closed reductions on Peds in the ER

got2luvnights · May 19, 2004

I'm with ya sister. Think about how that kid is gonna be the next time he/she has to go to ER, docs office whatever? No offense, but pt is gonna fight.
The swelling (majority of it) must have come from the repeated unsuccessful manipulation. Elbow fx's and dc's usually do not swell that much. Poor kid. :angryfire
Sorry you had to be the one to witness it. I worked as an ortho first assist for a few yrs and that would never have happened with the group I worked with. I am sorry it happened at all. Was it reduced at all by the time pt was transported? Did the swelling get bad enough that DNV's were comprimised? Out of all of the docs that I have come across in my yrs, orthos can sometimes be the worst. (and sometimes kind of weird) Example of the weird? The group I was 1st assist for, barked, barked barked and occasionally bit. I used to be so timid around them. One day after 5 back to back very long surgeries, I got barked at for nothing and finally bit back. 4 surgeries later when our shift was over, they took me out for shots of tequila for "finally growing a spine". Now, I did drink their money, but still called em all names in my head-still do.

ang75 The child had all sensation before reduction 1 day postop child lost feeling in ring and small finger and cast had to be split but did nothing for numbness and little for swelling. The patient was only x-rayed splinted and given pain meds before transported to our ER.

ang75 · May 19, 2004

Hopefully the sensation will come back after swelling goes down. Hopefully. There is also the radial nerve to consider.

Obviously this is weighing heavily on your mind. You could always go to your CN or see if it can be brought up for review.

PA-C in Texas · May 20, 2004

There have been two times in my career when I have not been able to reduce an elbow dislocation under block or conscious sedation in the ER on a ped patient. I attempted to do so several times with both, but was careful not to cause more soft tissue injury than had already occurred. The first got shipped out to a ped trauma center who had ortho on call, and they ended up having to do an open reduction.

The second one happened to be on one of the two days a week when we have a CRNA in-house in the morning. I called my supervising physician, who then talked to the CRNA, and we went to the OR for a full induction. Pt. had severe muscle spasm that not relieved by benzos. It was sort of surreal because it was the only time I have booked an OR for myself- without a physician present.

As soon as the succinylcholine was in, it practically slipped back into place by itself. Pt. had a very good outcome and went home later that afternoon with an appointment for FU with an ortho.

When I have doubts about what physicians are doing, I always try and remember that they have much more education and probably more experience than I have. Rather than look for something to confront them with, I tend to give them the benefit of the doubt.

That said, I have occassionally raised issues related to some isolated incidents with my supervising physician, who is the appropriate person for me to discuss such matters with. I always do so with a respectful attitude rather than a condescending one. More often than not, I have been enlightened as to why a certain procedure was performed or a particular action was taken.

You have to remember that medicine is a different world than nursing. I know that in several states, nurse practice acts are slightly vague and dependent on the collective actions of the nursing profession. Physicians don't really give a damn about what other physicians are doing so long as the care they provided is evidence-based. Have you investigated the literature regarding closed reduction of dislocations of the radial head? If not, you should do so before taking your complaint any further. Your suspicions aren't going to mean anything if you can't provide any justification for them.

That doesn't mean that you should just turn a blind eye. If the child was raising up off the table, he was probably not appropriately sedated for such a procedure. Read up and ask for physician opinions if you plan to take this thing anywhere. Be sure to have facts to back up your assertions because when this gets back around to whatever medical board will potentially review it, the stand alone opinion of an RN really won't carry much water. (Not to offend, but its just the reality of things.)

ang75 · May 20, 2004

For some of the last post, I disagree.

I would not go around behind the docs back questioning his/her ability to the other docs. That is most likely going to back fire on you and its gonna hurt. I stand by my advice and say go to your dept head or have the chart brought up for review-it probably will anyway. There are monthly case reviews for each dept of docs anyhow. This would be a great one for a M&M.

Or, you could always hold out, spend more time with this doc (volunteer for procedures) and see if anything else brings you concern.

I say again, I would not confront the doc or the other docs. My husband is a doc (I used to work for him in the ER) and he laughed when I asked his opinion. He agreed with me. Going to other docs would get you a horrible opinion with them and you would be crucified. His advice is to take the place and stand that is appropriate for a nurse to take and go to your dept head or pull the chart for case review.

Good luck with whatever you decide.

got2luvnights · May 23, 2004

There have been two times in my career when I have not been able to reduce an elbow dislocation under block or conscious sedation in the ER on a ped patient. I attempted to do so several times with both, but was careful not to cause more soft tissue injury than had already occurred. The first got shipped out to a ped trauma center who had ortho on call, and they ended up having to do an open reduction.
The second one happened to be on one of the two days a week when we have a CRNA in-house in the morning. I called my supervising physician, who then talked to the CRNA, and we went to the OR for a full induction. Pt. had severe muscle spasm that not relieved by benzos. It was sort of surreal because it was the only time I have booked an OR for myself- without a physician present.
As soon as the succinylcholine was in, it practically slipped back into place by itself. Pt. had a very good outcome and went home later that afternoon with an appointment for FU with an ortho.
When I have doubts about what physicians are doing, I always try and remember that they have much more education and probably more experience than I have. Rather than look for something to confront them with, I tend to give them the benefit of the doubt.
That said, I have occassionally raised issues related to some isolated incidents with my supervising physician, who is the appropriate person for me to discuss such matters with. I always do so with a respectful attitude rather than a condescending one. More often than not, I have been enlightened as to why a certain procedure was performed or a particular action was taken.
You have to remember that medicine is a different world than nursing. I know that in several states, nurse practice acts are slightly vague and dependent on the collective actions of the nursing profession. Physicians don't really give a damn about what other physicians are doing so long as the care they provided is evidence-based. Have you investigated the literature regarding closed reduction of dislocations of the radial head? If not, you should do so before taking your complaint any further. Your suspicions aren't going to mean anything if you can't provide any justification for them.
That doesn't mean that you should just turn a blind eye. If the child was raising up off the table, he was probably not appropriately sedated for such a procedure. Read up and ask for physician opinions if you plan to take this thing anywhere. Be sure to have facts to back up your assertions because when this gets back around to whatever medical board will potentially review it, the stand alone opinion of an RN really won't carry much water. (Not to offend, but its just the reality of things.)

