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Too many attempts at a spinal tap?

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by Moe75_Rn Moe75_Rn (New Member) New Member

Moe75_Rn specializes in Neuro, HIV/AIDS, Mother/Baby.

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I just started working on a unit. There was a patient (not mine directly)

that needed to have a lumbar puncture. Long story short, atleast 5 attempts were made, all by residents, with no success. The parents of this patient were not informed of all these attempts, and the patient only being one day old could obviously not speak for himself. Is this an acceptable practice, and would you speak to someone about it. It just eats me up inside everytime I think about. I feel that if the residents didnt get it on the first try then the attending should of been called in. I am planning on saying something to my manager but I want to see what you guys think as well. Thanks for the help.

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5 is far too much. I would report it.

I am not sure if there is a rule at my facility but I don't think residents try at an LP more than 3 times before calling the attending. 3 times is the most I have seen residents try (and that wasn't usual), then the attending was called and of course the attending got it on the first go.

I think they should have a 2 stick rule like nurses have for IV's. After 2 sticks, we call an expert in from the hospital IV team.

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KellNY is a RN and specializes in High Risk In Patient OB/GYN.

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I just started working on a unit. There was a patient (not mine directly)

that needed to have a lumbar puncture. Long story short, atleast 5 attempts were made, all by residents, with no success. The parents of this patient were not informed of all these attempts, and the patient only being one day old could obviously not speak for himself. Is this an acceptable practice, and would you speak to someone about it. It just eats me up inside everytime I think about. I feel that if the residents didnt get it on the first try then a physician should of been called in. I am planning on saying something to my manager but I want to see what you guys think as well. Thanks for the help.

Awww...poor little guy (or girl?). I'm not sure what the policy is at your hospital, but just wanted to mention that a resident is a doctor. I'm guessing that you work at a teaching hospital, and part of being a pt at such a hospital is that residents may (read: will) perform any number of necessary procedures on the pt, so the parents needed have been informed.

(although as the nurse I may have mentioned it without pinning blame on anyone, maybe something like "Junior had a spinal tap and may be a little sore since it took multiple attempts. You'll also notice some bandages on his/her back--those are what they're for". That's just me)

I know some attendings would get annoyed being called in for a routine spinal tap and wonder why another resident didn't try, so they may have been following what they were told to do.

Were any Xrays done to see if maybe there was a spinal malformation that was preventing a tap?

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303 Posts; 4,416 Profile Views

5 is far too much. I would report it.

I am not sure if there is a rule at my facility but I don't think I have ever seen a pt being poked 5 times for an LP. 3 times is the most I have seen residents try (and that wasn't usual), then the attending was called who got it on the first go.

I think they should have a 2 stick rule like nurses have for IV's at my facility. After 2 sticks, an expert is called in.

I disagree with what the above poster said about "well it is a teaching hospital and they are licensed doctors". Would you want your child or family member to be poked 5 times for an LP?

I would use whatever procedure your facility uses for complaints about care given.

Good luck.

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DutchgirlRN has 33 years experience as a ASN, RN and specializes in OB, M/S, HH, Medical Imaging RN.

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Years ago my dh had a severe headache, I forget why the ER doctor thought he needed a spinal tap, a anesthesiologist was called to come down and do the tap. I waited outside the room. It took forever. When they finally opened the door my husband was almost hysterical they had tried 8 times on him! I threw a fit. I called OB/GYN and asked for a CRNA to come down. He got it on the first stick. The test was negative but after that he had a spinal headache and had to have a blood patch. I was furious. I had intended to report the anesthesiologist but later found out that he had dropped dead of an MI.

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KellNY is a RN and specializes in High Risk In Patient OB/GYN.

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I disagree with what the above poster said about "well it is a teaching hospital and they are licensed doctors". Would you want your child or family member to be poked 5 times for an LP?

I'm not sure what you disagree with. If it is a teaching hospital, then a resident certainly is allowed to (attempt to) perform a spinal tap on a neonate. This is true whether or not you agree that it should be.

Did I say it was the best practice for the patient? Did I say I wouldn't be fuming if it were my child or even my patient? Did I say had I been present that I wouldn't have told the anesthesia residents that they should maybe either call an attending or check the spine to see what the problem was? I never said "Well, they're MDs, let them just poke away blindly".

Was an attending present and/or available at the time? Was it a STAT order? Was there a known anomaly of the spine? What year residents were they?

I'm a little hesitant to flip out and judge a case that we know little about (it wasn't even the OPs pt).

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84 Posts; 2,297 Profile Views

I just started working on a unit. There was a patient (not mine directly)

that needed to have a lumbar puncture. Long story short, atleast 5 attempts were made, all by residents, with no success. The parents of this patient were not informed of all these attempts, and the patient only being one day old could obviously not speak for himself. Is this an acceptable practice, and would you speak to someone about it. It just eats me up inside everytime I think about. I feel that if the residents didnt get it on the first try then a physician should of been called in. I am planning on saying something to my manager but I want to see what you guys think as well. Thanks for the help.

Don't know how to tell you this, but residents are physicians. I've never done a lumbar puncture on a neonate, and I'm guessing that you haven't either. However, I'm guessing that it's not that easy and that it often takes more than one attempt. You haven't mentioned anything about an adverse outcome, so I guess everything went okay in the longterm, and since you weren't responsible for the patient, I would say that you don't really have anything to report.

