Transcript

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Visit aka. ms slash knock knock high. Again, that’s aka Dot M S slash knock, knock. Hi. Knock,

knock. Hi.

Hello everybody. Welcome to knock, knock. I with me, your host, Dr. Glaucomflecken this is your one stop shop for all things eyeball related. And occasionally some non eyeball related [00:01:00] things. So, uh, I’m excited about today. Cause, uh, one of my favorite things to talk about is emergency medicine eye stuff.

Uh, and there’s so many topics. That’s how I started these knock knock eye episodes was, was talking about, um, uh, pants patients. You know, the, the emergencies that require me to put on my pants and come in to see the patient, which is not very often, you know, there’s maybe six or seven of them. Uh, and so we’re, we have a little bit, here’s the agenda for today.

Okay. First, uh, match day is right now we’re in the, this, this really fun window for everybody where, uh, the people that have matched are waiting. Just waiting. Like there’s, there’s their name and the program they’re attached to is out there. It’s it exists, but they do not have access to it. The reason, the main reason for that is because you have a lot of people that did not match and they are going through one of the most difficult challenges in their career, their [00:02:00] early career, which is desperately trying to find a program that will accept them.

Uh, and so that’s a, that’s a very, a hard, hard situation. In fact, I made a video about. in support of students who don’t match. Uh, you can look at my YouTube channel and find it. It’s, um, uh, uh, the med student goes to therapy. It’s all about a student who did not match and the words of support that I would give to those students.

Uh, in short, it’s, um, that, uh, this, it’s just one bump in the road. And, um, and there are lots of examples of people that have tried again and again and again, and still. Make it, uh, and a career in medicine is long and if you are dedicated, which so many, we are all dedicated to this field, you know, you have to be dedicated to patient care, to medicine in order to go into this because it’s not easy and if you don’t match.

You know, you’re, we’re just, we’re, you’re at the [00:03:00] mercy of the algorithm. All right. And, uh, often it says nothing to do with your intelligence, your ability, your, uh, your work ethic. And so, uh, don’t let this one weird algorithm thing, driven thing define who you are and who you can be as a physician, one step back and, uh, and you’ll be stronger for it.

And so anyway, go check out that video. Uh, no, I think I, I, I made it maybe a year ago, maybe two years ago, but, um, uh, I still have people that, that come to me around match day or that email me and say how much it helped them. And I, I it’s, which is awesome. And, um, and kind of the point of that video is to just give some support to people who are struggling amidst a lot of people who are celebrating.

I can’t imagine how hard that would be. So anyway, this is a weird week. It’s a trying week. It’s a, it’s a week for [00:04:00] also celebration. Uh, and, uh, but it’s also a little weird that you, you learn that you match on Monday and then you can’t find out where until Friday. And so I’ve made videos about that too.

Uh, and, and so, but we, we do have, and the reason I’m bringing this up, cause I think I talked a little bit last week about the match as well, is that we do know some statistics. So let me just, uh, just a couple of things that have jumped out here. And I found these over on Twitter. Um, there are 805 unfilled family medicine spots this year, but which is higher than last year, there’s also 144 unfilled pediatric spots, which is higher than last year.

But the family medicine thing really just 805 unfilled spots. That’s an extraordinary number. And the fact that it’s, it’s just every year, it’s like getting worse and worse. And honestly, like you can [00:05:00] go back and forth on what the reasons for this are contrary to what some, uh, family medicine attendings think.

Uh, I don’t think I am the cause of that. That is like. One of the only, the negative feedback things I’ve gotten from a portrayal of a specialty is, uh, um, I’ve had some family medicine docs over the years that have emailed me and be like, you know, I wish you would stop portraying a family medicine physician as this underappreciated, underpaid, exhausted, um, disheveled person because it’s turning students off from going into family medicine to that criticism.

I say, No, because I’m not telling anybody anything they don’t already know. It is not going to be a silly comedy video that’s going to make someone not want to go into a specialty. People know what they’re getting into with family medicine. [00:06:00] People go into family medicine because they love family medicine.

