-site resources; almost all surgical issues were transferred to one of the surrounding facilities. We could put in large bore chest tubes, but despite a search of the premises, we had no heimlich valves, no pigtail catheters, and barely any angiocaths of sufficient length to deal with small pneumothoraces. The patient didn’t want a large chest tube and didn’t want to stay overnight, much less get transferred somewhere else. We ultimately settled on attempting inserting a 14g angiocath, drawing off any air I could with a 60cc syringe, and fashioning a makeshift heimlich valve from a disposable glove finger with a hole poked in it. He tolerated the procedure well and after I pulled off a fair amount of air with the syringe, I rubber banded the glove finger/heimlich valve to the angiocath, which seemed to be working. He felt improvement of his chest pain and breathing and agreed to stay in observation at our small hospital (with some help convincing from his mother).
By 10pm, the patient’s symptoms returned, despite the makeshift heimlich valve. I realized we were going to need something that could provide continuous suction, at least overnight, to give the lung a chance to seal itself. The patient was still totally against placement of a bigger chest tube, and refused to be transferred. I did not want this patient to sign out AMA, but being a young, hot-blooded male, that’s the way things were headed.
So I attached the adapter from a 7Fr ET tube into 10cc syringe, then cut down an NG tube until I could slide it tightly over the other end of the ET tube adapter. I then used a Christmas tree connector to connect that to the Pleurovac suction tubing (and plenty of plastic tape to make sure that none of these pieces would spontaneously separate during the night). I then attached the whole contraption to the 14g angiocath still in place. Patient was placed on continuous suctioning through the waterseal, and I signed the patient out to my colleague at 6am. The repeat CXR at 9am showed resolution of the PTX. Suction was turned off, and several hours later he was deemed stable for D/C by my colleague. The patient did well post discharge, and to the best of my knowledge did not have recurrence of the pneumothorax.
Iserson: Use what you have available to solve the immediate problem. The Apollo 13 crew did this, and so can we. Often, this takes an entire team to devise such a complex solution, so ask the whole healthcare team to make suggestions.
It was the mid-90s and an ortho resident was performing a closed reduction and casting on a elementary school aged child with a both bone forearm fracture. In those days, ortho loved Demerol and Versed to sedate these kids. Usually, small amounts were given as the resident felt indicated. Of course, it was also before all of the time outs, close attending supervision, sedation credentialing, etc. Once the proper reduction was obtained, it was not uncommon to need to give some Narcan since apnea would occur when they no longer had the pain stimulation.
As a resident, I was giving a case report to an attending. We could see into the room where the ortho resident was working. Suddenly, the ortho resident yells out that the kid wasn’t breathing. The nurse hadn’t brought in Narcan and there wasn’t a pediatric ambu at the bedside! My attending and I ran into the room to find a now blue lipped child on the bed. I had been a paramedic for ten years and recalled an old trick. I took the adult mask and turned it upside down. Placing his chin in the nose of the mask and laying the rest over the face and we bagged him back to pink while the nurse got Narcan.
Iserson: This rapid maneuver is often used in resource-poor settings to provide suitably sized oxygen masks: inverted adult for large child; inverted child mask for infants. When trying to ventilate a child or small adult with a large mask, positioning the lower part of the mask beneath the chin can be an option as well.
About 3AM one night in the ED the right lens dropped out of my eyeglasses. Being very nearsighted this presented a problem seeing a bedside monitor or even seeing the patients. I had the lens and the tiny screw but no tiny screwdriver to fasten the screw back in. I knew I’d look like a total moron-doctor if I finished the night with the lens scotch taped into the frame. I usually carry a jeweler’s screwdriver in my briefcase for just such an event but it was missing. I searched around for an improvised screwdriver: paper clip, scissors, eating utensils from the break room, hypodermic needles, surgical instruments. Nothing came close to working. After trying to read a few EKGs with only one eye I had an idea. I got the fingernail clippers out of my briefcase, took an 18ga. hypodermic needle and clipped the point off the needle 2mm from the end. Not only did the clippers remove the point, but they flattened the remaining bore of the needle into a perfect miniature screwdriver tip which exactly fit the screw on my glasses. As a bonus, the hub on the needle made a perfect swivel point for my index finger, just like a real jeweler’s screwdriver.
Iserson: While EPs may rarely need a miniature screwdriver, the process of devising and making it on the spot to solve an immediate problem illustrates the novel thinking that has led physicians & medics to improvise makeshift laryngoscopes, scalpels, suture equipment, & many other devices.
Published entrants gain free admittance to Blood and Sand, a tropical CME in Atlantis, Bahamas. For a chance to win, send your best MacGyver Moment to firstname.lastname@example.org
Illustrations by Nicolet Schenck