[littlefeet]

I work in an ER department and we had a three year old female carried in by mom in a postical state. She had a temp of 104 and had vomited on the way to the hospital. Blood tests showed an increase white count and her urinalysis was clear. We got her fever down but during our assessments we noticed she began to be unable to use her body strenght to sit up or stand. When mom went to pick her up the little girl began screaming in pain and shaking uncontrollably. The child was just not acting like a typical febrile seizure. A pediatrician was called in and he decided to do a lumbar puncture. He requested sedation for the child. He gave her 2mg of midazolam (versed) IV push. This in my opinin did not sedate the child enough for the procedure. She was still talking and looking around and crying because she was scared. She was alert enough to tell her mom at that point that she was scared and wanted to go home. He then asked the parents to leave the room which upset the child right away. A nurse and I were told to hold her in place for the lumbar puncture and not to let her move. He then proceeded to do the puncture but didn't not freeze the area. As he stuck the spinal needle into her back the child screamed out in pain and moved to try and grab what was poking her in the back. He then got mad and said he needed someone stronger to hold the child in place. He preceeded to do the lumbar puncture without any further sedation or freezing to the area. I left the room and was very upset to the point of tears. Another nurse told me that sometimes it is just better to get the procedure done than mess around with freezing and have to poke the child with the freezing and the spinal needle. My thoughts are that we give adults local freezing when we do a lumbar puncture...is it not cruel to not give the same to a child? I just need a little feedback about this because I was made to feel as though I was over emotional and too sensitive.

[PedsER-RN]

In my department it's left to each doc if they want to use IV sedation or not (usually only for bigger kids-toddler/preschool and older). If they choose to do so, they child is typically sleepy but not 'out', and may even talk a little. Some of our docs do a local with some Lidocaine, but usually just on the older kids. Some of our docs send the kids down to radiology to have the LP done under flouro. Whether the parents stay is up to the doc (most prefer they step out-sometimes they can be really distracting during the LP).

In your situation I would think that if the doc was going to use versed in the first place, he would want to use enough to actually sedate the child. Awake and conversing with mom is not adequate sedation. And blaming the holder for an unsedated toddler moving around is a copout.

[tencat]

What a creep. I'm sorry, but if that had been my three-year-old daughter the doctor woulda had his head ripped off. I have had a lumbar puncture, and I was given a numbing shot pre-puncture. What is it with these guys and kids???? I heard a story a couple of days ago where a pediatric surgeon wanted to debride an infected abdominal wound WITHOUT any kind of pain medication for the 8 year-old patient. A nurse stopped him, but he really didn't see the need for pre-medicating the patient. I love kids, but I don't think I can work with them as a nurse because if it were me as the nurse in those situations I'm afraid that I'd be terribly unprofessional and let the docs know EXACTLY what I thought of those ideas....and probably get myself into a lot of trouble. How do you deal with those kinds of things without wanting to rip someone's head off????? And when do you step in and protect the patient? I don't blame you at all for being upset about the whole thing, and I don't think you did anything wrong. I just would like to know myself when it's appropriate and when it's not to confront a doctor on something like this.

[grannynurse FNP student]

I thought these days and doctors were a thing of the past. Research has shown that even infants perceive pain. There is no excuse not to medicate anyone, including an infant, prior to any painful procedure. The hospital the ER, some of the nurses and physicians need an update with their pain medication and infant and children perceptions.

Grannynurse

[babynurselsa]

The American Association of Pediatrics has a definite statement regarding pain in children right down to the neonate. Unfortunately it is not always followed. That is a large part of the reason I no longer work NICU.
The attitude that I take is how would you feel about it if it were YOUR child?

Had en ER doc fighting to do an LP on a 3 yr old several years that he actually BENT the needle while in the childs back. I was not there for this but heard about it later. Of course these docs were notorious about not sedating kids for anything.

[prmenrs]

My choice would have been to sedate the child better. Don't forget that zylocaine STINGS like the dickens and takes a little while before it's fully effective, so it hurts possibly as much as the LP. On the other hand, they'll squirm and cry for THAT and maybe, maybe hold still for the LP. Or not.