They want to take care of everybody from birth to old age, birth to death. And the whole gamut of ages and diseases and they wanted to be a part of the community. There’s so many reasons to want to do primary care, family medicine and pediatrics. And so maybe I’ll give you this. Some of my videos might convince someone that they, they should do a certain specialty, but I don’t think I’m going to maybe cardiothoracic surgery.

That’s the only one I’ve barely ever depicted that specialty. Uh, and I’d be fine with that. But I don’t buy the family medicine thing because I portray family medicine as a sympathetic character and that’s the way it should be because they are overworked and underappreciated. And, uh, but honestly, I think yeah.

With these unfilled family medicine spots, you can’t look any further than well, maybe even two things [00:07:00] now. But, um, the whole vaccine issue is one thing because obviously primary care pediatrics, they’re there, they are preventive health is a huge part of what they do. And so the, all the attacks, all the misinformation, all the vaccine, uh, hesitancy around established vaccines like polio.

Like MMR, come on, like, honestly, that that’s probably within the past couple of years driving it a little bit, but also just compensation. I mean, we can say till we’re blue in the face that, oh, you don’t go into medicine for the money, but you do want to make a decent living as a physician because you’re spending your entire twenties training to do this job.

All right, you’re behind your peers. You’re behind your peers who have been working since they were 22, uh, in their career, rising [00:08:00] through the ranks, making more and more money. Uh, and not only are you starting your career basically at the age of like 30, 31, 32, but you also have multiple hundred thousand dollar loan bill to pay for.

And so the cost of education is rising every year. Tuition is rising every year. And the compensation for primary care is decreasing every year. Something’s got to give. So you can’t, it does not shock me at all to see these numbers of residency spots going unfilled because ultimately, yeah, people might love family medicine and want to go into family medicine, but man, it’s getting harder and harder to look at that, that these fields and be like, man, look how little people appreciate what we do.

Cause that is a hard job. You guys. Excuse my, my, my cursing, but honestly, and it’s, it’s, it’s awful. It’s the, the way we deprioritize family medicine [00:09:00] and, and prioritize surgical care, uh, procedural care. I mean, I was saying that as an ophthalmologist, yeah, you know, sure. That goes against my specialty interests, but I recognize.

That how hard primary care physicians work and, and the, it’s just, um, you gotta, you gotta think that compensation, uh, is, is driving a lot of this. And so I don’t, I don’t know how to fix it, but man, it’s, it’s hard to see. And, you know, we’re feeling in certain parts of ophthalmology to pediatric ophthalmology is like a crisis.

There have been like meetings at conferences about what, what on earth are we going to do about pediatric ophthalmology? No one wants to go into pediatric ophthalmology. Uh, and so I think just peds across the board is, it’s just, it’s becoming more and more challenging. 805 unfilled family medicine spots, 144 unfilled pediatric spots, higher.

Then last year, um, man, that’s hard. That’s that, that does not bode [00:10:00] well for just rural communities who rely on family medicine, who rely on pediatrics. Um, uh, you know, my rural medicine character is not an accident. Like. There’s a lot of truth to that character. Who’s doing literally everything for that community.

What happens when you can’t train enough of them or you D distance, uh, incentivize going into that field so much that it doesn’t become economically viable to go that route. So either pay them more, pay them what they’re worth. Or let’s get some free med school going on because something’s got to give you guys something’s got to give all right, uh, let’s see.

Why don’t we take a, okay, I didn’t, I didn’t finish going, telling you what the agenda was for today. So we’ve already talked about the match day stuff, uh, uh, congrats to everybody. By the time you hear this [00:11:00] episode, you’ll, um, you know, everybody’s going to know where they’re going. And just, and then gets to be the, the, the best part of fourth year of med school, that post match pre graduation that’s that’s prime ophthalmology rotation.

Area of med school guys. That’s that’s when we start getting the, I’ll never forget this. And in residency as a resident, you get the, the orthopedic surgeon, the med student who matched an orthopedic surgery, who’s like, you know what? I’m kind of, I’d love to do an eye rotation. It’s like, yeah, okay, buddy.

