Barbaric doctor or oversensitive nurse?

[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.

[NotReady4PrimeTime, RN]

You were totally right in insist on some kind of analgesia for your patient. LPs hurt, as my daughter will attest. She has mild scoliosis, which we didn't know UNTIL she had to have an LP when she was 22. The ER resident poked her multiple times before admitting defeat and getting the attending. She had lidocaine, but said is still hurt like a sonofagun.

On the other hand, when I asked about sedation/analgesia/local for an LP being performed in the unit I was told by the peds oncologist who was going to do it that in their clinic they never use any kind of sedation or local for their LPs (which they do a lot of for intrathecal chemo). I sort of bypassed her by going to our attending and getting an order for some fentanyl, and all was dandy.

In Canada there is a newer topical anaesthetic called Maxilene (4% liposomal lidocaine) that works in 30 minutes. Studies have shown it to be very effective for procedures such as LPs, IV starts and art line placement. We use it in our unit if we know far enough in advance to apply it.

A few years ago, we had a cardiovascular surgical resident who knew very well that our protocol for mediastinal chest tube removal included a 1mcg/kg dose of fentanyl 2-5 minutes before the tube is pulled. But would he wait until the drug had even cleared the dead space in the line? Oh, no. So I made it a habit of being in his way until I was sure the kid was feeling the fentanyl. Another time I had a general peds surgeon wanting to remove an infected tunneled central line from a toddler without any kind of analgesia or sedation. He's one of those docs who believes nurses were created by God to serve the physician, so he sent me out of the room to get him a suture removal kit. (In fact, he told me three times to get him the kit, and each time I dragged my feet until I could see our attending through the window.) I returned with the kit and two doses of fentanyl ordered for me by the PICU attending, who then followed me into the room to make sure I was able to give it before the surgeon laid hands on the child. Passive-aggressive? Maybe. Did it work? Absolutely. Would I do it again? No doubt.

[bijou214]

the "why stick the baby twice when the lp is just 1 stick" excuse for not giving pain meds is one of my biggest pet peeves!!! i remember i was maybe 1 month off orientation and holding for an lp. i asked the docs what they wanted to do for pain. the resident gave this excuse and looked at ME as if i was barbaric for thinking we should stick the baby twice. in fact, he told his intern that it's better practice to just stick the baby once for the lp.

THEN. gah! then he proceeded to allow his intern to do the lp. the intern missed. the intern tried again. the intern missed. the resident tried. he missed. the resident tried again and got bloody fluid. they called the fellow. she tried and missed. she tried again and finally got clear fluid. can we please count the sticks?!?!

[NotReady4PrimeTime, RN]

I once asked an oncologist if she wanted some lidocaine for anLp she was doing in our unit. She told me quite bluntly that NONE of the kids in the oncology clinic ever had local or topical anaesthesia for LPs or bone marrow aspirates. I was aghast... those kids have LPs and bone marrows done routinely for years!