[NP-Clinical] cerumen removal

Tue Jan 2 03:26:29 PST 2007

Ed -
Ah... ER hell... so fresh in my mind after just leaving one. If the canal looks real traumatized after irrigation I do rx otic suspension drops such as cortisporin. Only because I get concerned about them developing an Otitis Externa. If just a bit of blood I don't worry much. But lots of times they were already digging on their ear before they see you so it is traumatized.

For sure I would give the cardiologist the drops just because he could make my life miserable if an infection developed. 

Now why are you doing irrigations???? Nursing can do that or ER techs. I won't let my techs use a curette but they sure as hell can flush ears.

Christine Smith, NP
Antioch, CA
  ----- Original Message ----- 
  From: ed piasecki 
  To: np-clinical at nurse.net 
  Sent: Monday, January 01, 2007 9:35 PM
  Subject: RE: [NP-Clinical] cerumen removal

  I had a new years from hell in the ER here in blessed Iowa.

  One of the cardiologist pops in needing his cerumen impaction resolved stat. Of course because I am the "mid-level" on duty I get the privlege to remove his wax. 

  The part that urked me was he was upset when it bleed after colace and irrigation only. This guy had some real potatoes growing up there. 

  My question is does the group prophylax with otic antibiotics after they get bleeding? How far do you go to remove the impaction?

  Thanks for your input in advance,

  Ed Piasecki

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    From: "Christine Smith" <chrisbsmith at mindspring.com>
    Reply-To: NP Clinical <np-clinical at nurse.net>
    To: "NP Clinical" <np-clinical at nurse.net>
    Subject: [NP-Clinical] INGROWN NAILS
    Date: Sun, 31 Dec 2006 19:01:45 -0800

    I do about 5 ingrown toe nails a week. If they are really against a wedge resection then I will have them try the soapy soaks and wedge a piece of cotton under the nail like Andy does. This seldom works in  my opinion, but I suspect it is because it is painful and hard to get the cotton under. If you are going to recommend that the best way to get the cotton under the toe nail is give the patient an cuticle  stick (those wooden sticks that have a beveled edge for pushing cuticles down sold in cosmetic section). I bought a bunch and just stock them so I can show them how. Take a regular cotton ball and wrap a dab of cotton around the beveled portion of the  stick like wrapping cotton candy. Then wedge it under the nail. 

    However, for the most part I do a resection, wrap with a pressure dressing, have them remove it in 24 hours and start warm soaks TID before our recheck. . I see them 48 hours afterwards. They are doing well by then. I rarely ever give antibiotics unless the erythema has spread up into the toe - which is seldom. Most times, once the offending section of nail is removed, it clears up.

    I also do the digital block with Bupivicaine and I give them Motrin 800 in the office with a Vicodin rx #12. I tell them to pop two Vicodin right after they fill it, go home, elevate foot and sleep. By morning, almost all of mine return to work on Motrin all day with a Vicodin back up. Suckers hurt - I know from experience. Especially since most my patients are male laborers and need to get right back to work the next day. I try to get them to let me do it the night before their day off so they can limit walking but not always feasible.

    I once "operated" on my daughters boyfriends toe on my bed. I put him on Motrin and sent him home. That night he called me at 2am in tears due to the intense pain. I was sure I did something wrong, sure I was going to lose my license, sure the kid was going to lose his toe. I was panicked! I drove one hour to his house, assessed a normal looking toe and a crying 22 yo 220lb kid. I repeated the digital block with marcaine (even though the toenail was now resected) and gave him two old Percocet I had. He ended up fine. I thought he was a wimp, until I had my own toe done. I am telling you, these puppies  hurt!

    I talked to my own podiatrist about this (Lorraine Loretz's old professor). He told me that he always give Motrin 800 to women and Vicodin to most men. He said men are either wimpier or just need it more - he is not sure why, but that Motrin seems to be enough for females. He also told me antibiotics are rarely needed but if there is very much infection it can be more difficult to get a good digital block.

    I am sure Lorraine has her own thought on this.

    Christine Smith, NP
    Antioch, CA

      ----- Original Message ----- 
      From: Andy Craig 
      To: 'NP Clinical' 
      Sent: Sunday, December 31, 2006 12:09 PM
      Subject: RE: [NP-Clinical] Foot/nail care by NP's

      If I see someone with an ingrown nail that is real early and mild severity, I offer conservative treatment as an option: warm soapy soaks TID and a small piece of cotton tucked under the end of the nail to lift it up a bit off the nail fold and relieve some of the pressure.  But 9 times out of 10, my tx of choice is cold, hard steel ;)  (wedge resection.)  Especially if it's infected.  And if it is I typically rx Keflex for 7 days while they heal.  I leave them in a bulky dressing with a small piece of vaseline gauze tucked into the proximal nail fold for the first 2 days; After 2 days I see them back, remove the gauze, apply a band aid and have them do warm soapy soaks TID for a week

      Andy Craig, NP
      Charlotte, NC

        -----Original Message-----
        From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net] On Behalf Of ed piasecki
        Sent: Sunday, December 31, 2006 2:27 AM
        To: np-clinical at nurse.net
        Subject: RE: [NP-Clinical] Foot/nail care by NP's

        To the Group:

        Same topic, different piece:

        Infected ingrown toe nails. Do most treat with antibiotics and then remove nail or do both together?

        Ed Piasecki

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