Like you come in, you know, we’ll talk for 30 minutes and then you can go to the library slash home slash gym. Whatever you want to do, Mr. Future orthopedic surgeon, who’s never going to look at an eyeball for the rest of his career. No bones in the eye. I keep reminding people, but anyway, it’s a fun, it’s a fun, a couple of months for the fourth year med students and they’ve earned it.

They’ve earned it. They’ve been working hard. They match they’re happy. They get to look for [00:12:00] housing and, and just think about their future. So congrats to all of you. All right, let’s take a quick break. And then we’re going to come back and talk. We’ll talk the pit, the new show about emergency medicine, the pit, and then talk about emergency or.

Department eye procedures.

Hey, Kristen, what’s up? I’ve been grossing you out about these little guys. Demodex mites for months now. Yes, you have. Thank you for that. Well, good news. I have more facts to share with you. Oh, great. Yeah. These mites have likely lived with us for millions of years. Passed down through close contact, especially between moms and babies.

You know that? That’s. Yeah, they’re, they’re born, they live, crawl around and die on your eyelids and in your lash follicles, the entire life cycle from egg to adult lasts about two to three weeks. That whole time they live right there on your eyelid. That’s making me itchy. Okay. It is fun to gross you out, but we do all have these.

All right. [00:13:00] It’s really common. It causes a disease when there’s an overgrowth of these mites called demodex blepharitis causes the eyelids to get red, itchy, irritated. You get this crustiness to the eyelids, but I have really good news. This is actually really good news. Okay. We have a prescription eye drop for this.

Okay. That is, that does make me feel better. Visit mites love lids for more information about demodex blepharitis and ways we can treat it. Again, that’s M I T E S. L O V E L I D S. com to learn more.

All right, we’re back. All right, let’s talk about the pit. So I’ve heard so many things about the pit. Some good and some not so good really the not so good from medical professionals about the pit is just that it’s too Realistic it’s it’s too visceral. It just drums up too much like oh, yeah I’ve been in that exact situation and I get it.

[00:14:00] Like why would you want to do that? In your job and then you come home and you want to watch something entertaining, but it’s just reminding you about your job. I don’t know. Um, and, and, and I mentioned this on one of our, our, the knock knock high episodes, but, uh, I saw a really good description of this.

It’s like you want to, uh, an apology to the person who said this initially, I don’t remember who you are, but the ER was for like showing glorifying. Emergency medicine and, and, and people know, you know, uh, attributed it to, to, to convincing med students to go into emergency, like a boosted numbers of students choosing emergency medicine, the pits kind of like the opposite, it shows the nitty gritty, the, the dirty underbelly of emergency medicine, the, the, the, the true nature of emergency medicine being.

Uh, the, the safety net of society and all the abuse that [00:15:00] comes with it. Um, all of the, the, the anger, the, the conflict, the blood, the vomit, the, the feces, the, all the things. So it’s just a very visceral portrayal of emergency medicine. Well, I it’s been on my list. I haven’t gotten around to watching it yet, but.

Just, uh, a couple of days ago, I was looking through the comments again on our YouTube channel at Glockenfleckens. All right. All these episodes are up there. I always look at the comment section, uh, at Joe Sarcero on the last, uh, most previous, um, most recent episode where I talked about the wildest eye surgery you’ve never heard of.

Which is the using a tooth to make a keratoprosthesis, a corneal prosthesis. Anyway, uh, at Joe Sarcero said, you’ve probably already been told many times. The last week’s episode of the pit featured a patient who had been hit in the eye with a baseball actually. Joe, this is the first time I’d heard about it.

All the gory eyeball procedures were [00:16:00] performed by ER docs with no sign of an ophthalmologist. Would appreciate your take. Well, that’s all I have to hear. I got on, I haven’t looked, I haven’t watched any of the other episodes, but I did find that scene. And let me tell you, I am excited. I’ll, this is why I’m excited about this, about to talk to you.

I’m going to tell you, I’m going to take you through that scene. If you haven’t seen it and talk about what went right, what went wrong. It’s episode one or sorry, season one, episode 10. Uh, and this, um, all right. So the reason this is exciting to me is because. Usually, and this is true for the show ER, which I grew up on, I loved ER, the, the most you ever saw from an ophthalmologist or from any, from eye stuff in general, you might see an eye chart.