While you're waiting for the local and sedation to take effect, you can spend a little time getting the child calmed down---soft voices, mom rocking, etc.

I don't the think the doc is "barbaric", just not empathetic, patient and possibly a little dumb. JMO.

[fergus51]

I think anyone who doesn't treat pain is barbaric. I actually had a doc who wanted me to assist with a chest tube insertion without medicating the baby. Nope, not gonna happen.

The question I always ask myself is how would I feel if this was a member of my family? I would not allow a doc to do an LP on my family members without appropriate sedation/pain management.

[babynurselsa]

Many years ago I walked into work one night to a baby who had had a VENTRICULOSTOMY placed without so much as lido to teh scalp. I was nauseated at just the thought. This was the same neo (plus a neurologist) that was the last one I worked wtih that is why I no longer work NICU.
"Neonates don't feel pain and even if they do they won't remember it."( can you guess what era he got his training???)
When we debunked that one with article after article along with the AAP statement regarding neonatal pain he changed his "rational" to "I don't want to bottom out the baby's pressure."
I treat my little patients like I would DEMAND my children be treated. I believe in as ATRAUMATIC tx as possible.
Let me tell you about being a 10 yr old with a twist fx of the femur who never so much as recieved a tylenol. I remember beign told "if we gave you anything we would have to give you a shot, now you don't want a shot do you?" Not even when they RESET THE BONE did I get anything. This was in teh 70's. I guess 10 yr olds didn't feel pain then either.

[onehusbandsevenkids]

Ok, I'm "just" a nursing student but my best friend has been a nurse for almost 9 years now and the stories she has.....ugh....(about docs)

Here is my question. We have learned that nurses are to be the patient's advocate. So....would the right thing in a situation like this be to have a word with the doc and advocate for the child (or whoever) to have pain relief? Can't you just say something like, "Doctor - this child needs and deserves some pain relief before you do this procedure."

I can't fathom standing by and assisting with something like this knowing full well that there are things that would have helped.

I guess I'm confused as to where crossing the line falls between advocating for your patient and being unprofessional. I mean are nurses mostly expected to just kiss the docs rear ends and do whatever they say even if it's detrimental to the patient?

Oh, and I too would be livid if it was my child. Children don't forget things like that...ask me how I know.

[HappyJaxRN]

Originally Posted by littlefeet

I work in an ER department and we had a three year old female carried in by mom in a postical state. She had a temp of 104 and had vomited on the way to the hospital. Blood tests showed an increase white count and her urinalysis was clear. We got her fever down but during our assessments we noticed she began to be unable to use her body strenght to sit up or stand. When mom went to pick her up the little girl began screaming in pain and shaking uncontrollably. The child was just not acting like a typical febrile seizure. A pediatrician was called in and he decided to do a lumbar puncture. He requested sedation for the child. He gave her 2mg of midazolam (versed) IV push. This in my opinin did not sedate the child enough for the procedure. She was still talking and looking around and crying because she was scared. She was alert enough to tell her mom at that point that she was scared and wanted to go home. He then asked the parents to leave the room which upset the child right away. A nurse and I were told to hold her in place for the lumbar puncture and not to let her move. He then proceeded to do the puncture but didn't not freeze the area. As he stuck the spinal needle into her back the child screamed out in pain and moved to try and grab what was poking her in the back. He then got mad and said he needed someone stronger to hold the child in place. He preceeded to do the lumbar puncture without any further sedation or freezing to the area. I left the room and was very upset to the point of tears. Another nurse told me that sometimes it is just better to get the procedure done than mess around with freezing and have to poke the child with the freezing and the spinal needle. My thoughts are that we give adults local freezing when we do a lumbar puncture...is it not cruel to not give the same to a child? I just need a little feedback about this because I was made to feel as though I was over emotional and too sensitive.

That's totally unacceptable! Every single lumbar pucture I saw preformed on a pediatric patient from a 2 year old to a 9 year old, the MD had the kid SEDATED....This poor kid! That's horrible!