Pediatric vaccine gone wrong

[Kazed]

So I work in a family practice, being trained on vaccines. Have done 100 so far, minimal issues. 18 month is in for his 12 month shots (delayed), first injection went bad... child flung free from fathers grip with needle still in arm, lost some vaccine, some mild bleeding. Wait and then go in for last 2 injections. Did subcutaneous first. Kid again jerked his arm, lost some vaccine and again bleeding. Nurse supervising told father he needs to get a better grip and advised me to just do last one. I tried but the kid kept squirming. Needle went in then slipped back out. Had to quickly do it again.

Child's arm was red, Puffy, Slightly swollen at injection site. Advised parent to wait 20 minutes to check for reaction they declined. Explained the doctor should assess the injection site as it was a rough injection and it looked puffy. They declined. I told the doctor and noted in the chart. I feel like I never want to do pediatric injections again. The nurse said it happens sometimes but unless we get someone else to restrain the child I feel I cannot trust the parents to secure them.

[JKL33]

The success (lack of drama/trauma) of any method chosen is going to depend heavily on the skill and understanding of the person using it. In fact, the OP scenario is a failure of the use of manual staff/parental holding that no doubt was more traumatic than the conscientiously-employed use of a p. board.

I would like to clarify that my original comment about papoose boards is directly related to the situation presented, which was that one or two additional onlookers were watching a patient and a learner struggle in a routine, non-urgent situation rather than helping make a plan and providing useful guidance.

IOW, if one can employ the use of p. board with discernment and the skill necessary to minimize drama/trauma and the parent can also perceive the intervention positively (important!), that is a fundamentally different thing than using a restraint device because we can't figure out how to do bare minimum coordination of therapeutic/comfort holds and instead just stand around being useless while a coworker struggles. In this latter (rather unskilled) situation, jumping to a standard MO/"plan" of using a restraint device because one can't think of anything else (or can't skillfully employ any other method such as comfort hold) is not an idea that I would agree to for my child's care.

[Wuzzie]

This^

In spades. 

[Kitiger, RN]

On 8/25/2020 at 8:31 AM, JKL33 said:

Also wouldn't consider papoose board. That is not good optics for routine, non-emergent peds/family wellness care. Particularly when very brief assistance from another set of hands can make it completely unnecessary the grand majority of the time.

I hadn't considered this; you are right.

 

[HiddencatBSN, BSN]

10 hours ago, Wuzzie said:

Okay, I've done my best to not take the bait but honestly I resent your implication that I inflicted trauma on the patients I used the papoose board on. Apparently you missed the part about proper preparation and kid friendly terms. It does not have to be traumatic if it is introduced and used correctly, however it is clear that you have a different viewpoint and are unwilling to accept that perhaps other people could be successful with a different approach.  Just to be clear I never used a papoose board in such a manner that it inflicted any additional trauma on any patient I have ever taken care of. I do not in any way condone it's misuse and feel terrible for the children who suffered at the hands of misinformed, under-educated, unskilled and uncaring health care providers. I do not happen to be one of them. 

Whoa now. My point was that this isn’t about me and what works for me, or you and what works for you, but what is best for the patients we’re caring for. 

 

[Wuzzie]

8 hours ago, HiddencatBSN said:

Whoa now. My point was that this isn’t about me and what works for me, or you and what works for you, but what is best for the patients we’re caring for. 

Yes and sometimes parents and/or staff members unfamiliar to the child restraining them is not the best for the situation. A papoose board does not always cause trauma which is what you repeatedly said. If it is used incorrectly or as a last ditch effort after the drama has already started of course it’s going to be horrible. But upset parents and stressed out staff aren’t any better. It’s going to be bad all around. Perhaps you’ve seen papoose boards being used in these situations in which case I would understand your strong aversion to them but to imply that I have chosen to use them only because they “work” for me is galling. FTR, I have never put a hysterical child on one, never forced a parent to allow its use and never used it for an inappropriate procedure because I actually do care about my patients. Thanks for your input. I truly hope you have a great weekend. 

[Closed Account 12345]

I would not allow a nurse to give any injection/vaccine in my toddler's deltoid. If you're the nurse giving an injection, let your preceptor know that you will be following best practice, which includes using the vastus lateralis site in toddlers.  Their little arms are too scrawny, and I imagine that's much more painful.

Did you notify the provider that the child only received a partial dose of the vaccine so that plans can be made to ensure the child is fully vaccinated?  He may need an additional dose of the vaccine that wasn't fully administered.

At my pedi's office, they have my toddler lay on the exam table. Her knees align with the edge, and the nurse secures the dangling lower legs against the the side of the exam table with her own legs/body.  This allows me to be face to face with my daughter and hold her little arms to her chest. It works very well, and it allows me to comfort and sooth her and tell her I love her as the nurse quickly gives the vaccines.  It gives the nurse total control over the injection site.  Then I'm able to scoop her right up. Holding a wiggle worm toddler in my lap and trying to control all extremities for a vaccine would be very tricky. 

Don't feel bad... You're learning, did the best you could with a bad situation, and your preceptor left you hanging.  If you're working with a parent who can't or won't safely restrain the child, the parent shouldn't be used as a restraint.  You might benefit from watching some pediatric vaccine administration videos and reading about the rationale for the best practice site. Then you'll feel more confident going forward. 