You definitely will see a piss poor pen light exam checking the pupils. It’s the worst, the worst pupil exam you’ve ever seen in your life. Uh, [00:17:00] and so I was, I was pumped. I was so excited. To, to, to, to see an actual eye problem, start to finish. It was thrilled, thrilled to death. And so of course I came at it skeptically because I’ve never seen it done well.

All right. So here’s what happened. Patient comes in, um, baseball line drive, like a hundred miles per hour. It’s a pitcher right to the eye. Something I’ve seen like numerous times. The guy, the, the kid’s got a, a big swollen eye and gets, gets whisked back immediately, uh, through the, the, the pressure of, of his, uh, his, his father who there’s like a conflict with the front desk and the, the father about, you know, cutting the line and, and then the kid shows his swollen eye and the front desk is like, oh, right away, please come back.

I’m not sure how true that is, but anyway, makes for good television and so, um. The kid’s sitting there. Here’s what happens. So first, the first time [00:18:00] we see him back in the, in, in a room and the emergency department, he’s got a shield on love it. Absolutely. You put a shield on if you’re, if you’re concerned about an open globe, which a line drive to the directly to the eye.

Yes. You’re concerned open globe. A rupture is one of those things that can happen specifically at the limbus of the cornea. and behind the extraocular muscles. Those are the two weakest points of the sclera. So if you’re going to have a, a, an open globe from a blunt force trauma, it’s probably going to be one of those two things.

It hits the eye hard enough. The object that it increases the pressure to a tremendous degree, pop and open the eye. Those are the two places you’re likely to see that right at the limbus of the cornea, the edge of the cornea where the cornea meets the white part of the eye, the sclera or behind the extraocular muscles.

So yeah, first thing you do, if you’re not sure you put a shield on the eye, you don’t want that. You don’t want the kid rubbing his eye, um, uh, because you could rub, uh, what’s [00:19:00] inside the eye. Uh, outside of the eye. And then one thing they did, they gave four milligrams of morphine, four milligrams of Zofran.

Great. Perfect. I love it. That’s great. Well, that’s, that’s like in our, that’s, that’s in our list of things we do for a possible open globe. You want Zofran. The reason is because the last thing you need is for a patient with an open globe to start vomiting because that pressure, that interest thoracic pressure, extending up into the neck and into the face.

They could extrude some of their intraocular contents. All right. Then we get to vision testing. They did a decent job with vision testing. All right. They started with, you know, can you see anything? I think they did the hand waving. Can you see like hand motion? There was no hand motion. So then they checked for light perception and turns out the kid could only, and out of that, I could only see light perception.

The problem is they didn’t cover the good eye before checking light perception for the bad eye. And so it’s, it’s really hard [00:20:00] to, you got, you always check vision. One eye at a time, cover one eye before you check. But just the fact that they had the right turn, like light perception vision, that’s never been done in media.

That’s great. I love it. So light, we’ve got light perception vision. And then, uh, the, the, the nurse, uh, asks, uh, the doctor there, uh, do you want to get the, do you want the portable slit lamp? All right. Those exist. We have them in the eye clinic. Uh, I can guarantee you that does not exist in any emergency department in the entire world.

Those are expensive and they emergency department, they barely have functioning slit lamps. They’re not going to have a portable slit lamp. If they’re, let me know if you know of an emergency department that has a portable, I will shout them out. I will shout them out the next episode. If you have a portable slit lamp in your emergency department, I will be incredibly impressed.

Regardless, it exists. It’s a thing, and it would be helpful in these types of situations. I would want to bring mine with [00:21:00] me from clinic to see a patient like this, especially if they did not have a slit lamp, a regular slit lamp that the patient could get into in the emergency. Uh, so anyway, portable slit lamp.

I never, we, I don’t know if we actually see them do it, but then they, they, they proudly that this, the resident or the intern, I’m not sure who it was proudly diagnosis. a grade four hyphema. So we got a grade four hyphema. That is a classic thing that happens in serious blunt force trauma. A grade four hyphema basically is the anterior chamber is full of blood.

