How Does Nasal Packing Stop Nosebleeds?

It is not unusual for an ENT or an Emergency Room physician to see a patient with a very bad nosebleed... the kind that can potentially be life-threatening given how much active bleeding is occurring.

In these situations, nasal packing is the fastest and best way of stopping the nosebleed.

For any type of active bleeding, direct pressure tamponades the bleeding thereby stopping it... whether it be a stab wound to the leg or a bad nosebleed. In essence, direct pressure exerts a certain amount of pressure that exceeds the blood pressure preventing blood flow. The corollary being if the amount of direct pressure being exerted is LESS than the blood pressure, bleeding will still occur.

With nasal packing, pressure is exerted by the packing material and pressed against whatever the bleeding source is within the nose.

My personal favorite packing material is called the rapid rhino made by Arthrocare (I have no financial ties to the company). It is in essence a balloon covered by a bio-compatible self-lubricating fabric. This device is inserted into the nose in a deflated state. 

Once fully inserted into the nose, it is than inflated using a standard syringe. Enough air is inflated into the device such that the pressure exerted by the balloon exceeds the blood pressure of the vessels within the nose.

The key point here is that enough pressure must be exerted by the balloon device. If the patient's blood pressure exceeds the balloon pressure, bleeding will still occur and MORE air must be pushed in. As such, in patients with high blood pressure, more air must be inflated into the balloon device to stop a nosebleed compared to a patient with low blood pressure.

So, here is what it looks like to insert a rapid rhino nasal packing.

Step 1: After hydrating the fabric, the nasal packing is placed at entrance of nose.

Step 2: Nasal packing is fully inserted into the nasal cavity.

Step 3: The nasal packing balloon is than inflated with enough air pressure to stop the nosebleed.

Obviously, blood pressure must also be controlled and the nasal packing can be removed in about 3 days for patients not taking any blood thinners or anti-coagulants (coumadin, plavix, ticlid, pradaxa, aspirin, ibuprofen, etc). For those on such medications, packing may need to be kept in place longer.

For more information about nosebleeds.

INOVA Health System ER Wait Times iPhone App

A reader informed me that INOVA Health System has developed a free iPhone app called InovaER that provides wait times of all 9 emergency rooms within its health system throughout Northern Virginia. The app was released Aug 4, 2010.

Pretty cool! Hopefully other hospital systems including Fauquier Hospital will join with other regional hospitals (Culpeper, Warren, Prince William, Haymarket) to create a similar program.

Download the app here.

How To Persuade a Specialist to see a Patient Quickly!

With the advent of SmartPhones like the iPhone, communication between not only physicians but also patient-physician has become much easier.

To illustrate how such technology has eased communication in order for a patient to be seen quickly by a specialist was recently demonstrated when I received a phone call at home around 9:30PM from the Emergency Room regarding a facial fracture.

ER: Dr. Chang, we have a patient here who seems to have a facial fracture on CT. Overall, however, he does not appear to be in extreme discomfort and there does not appear to be any functional deficits.
Dr. Chang: Tell me about the fractures.
ER: It's a left zygomatic fracture. However, he is able to open and close the mouth as well as swallow without difficulty, so it's not emergent, but probably needs followup.
Dr. Chang: OK. What's his name? Tell him to come to my office in the morning at 9AM.
ER: Sounds great. Will let him know. His name is "John Doe" (not the patient's real name).

I than went to my home computer and loaded up his CT images to evaluate the so-called fracture. Often-times, most facial fractures do not require any intervention. However, some facial fractures, if severe enough, do require repair.

I loaded up the CT images and saw this (floating left zygomatic fracture):


Hmmmm. DOES need surgical intervention, but not something I can handle and this patient will need to see a specialist in facial fracture repair down at a tertiary care center like University of Virginia Medical Center. So, I take out my iPhone and take a picture of this relevant key image and email it to the facial plastic surgeon at UVA to arrange for an appointment (of note, no patient identifiers are included with the image to abide by HIPAA regulations).


Within a few hours, I get a reply back from the UVA plastic surgeon that this patient definitely needs surgical repair and that he would be able to see him the next day afternoon with surgery time blocked off for repair 3 days later.

The moral of the story is that technology is now good enough that given all information provided including radiological images (a picture is worth a thousand words), amazing things can happen, like get a patient seen in less than 24 hours by a sub-specialist who normally is unable to see new patients for 6-8 weeks. Without this image, it may have taken more effort and surgery may have been delayed by a week or two.

Patients can also do this if they are able to email their physician. It's not enough to provide only textual information which may not provide a compelling enough story... Include relevant images!!! Of course, you may need the help of a health professional to guide which images are most important.

It's worth repeating again...

Include relevant images!!!

The extreme importance of images is also why I ALWAYS want to see the CT scan images of any patients who comes in for an appointment and why patients should ALWAYS bring a copy of their CT scan burned onto a CD before seeing their ENT. A report is NOT good enough.

HOWEVER, the very importance of an image to a surgeon can be a double-edged sword as the image you send may PROVE that there's nothing significant going on to the point that a specialist may say that scheduling an appointment would not be worthwhile.