[LovingPeds, MSN, APRN, NP]

I never use the deltoid in a child less than 3 years of age unless they're having to be caught up and have a great number they have to get. I have had to give up to six vaccines for kids who are very, very behind. This is usually children who are around two or older. We always try to use combination vaccines if we can so as to not give as many shots. With six shots, it's sometimes necessary to space them out into the deltoid. I would not do this as a matter of general practice in toddlers though. The vastus lateralis is a larger muscle and is much easier to control for vaccination in busy little bodies.

We do allow parents to restrain. I usually allow parents to make the decision for how to hold the child. They can either hold the child in their lap or we can lay the child down on the exam table. I'm comfortable either way so I give the parent the choice. They know their child and what may be easiest/most secure for them better than I do. Either way, with the thigh the parent is responsible for holding their arms and hands. I control the legs. I do not start until I am satisfied that the parent is in complete control of those little hands and arms. If the parent is not in control, then a nurse will hold the patient. If the parent lets go on any of the vaccines, a nurse will hold the patient.

You have to have good control of what ever area you are giving the vaccine to. If you're giving it in the deltoid, then you need to hold that arm with one hand and give the vaccine with the other in addition to the parent holding. Never rely only on a parent or anyone else to solely hold and control that area for you.

When you give the vaccine, place your wrist firmly against the patient's muscle and hold it there. Then use a downward motion for the injection without moving your hand. That way if the child moves unexpectedly, you still have control of that syringe because your hand has been steadied. It's a similar technique to bracing with your hand while looking in ears.

If this child received a partial dose, then he wasn't fully immunized.  Any dose less than the full 0.5 mL is not valid and will need to be repeated. Honestly, all of this is on your preceptor. They should have stepped up to help. They should not have let his child leave the office without that full MMR/varicella dose or any of the others. If it gets put into his record as a full dose, this child will not receive these invalid vaccines again as he needs to.

The ease comes with experience. Don't let one bad experience stop you from giving pediatric injections.

[LibraSunCNM, BSN, MSN, CNM]

On 8/29/2020 at 11:15 AM, FacultyRN said:

At my pedi's office, they have my toddler lay on the exam table. Her knees align with the edge, and the nurse secures the dangling lower legs against the the side of the exam table with her own legs/body.  This allows me to be face to face with my daughter and hold her little arms to her chest. It works very well, and it allows me to comfort and sooth her and tell her I love her as the nurse quickly gives the vaccines.  It gives the nurse total control over the injection site.  Then I'm able to scoop her right up. Holding a wiggle worm toddler in my lap and trying to control all extremities for a vaccine would be very tricky. 

This is what my daughter's practice does and it has always worked really well.  I can't imagine using a papoose board (and side note, yikes, we need to find a new term for that thing!) for vaccines for an 18 m/o, that would be traumatic enough for me as a parent to watch, let alone for my kid to be strapped into.  But your mileage may vary.

[Kazed]

On 8/30/2020 at 7:37 PM, LovingPeds said:

I never use the deltoid in a child less than 3 years of age unless they're having to be caught up and have a great number they have to get. I have had to give up to six vaccines for kids who are very, very behind. This is usually children who are around two or older. We always try to use combination vaccines if we can so as to not give as many shots. With six shots, it's sometimes necessary to space them out into the deltoid. I would not do this as a matter of general practice in toddlers though. The vastus lateralis is a larger muscle and is much easier to control for vaccination in busy little bodies.

We do allow parents to restrain. I usually allow parents to make the decision for how to hold the child. They can either hold the child in their lap or we can lay the child down on the exam table. I'm comfortable either way so I give the parent the choice. They know their child and what may be easiest/most secure for them better than I do. Either way, with the thigh the parent is responsible for holding their arms and hands. I control the legs. I do not start until I am satisfied that the parent is in complete control of those little hands and arms. If the parent is not in control, then a nurse will hold the patient. If the parent lets go on any of the vaccines, a nurse will hold the patient.

You have to have good control of what ever area you are giving the vaccine to. If you're giving it in the deltoid, then you need to hold that arm with one hand and give the vaccine with the other in addition to the parent holding. Never rely only on a parent or anyone else to solely hold and control that area for you.

When you give the vaccine, place your wrist firmly against the patient's muscle and hold it there. Then use a downward motion for the injection without moving your hand. That way if the child moves unexpectedly, you still have control of that syringe because your hand has been steadied. It's a similar technique to bracing with your hand while looking in ears.

If this child received a partial dose, then he wasn't fully immunized.  Any dose less than the full 0.5 mL is not valid and will need to be repeated. Honestly, all of this is on your preceptor. They should have stepped up to help. They should not have let his child leave the office without that full MMR/varicella dose or any of the others. If it gets put into his record as a full dose, this child will not receive these invalid vaccines again as he needs to.

The ease comes with experience. Don't let one bad experience stop you from giving pediatric injections.

Thank you for the advice. I am nervous about the child's protection against the diseases he was being vaccinated against.  I don't feel the nurse or doctor took it as seriously as I felt it was

[LovingPeds, MSN, APRN, NP]

On 8/31/2020 at 7:04 PM, Kazed said:

Thank you for the advice. I am nervous about the child's protection against the diseases he was being vaccinated against.  I don't feel the nurse or doctor took it as seriously as I felt it was

I can't speak for their actions or reactions. Take it as a learning experience. Every one here has had one. If it ever happens again, you can specifically mention that he didn't get the full dose and show your preceptor and the physician the CDC recommendations for partially administered doses.