100 percent almost. And what we call an eight ball hyphema, which is where not only do you have the front of the eye full of blood, but it’s deoxygenated blood, which means there’s no circulation of anterior of aqueous humor, which means that it’s even more severe. So there’s one step beyond grade four.

It’s like an eight ball hyphema. So it’s [00:22:00] black. It does not look red anymore. It looks black inside the eye. Regardless when you have it. A grade four hyphema, that much blood in the eye, patient’s light perception vision. You got to check the eye pressure and they were on it. They’re like, we got to check the eye pressure.

Let’s check the eye pressure. Then we get a tonal pen sighting, you guys, a tonal pen, an honest to God tone. But now if this was an actually. Like accurate depiction of how this would work. The, uh, the intern would be, uh, um, would, uh, be, be, uh, pushed to, to tears trying to calibrate this thing, but you know, that we can’t wait around for that.

That might take 15, 20 minutes. So, uh, so no, they had it, they got it, but the, the, um, prepare came. On the I saw him do it. Uh, I also did a little, um, uh, uh, fluorescein test as well. Uh, so what they did and this is really smart before the [00:23:00] intern. Check the pressure, the attending came in and check to make sure there was no open globe or no obviously visible open globe.

And he did that by putting fluorescein on the eye, and you heard the words negative sidel. I will say emergency physicians, they love their sidel test. That’s one of the things that you guys, you try to like impress us ophthalmologists with negative sidel. And it always does impress me. It’s great. I love it.

Like good. You’re doing this side. I’ll, you know, what side L is. That’s just a way to look and see if there’s a stream of aqueous fluid coming out of the eye, which would indicate an open globe. And you use fluorescein and a blue light, a cobalt blue light to determine that. So great. We are doing fantastic.

The pit is killing it. All right. They get the tone open. They check it. Oh. 58. It’s 58. They got a high pressure. Now, here’s where we, we, [00:24:00] we kind of just a little bit go off the rails because you got to ask yourself, what is the reason for this 58? Now, I was thinking in the moment as an ophthalmologist, I’m like, You got a grade 4 hyphema.

You got all this blood in the front of the eye. It’s, it’s going to be blocking the drainage system in the eye, causing the pressure to rise. That gives you a 58. So what do you got to do? You got to get rid of the blood. You got to do what’s called an anterior chamber washout. You go in with tiny instruments and a needle, and you basically just go, you just, you, you wash out.

You wash out all that, all that blood to try to get the pressure down. Um, which I think I’ve had to do one time and it’s, it’s not easy because a lot of times that blood is, is coagulated and so it’s hard, you get a big clot and it just, it’s, it’s like a last resort type of thing, but with blunt trauma, another thing that it could also be is a retro bulbar hemorrhage.[00:25:00] 

Now in this, in the pits world, you know, that’s the diagnosis they made. There was a grade four, high FEMA, high pressure, but they assumed it was a retro Bulbar hemorrhage. Now, when we first see this kid, I would like, I was like, there’s no proptosis like that, there’s, there’s, this is not. This is not a retro bulbar hemorrhage, then whenever they’re prepping to do the lateral canthotomy, cantholysis, they show it’s like a prosthetic, clearly they did some fancy makeup work that made it look exactly like a retro bulbar hemorrhage would look.

So cool. I don’t think they got the right diagnosis based on what the kid looked like when he came in. I think his high pressure would probably be just due to a, um, uh, just due to a grade for hyphema. But then when they showed the eye up close. With all the makeup and everything, they did make it look very convincing for a retro bulbar hemorrhage, which would be there was [00:26:00] chemosis.

There was there was swelling of the conjunctiva and there was also a very clear proptosis. So, okay, so let’s just suspend a little bit of belief here and say, okay, yes, clearly in this situation, the can’t thought of me needed to be done. All right. So I would say the best and I haven’t seen it very often.

Okay. The best depiction of our lateral canthotomy cantholysis I’ve ever seen. And, and this is important too, that the comment on, on my YouTube channel was, uh, there were no ophthalmologists involved here. Like how accurate is this? All of this would happen without an ophthalmologist because you guys, we, we are at home.

