Tricks of the Trade - The Wooden Tongue Depressor: A Multiuse Tool for the Emergency Physician

ACEP News
July 2008

By Matthew R. Lewin, MD, PhD

As an emergency physician and expedition doctor, I am always looking for items with multiple uses--the smaller and lighter the better. Wooden tongue depressors certainly fit this description.

The utility of examining the mouth was little appreciated by Western physicians prior to the 17th century. Between the 17th and 20th centuries, these blades evolved from flat spatulas made from bone, ivory, nickel, silver, or wood. The flat, wooden, disposable tongue depressors familiar to most physicians today have been in use since the beginning of the 20th century. Though intended for examination of the oropharynx, innovative physicians have found many alternative uses for the tongue depressors.0708tricks1

arrow redTrick of the Trade: Anterior epistaxis hemostasis. Anterior nosebleeds are a common complaint, and there are many traditional remedies, such as pinching the nose or putting ice over the nares to constrict the blood vessels. It is highly inconvenient and uncomfortable, however, for patients or caregivers to hold consistent, sustained pressure over a patient's nostrils.

A trick is to tape two tongue depressors together to fashion a makeshift nose clip. Wrap the tape at about two-thirds the way up the tongue depressors from the distal point of contact with the nose. The resulting hands-free nose clip provides sufficient pressure to stop most anterior nosebleeds (see photo 1).

One should be careful about compressing the nose to the point of discomfort or if the patient is coagulopathic, because it is possible to bruise the nares or tip of the nose.

Comfortable pressure with the nares pressed against the septum should be sufficient. Have the patient swish and swallow some water so that you can observe the back of the oropharynx for signs of posterior or inadequately controlled bleeding.

arrow redTrick of the Trade: The illuminated tongue depressor for examination of the oropharynx. Examining the oropharynx in poor light or in patients with large tongues or small mouths can be aided by taping a penlight to the proximal end of the tongue depressor while inserting the distal end into the mouth. This is especially helpful because the practitioner now has a free hand to perform procedures such as diagnostically swabbing the throat for bacterial pharyngitis or draining a peritonsillar abscess.

arrow redTrick of the Trade: Decision to image for mandible fractures. Not all patients who sustain mandibular blunt trauma need radiographic imaging. One screening maneuver for mandibular fractures is the "tongue blade test."

0708tricks2Most patients with mandibular fractures will not be able to exert much bite force because of pain. The masseters are considered the strongest muscles in the body, and normal adults can usually easily bend and break a tongue blade that is clenched between their teeth. Patients with mandible fractures are unable to perform this task without an extreme level of discomfort, and difficulty performing this task suggests a high risk for a mandible fracture.

Traditionally, patients have been asked to hold the tongue depressor between their teeth, and the practitioner tries to break it (see photo 2). In my practice, I let the patients try first, because it gives them more control and, I believe, elicits less anxiety. In a prospective series of 110 patients with suspected mandible fracture, the test was found to be approximately 96% sensitive and 65% specific.10708tricks3

arrow redTrick of the Trade: Dorsal finger splint. A mallet finger results when the extensor tendon is torn from its attachment to the bone. A recent Cochrane review of standard interventions for mallet finger could not distinguish if any one splinting technique is superior to another,2 so my main goal is to optimize splinting and the patient's ability to engage in the activities of daily living.

Commercial finger splints for mallet finger unnecessarily block the ventral aspect of the fingertip. This is obstructive in performing common tasks such as typing, for instance. If a foam-lined aluminum splint is not available, tape a tongue depressor to the dorsal aspect of the injured finger. This splints the injured phalanx in extension and leaves the functional ventral fingertip surface available for use (see photo 3).

Considering that it takes 6-12 weeks of splinting for these seemingly minor injuries to heal, maximizing your patient's functionality is most helpful.

arrow redTrick of the Trade: "Ken and Katie Caterpillar" for the treatment of pediatric molluscum contagiosum. Molluscum contagiosum is a cutaneous lesion caused by a DNA virus from the pox family. Lesions can be single or widespread, itchy, and painful.

This imaginative trick was dubbed by its creators as "Ken and Katie Caterpillar" (see photo 4) for entertaining and distracting children while applying tape or spot bandages to molluscum contagiosum. It has been reported anecdotally to be effective.3 The bandages or tape are affixed to a tongue depressor so that they can be quickly deposited over the lesions of interest while reducing patient anxiety.

References

  1. Alonso L.L., Purcell T.B. Accuracy of the tongue blade test in patients with suspected mandibular fracture. J. Emerg. Med. 1995;13:297-304.
  2. Handoll H.H., Vaghela M.V. Interventions for treating mallet finger injuries. Cochrane Database Syst. Rev. 2004;(3):CD004574.
  3. Silverman R.A., Lucky A. Ken and Katie caterpillar: helpful props for treatment of molluscum contagiosum. Pediatr. Dermatol. 2003;20:279-80.

Dr. Lewin is a guest columnist for "Tricks of the Trade" and a member of the faculty in the department of emergency medicine at University of California, San Francisco. He has served as the expedition doctor for many of the American Museum of Natural History's scientific expeditions to extreme environments, such as the Gobi Desert. He welcomes any correspondence at Matthew.Lewin@ucsfmedctr.org. 

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