You can try sending them home with that giant inflatable sausage in their nose, but you can sense the impending panic attack, tingling fingers, and pinching chest pain begin to stir in the depths of their uneasy psyche. You know they’ll just come back again unless you find a third option.

In these cases I like to try a “nose sandwich.”

The ingredients are tissue adhesive (e.g. Dermabond or Indermil), an absorbable hemostatic sponge (such as Surgifoam), and some bacitracin topical ointment. While the patient holds pressure on the nasal septum, trim your absorbable hemostatic sponge as needed. Place a small amount of bacitracin on one side only, and rest this side down on a narrow, firm object such as trimmed piece of a sterile tongue depressor or a culture swab. The bacitracin provides some antibiotic coverage, but also keeps you from gluing your tongue depressor or swab patient’s nose, requiring forceful removal and resultant psychic distress.

Just before the patient stops holding pressure, liberally coat the edges of the other side of your hemostatic sponge with tissue adhesive – this side will be applied to the nasal septum. Lift up the whole ensemble before the adhesive has a chance to dry, gently insert into the nare, and press firmly against the nasal septum. Keep the sustained pressure for at least a minute (tell a few jokes.)

Once you remove the tongue depressor or swab, trim any excess material poking out of the nare and have the patient resume holding pressure for another 20 minutes. If you need a little extra volume, insert additional layers of hemostatic sponge (no tissue adhesive this time) adjacent to the first one. To further prevent blood or hunks of hemostat from falling out of the nose, gently cover the affected nostril with a steri-strip, using a little benzoin to help it stay in place. Don’t cover both nostrils unless your patient does not need to breathe at regular intervals.

Most patients find this form of nasal packing to be much more comfortable than inflatable packs, even if you have to insert more than one layer of absorbable hemostat. Usually it falls out in 3 days, so prepare the patient for this likely outcome. I usually tell the patient to remove the steri-strip in 48 hours if it hasn’t come off already. Because the entire unit is absorbable, I don’t consider the dangers of aspiration or ingestion to be higher than they would be for a regular blood clot from untreated epistaxis, but it’s worth discussing the possibility with the patient.

He made these nose tongs for me. He cares!

Prescribe the same antibiotics and follow-up would ordinarily give with any nasal packing. Everyone loves a freebie, so give your patient their very own nasal clamp to take home in case they ooze through a little. If you make your own out of two tongue depressors, write “30 minutes – NO PEEKING” in huge letters. Having the rules in plain sight seems to encourage honesty and produce maximum benefit from any placebo effect.