And as I’ve already mentioned, my pants are not on. Now this is a pants patient. I am putting my pants on to come in to see a patient, but the patient’s got an eye pressure of 60, and he’s light perception vision. You can’t wait for me to get my ass in the emergency department. You have to do the lateral canthotomy.

And the inferior cantholysis, [00:27:00] and it’s hard to do because it’s bloody. You can see it. They actually portray it very well. They put the lidocaine in just a quick little dab of lidocaine, and then you make the first cut and then it’s just bleeding everywhere. All right. That’s what you’re going to. That’s what’s going to happen.

You’re going to bleed everywhere. So you’re going by feel and they make that point. Noah Wiley, good old John Carter, Dr. Carter makes the excellent point that it’s, you go by feel. It’s like guitar strings. You just feel that tendon and then you cut the tendon. And then the last thing that happens that we see is not accurate.

Cause what happens? Think about anatomically what’s happening here with the retro bulbar hemorrhage, you’ve got blood behind the eye. That’s pushing the eye forward. And. And so, and what’s, what’s keeping the eye from just, just propelling itself further, like out of the orbit is the fact that you have the eyelids that are holding it back.

And so the eyeball [00:28:00] is getting squeezed behind between the blood behind it and the eyelids in front of it. And that’s what’s causing the pressure to dramatically increase and cause blindness. So what you’re doing is you gotta, you gotta cut off the lower eyelids. Sometimes even the upper eyelid. You guys gotta, you gotta open up those lids to allow the eye to just relax forward.

Except whenever they do this procedure on the pit, what do we see the eye do? The eye sinks back into the orbit. That’s not what’s going to happen. If there’s a true retro bulbar hemorrhage. You cut the eyelid off. You do the lateral canthotomy. The eye is going to relax forward because the blood again is pushing everything forward.

So the eyes can actually come forward even more before. Finally, as the blood resolves, the bleeding stops, it’s going to relax back eventually once the swelling goes away. But you’re going to see and then they check the pressure. The pressure is 18 overall. I give it like an Yeah. A [00:29:00] 90, I give it a solid 90 out of a hundred.

They did a phenomenal work with this, uh, a few little ophthalmologist quibbles, but you know, but it’s okay. I I’m, I’m a reasonable person. You guys, I can suspend a little bit of that. Uh, I’m not that much of a stickler on these things. Uh, so they did a, a, just a, a great job. Whoever they got consulting them.

Um, they did great work. I wish it was B I would, no one’s ever asked me. I’m kind of hurt by this. No one’s ever asked me to be a consultant for a medical TV show. I mean, have they seen my content? That’s probably why they haven’t done it. Anyway, let’s take a break. I’ll be right back.

All right. I thought we could close this episode out with some other emergency department. I procedures that we do. All right. So we’ve already talked about lateral canthotomy. We don’t need to talk about that one. That’s like. Probably the, the big scary one, but occasionally we [00:30:00] do do other things. Um, so anterior chamber tap and inject.

So we will do this in the event of endophthalmitis. So, or with high pressure, actually with endophthalmitis, that’s, that’s an infection. In the eye and including the back of the eye, so often we’ll do a tap and inject, but in the vitreous for that, sometimes we’ll do a tap an anterior chamber tap. If there’s really high pressure and we need to acutely lower the pressure and eye drops aren’t working.

Um, in some places you can do, well, really, you can’t do a lateral, a laser peripheral erodotomy because the laser is not going to be in the emergency department. Um, so the tap and inject either in the front of the eye for high pressure or back of the eye for Taking a piece of the like vitreous fluid, sending it for, for, um, for like gram stain and culture.

And then also you, if you have an infection and not the Midas, you would inject, you take out the fluid and then you inject intra [00:31:00] vitriol, intra vitriol antibiotics. That’s hard to say. Um, so that’s one procedure we’ll do in the emergency department. I’ve done that a couple of times. Another one we’ll do is called forced duction testing.

This might. Really sound like the worst of the way when I describe this. So if we’re concerned that a patient has, um, uh, intra or extra ocular muscle entrapment, there’s lots of extras, intra, extra as ophthalmology. Wait, there’s a reason we use. We use acronyms for everything. You guys, it just, it gets out of control.

