Barbaric doctor or oversensitive nurse? - page 3

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... Read More

  1. 0
    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.

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  2. 0
    Quote from rn in 3 years
    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.
  3. 0
    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.
  4. 0
    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.
  5. 0
    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.
  6. 0
    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?!?!

  7. 0
    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!

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