Barbaric doctor or oversensitive nurse?

littlefeet · Jan 25, 2006

This doctor would have nothing to do with the suggestions I was giving. I explained to him that she was not sedated enough for me to hold her and as he was about to puncture her with the needle I said "stop, are you not going to freeze with some lidocaine?" His answer was that will be two pokes which is more traumatizing for her than to just get it over with. Another problem with this whole situation is that in our ER with conscious sedation we have protocol to use end tidal CO2 monitoring on the patient. He was in such a rush to get this done he wouldn't let me get the monitor and we had barely enough time to get her on the pedi heart monitor too. He was just in a rush and didn't care that it would be my ass on the line if something bad happend. Of course I charted everything that he said and that I informed him of our protocol and was not allowed to hook her up. In future I will refuse to do this kind of procedure if proper sedation and protocol are not followed. Being a very new nurse it is sometimes hard to send up for the doctors but even with it being a week ago that this happend it is still bothering me and I feel guilty about the whole situation.

fergus51 · Jan 25, 2006

I completely understand Littlefeet. Docs can be quite intimidating, so this can be a learning experience for you. He can't physically make you hold down a child, so if you stick to your guns he doesn't have much choice but to wait for you to get an end tidal monitor, hook her up to monitoring, etc.

cmg26 · Jan 29, 2006

I do not work with the kids, I am in Long term care, but I would be upset too. I am sure your respect for this MD went to zero, but on the other hand, can you be a patient advocate by insisting that procedures be changed by starting with your ER Manager, remember chain of command. You probably feel guilty about all the pain the girl was in that you could of done something for her. It's over now, discuss with the higher ups and let them run with the ball.

rjflyn, ASN, RN · Jan 29, 2006

Based on what I have read first off Ketamine would have been a better choice for sedation if the doctor didn't want to use two agents ie a bezodiazapine and a narcotic.

Second as far as the use of lidocaine in peds alone for an LP most generally its about 50-50 weather it is used or not. This is one of those procedures that one the patient has to be still and because of that the fewer times the patient gets poked the easier it is to complete. Even with lidocaine the patient is going to feel pressure so its hard to tell if it is that or pain the patient is feeling and causing them to move, cry and fight. Of note the more skilled the doctor the more likely that lido doesnt get used as far as what I have seen, that and I have never seen a doc wait for the drug to actually work anyway.

As well I personally cant think of a single physician I have worked with that is going to allow a parent to remain in the room while an LP is being done. Thats going back almost 20 yrs.

Rj

rn in 3 years · Jan 29, 2006

If I was the mom I think I would have refused to leave the room. They would have had to drag me out of there. I hope that stubborness will help me when I become a Pediatric Nurse.

One other thing is that this child is probably TERRIFIED of medical personnel now.

pedsplease · Mar 3, 2006

Hi Littlefeet,

I may only be a student nurse, but what we are constantly being taught for the nurse's role is, "Patient advocacy, patient advocacy, patient advocacy". I was thoroughly encouraged by your post! To be honest, so far in my clinical experience I see a trend for nurses to stop caring and do whatever is easier. It was refreshing to hear your compassion for your patient. I hear/read constantly how patients are undertreated for their pain/anxiety. Lately I have read how pediatric patients are the most at risk for undertreatment of pain/anxiety-that to me (and I believe all of my professors would agree) should be a crime. I hope that when I graduate nursing school and have been practicing for many years that I will be as "sensitive" to my patient's needs as you. That in my book makes a great nurse!

irishnurse67 · Mar 3, 2006

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.

T

Pedi-ER-RN, RN · Mar 3, 2006

Thank God I work in a Peds hospital where I have never been witness to this. We usually don't sedate with versed for LP's in older children, but do use EMLA or other local anesthesia. We frequently do full conscious sedations for ortho reductions and other procedures. I don't advocate for a CS with things like I&D's if the child responds well to IV Morphine or Nubain, etc.. We HEAVILY sedate our cardiac kids that have to be cardioverted (I know they appreciate this!!). I think Docs sometimes are just too hurried to remember that the person they are performing a certain skill on is just that, a person!!!

I recently had to assist an OB-GYN doc with manually opening (nice word for ripping apart) an incision of a recent post op lap for removal of CA because the incision was infected, but not before the lady got tons of Demerol and Phenergan. Doc had no problem with providing adequate pain control.

Gompers, BSN, RN · Mar 12, 2006

I don't think the OP was being oversensitive AT ALL. Your instincts were right on.

In the NICU, our docs won't do an LP without the baby first getting an adequate dose of Fentanyl. All our babies are on monitors, but not all are intubated. If it's a term baby, they'll also order Ativan for sedation so the baby doesn't fight back. The last thing the docs want is for the baby to move during this delicate procedure, so they are very liberal with the pain meds.

We do need to be our patients' advocates. This is true in all areas of nursing!

I do something like Fergus mentioned. I won't say, "Do you want pain meds?" or wait for an order. I'll outright SAY, "You're ordering 2 mcg/kg of Fentanyl...right?" as I'm walking towards the narcotics cabinet. And if the baby is obviously still in pain or struggling during the procedure (whatever procedure it may be), I'll SAY, "I don't think that dose of Fentanyl helped much. Do you want me to give another dose of Fentanyl, or would you prefer Morphine OR Ativan?" I try to make it so it's still under their control (since some docs get a bit cocky about that) yet I'm still going to get SOME kind of order for pain med - "NO" is not an option the way I present it.

lpnstudentin2010, LPN · Apr 3, 2006

One other thing is that this child is probably TERRIFIED of medical personnel now.

mabey mabey not...I had an LP at 5 and was not scared of docs later that night. but i had just had surgery also so i had been put through a lot in those couple of weeks.

errn1968 · Aug 13, 2006

Every LP kit I have ever seen has the lidocaine in it. At our peds Er, we use EMLA cream first for 30 minutes, then they use lido. We don't usually consciously sedate for the procedure. I they have trouble they have scheduled it under fleuro. But I have seen that a good dose of the lidocaine usually does the trick.

firstaiddave907 · Aug 13, 2006

I feel bad for you littlefeet and for the child hopefulliy everything is ok with the child. I would of thought the doctor would of watied for the medication to work before he started.