But anyway, if you’re concerned about extraocular muscle entrapment, kind of like this kid in the pit, big blunt trauma hits the eye real hard, causes a, an orbital fracture, and then the muscle gets trapped in the orbital fracture that can cause a lot of problems. We’ve talked about that. That’s a pants patient, extraocular muscle entrapment.[00:32:00] 

Is a pants patient. You got to relieve that traction. You got to get that, that muscle out of the fracture as quickly as possible because then you have pieces of the muscle that could kind of die off. But anyway, as part of the testing to figure out, could there be extraocular muscle entrapment? You do what’s called force induction testing.

So you numb up the eye real good. Sometimes you’ll even put a Um, lidocaine underneath, like in the subconjunctival space, you’ll just inject a little bit of lidocaine underneath that conjunctiva. Numb the eye up real good and you take two forceps and you physically, you pinch the conjunctiva and you pull the eye in all the different directions to make sure that that eye can move where it needs to move.

Patients don’t like this very much. You know, a lot of times we’ll do some sedation for this. [00:33:00] Rarely patients can just tolerate this pretty well. It doesn’t really bother them. Uh, usually it’s kind of like, Oh, what are you doing? What are you doing? Kind of thing. Uh, and we, we do everything we can to make patients comfortable in the, it’s not usually like a, like a painful experience.

It’s just like a very strange feeling that someone’s moving your eye for you. And so, uh, we will move the eye. Using force deductions, using these forceps in all the different directions, and if we get like a hard stop, like, oh, I should be moving this eye more, you know, further up than I am, that’s a sign that you could have extracular muscle entrapment and you might need to go to surgery.

To relieve that. What else? Um, another procedure we can do. We can glue the cornea. Um, I’ve done this once before in the emergency department for like a puncture wound on the cornea that was leaking. So it’s technically an open globe, but just a small little puncture like a nail or something. Um, [00:34:00] as opposed to And usually it’s like a mostly a self sealing wound.

Sometimes you can just get those to close up and heal up just by gluing the opening the puncture wound. And that would save the patient a lot of time. Um, a trip to the operating room because you can do this at the slit lamp. And so I’d say it’s not really common. Most of the time patients will get to the operating room for something like this.

But in a research. A resource poor environment where you don’t have access to an operating room in a timely manner, you can try just putting some cyanoacrylate glue right on the cornea to plug up that open globe. Those are the big ones that come to mind. Obviously, there’s like suturing, like you could use suture eyelids, but emergency department, uh, emergency physicians do that a lot.

Um, I list sometimes they call us in for, you know, specific types of eyelid lacerations. So we’ll do that as [00:35:00] well. Uh, various boils and, and for uncles and, and styes and abscesses, all these things can be done as well. Skin stuff. Uh, and, uh, and so that’s, that’s probably mostly covers what we do in the emergency department.

Generally, we try not to do a whole lot of procedures down there because the eyes are very delicate thing. And the ergonomics are real off. They’re not, they’re not very good. I, I don’t know how emergency physicians do so many procedures in the emergency department, because like. Anytime I have to suture something there, like I feel like maybe I just don’t take care enough to set myself up for good ergonomics because like my back, I just like throw my back out.

It’s just it’s terrible like leaning over. I’m tall. And so it’s hard to, I don’t know. Sometimes the patient’s in a weird position and I all the respect in the world for for emergency physicians. They have a hard job. And I think the pit treatment. [00:36:00] Probably sounds like it portrays them pretty well. Now I’d like to an extreme degree.

So I don’t think it’s like wall to wall action. Hopefully it’s not because that’s hard to do for like 10 hours or however long their shifts are. But, um, anyway, uh, Respect, respect, and respect to the pit for giving me some good eyeball stuff to talk about. That’s our episode. Thank you so much for listening.

I’m your host. Will Chris, what’s it? Will and Kristen will Flanary. She’s not here. There’s nobody here with me. Will Flanary also known as Dr. Glaucomflecken. That’s me. Thanks to my executive producers, Aaron Courtney, Rob Goldman, and Sean T. Brooke, editor engineers, Jason Portizo. Our music is by Omer Ben-Zvi knock high is a human content production. We’ll see you next time.

Bye.

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