After this experience I would have to say I wish for this patient that you would of been the one doing this reduction. To answer your question earlier yes I have done extensive research on complex elbow fractures. While I appreciate that most reductions slip back in easily it cannot be overlooked that a elbow fracture is a serious matter and peds patients have growth plates that are not so forgiving. After a first failed attempt bone fragements have to be considered as a source.

To condense all other posts this patient was a transfer to our facility for surgery. The patient somehow got thrown into the ER and the treating 2nd year resident in general surgery stated that this child did not need surgery only a simple reduction and should come back in 2-3 weeks for a cast. During this procedure which was unsupervised by the ER doc in charge, anesthesia came down twice asking what the hell was going on, they were waiting for patient in the OR! It was not until stat x-rays had been called 3 times that the anesthisia doc came back in and loaded this kid up and rushed to the OR.

This case is being reviewed by risk management for obvious reasons. The parents were raising many questions as to why one minute the child is being transfered to another facility for surgery, then told no surgery was needed only a simple closed reduction, then off to surgery. The final report was devasting. What once was a radial head fracture and dislocation now added a radial neck fracture, injury to the ulna in the cornoid region, avulsion injury to the cornoid, serious damage to growth plates, significant ulnar neuropathy as well as the interosseous membrane was torn. The child spent 3 days in the hospital.

While I appreciate your comments and clairifications on the world of nursing vs medicine I find it intresting that all nurses involved in this case have been talked to extensively. If your correct in stating that nurses opinions on such cases do not carry much water then why is risk management so eager.

That said, thank you for your response and willingness to share your experience with these matters. You have given me a lot to debate over "that is a good thing". I would still appreciate any comments on this and or other situations in which nurses have found themselves debating over.

missnurse01, MSN, RN · May 23, 2004

Hello all,

could you tell me what beir block is-our er docs tend to give some iv meds and try, then call ortho in as last result and they always request consious sedation (which only anesthesia can do now-long story), never heard of any other way. We are kind of isolated, only one ortho within an hour's drive-guess that is why the er doc tries...

thanks!

ang75 · May 24, 2004

A beir-block is a procedure for upper extremity fx's. I have only worked with one doc who uses it, but I think it is great. Here goes...

A cuff (much like a bp cuff) is placed proximally on the affected limb. Then inflated to occlude blood flow. Next, an IV is started in the hand of the affected limb (usually just a butterfly) In which Lidocaine is injected for the anesthetic effect. The fx is now forthe most part numb and can be manipulated. Once that is done, the cuff that was inflated is now deflated slowly at increments so as not to give a huge Lidocaine dose IV. (Pt is on the monitor)The cuff is on a machine that auto deflates at set rate. Soooo less traumatic on kids. Actually, it is only used on kids and I have only seen it done on upperextremities. Hope this helps!

Hello all,
could you tell me what beir block is-our er docs tend to give some iv meds and try, then call ortho in as last result and they always request consious sedation (which only anesthesia can do now-long story), never heard of any other way. We are kind of isolated, only one ortho within an hour's drive-guess that is why the er doc tries...
thanks!

got2luvnights · May 24, 2004

A beir-block is a procedure for upper extremity fx's. I have only worked with one doc who uses it, but I think it is great. Here goes...
A cuff (much like a bp cuff) is placed proximally on the affected limb. Then inflated to occlude blood flow. Next, an IV is started in the hand of the affected limb (usually just a butterfly) In which Lidocaine is injected for the anesthetic effect. The fx is now forthe most part numb and can be manipulated. Once that is done, the cuff that was inflated is now deflated slowly at increments so as not to give a huge Lidocaine dose IV. (Pt is on the monitor)The cuff is on a machine that auto deflates at set rate. Soooo less traumatic on kids. Actually, it is only used on kids and I have only seen it done on upperextremities. Hope this helps!

Hello ang75

Would this have been a good option for the kiddo we have been talking about?

ang75 · May 25, 2004

Absolutely! The only prob is that there are few ortho's who feel comfortable doing it because of the IV lidocaine-although it works as I described above. The most traumatic part of the whole procedure is getting the IV-we all know how kids are with that anyhow. But there is actually less risk involved this way then with conscious sedation. The whole deal takes 20 minutes, sit on the pt for 20 or so more minutes and bam. Kid gets to go out for icecream and everyone is happy. I really hope you get a chance to see one done sometime. It is amazing how less stressed everyone involved is (parents and nurses included).

Let me know how things turn out with the whole situation.

Hello ang75
Would this have been a good option for the kiddo we have been talking about?