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Don't know how to tell you this, but residents are physicians. I've never done a lumbar puncture on a neonate, and I'm guessing that you haven't either. However, I'm guessing that it's not that easy and that it often takes more than one attempt. You haven't mentioned anything about an adverse outcome, so I guess everything went okay in the longterm, and since you weren't responsible for the patient, I would say that you don't really have anything to report.

As a NICU nurse, I will tell you that 5 attempts by a resident(s)to do an LP on a neonate is completely unacceptable. My guess is that the resident(s) didn't want to admit to their senior resident, fellow and/or attending that they were unsuccessful, so they just kept trying. Did they order pain medication? Did they give the infant a break between attempts? Did they monitor temperature, O2 saturation and glucose levels in the infant during these attempts? Did they contact their senior physicians to determine if there was a neonatologist or NNP available to supervise them or take over the procedure? Did they inquire as to whether it could be put off for another day?

I have worked in too many NICUs where the residents use poor judgement in attempting procedures on helpless infants. It is the duty of the nursing staff to advocate for the babies and their parents. I would be willing to bet that an infant subjected to that amount of pain and stress did indeed suffer some avoidable side-effects.

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Moe75_Rn specializes in Neuro, HIV/AIDS, Mother/Baby.

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Don't know how to tell you this, but residents are physicians. I've never done a lumbar puncture on a neonate, and I'm guessing that you haven't either. However, I'm guessing that it's not that easy and that it often takes more than one attempt. You haven't mentioned anything about an adverse outcome, so I guess everything went okay in the longterm, and since you weren't responsible for the patient, I would say that you don't really have anything to report.

Wow. I am just a concerned nurse, looking for a little advice. Really no need to get hostile, and I am quite aware that a resident is a physican. I apologize for the mistype. I should have stated that an ATTENDING should of been call in. I am also aware that you dont always get it it on the first attempt, but come on, 5 ATTEMPTS?! I feel like anesthesia should have brought in after the first two residents made their couple of attempts. Wouldnt you want that for your child or loved one? As far as longterm.. who's to say? This only happened a few days ago. Much too short of time to realize longterm effects. Finally, if you see something on your unit that bothers you or that you dont agree with, you just turn your head because its not your patient so not your problem? Hope that I never have you as my nurse.

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As a NICU nurse, I will tell you that 5 attempts by a resident(s)to do an LP on a neonate is completely unacceptable. My guess is that the resident(s) didn't want to admit to their senior resident, fellow and/or attending that they were unsuccessful, so they just kept trying. Did they order pain medication? Did they give the infant a break between attempts? Did they monitor temperature, O2 saturation and glucose levels in the infant during these attempts? Did they contact their senior physicians to determine if there was a neonatologist or NNP available to supervise them or take over the procedure? Did they inquire as to whether it could be put off for another day?

I have worked in too many NICUs where the residents use poor judgement in attempting procedures on helpless infants. It is the duty of the nursing staff to advocate for the babies and their parents. I would be willing to bet that an infant subjected to that amount of pain and stress did indeed suffer some avoidable side-effects.

There was a recent article in a New York magazine where they had five prominent physicians (although their identities remained anonymous) who talked about the "dirty" side of medicine that no one likes to talk about. One of the subjects they talked about was the autonomy of the residents and how they aren't learning enough because they don't have independence to become doctors and to make mistakes and learn from them. Should they the residents have asked for help-- I honestly don't know, I wasn't there. If the situation was under control, then I think that it was within their realm to continue trying. It's a teaching hospital, and when patients go to a teaching hospital, they have to understand that they are going to be treated by residents and medical students who are learning. End of story. It is one of the dirty sides of medicine, but in the end, it is what makes them better physicians. Furthermore, the presence of residents and medical students drives the attendings to be better physicians as well-- it makes them more honest and forces them to think of diagnoses that they otherwise wouldn't have thought of.

The attending obviously thought that the residents were capable of doing the LP without killing the patient and apparently they were-- it took them a while to do it, granted, but they did it. It just does not seem that this is the type of situation where it is a nurse's place to try and get a resident in place for doing his job. If the patient was in imminent danger of suffering serious side effects, then yes, she should intervene. Otherwise, she should continue assisting and do her job-- nursing.

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Moe75_Rn specializes in Neuro, HIV/AIDS, Mother/Baby.

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No. No moitoring was done. The baby was given sugar water with the first attempt but nothing after that. The attempts were spread out over about 4 hours. The head nursery nurse mentioned to one of the residents that maybe the attending should be brought in but she said that there was no need to bring him in for something that would only take a few minutes to do. Like I said in my first post, I am new to this unit and still learning all the policys and procedures. When I say that this wasnt my patient directly, it was the nurses that I was working with that day.

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Moe75_Rn specializes in Neuro, HIV/AIDS, Mother/Baby.

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The attending obviously thought that the residents were capable of doing the LP without killing the patient and apparently they were-- it took them a while to do it, granted, but they did it. It just does not seem that this is the type of situation where it is a nurse's place to try and get a resident in place for doing his job. If the patient was in imminent danger of suffering serious side effects, then yes, she should intervene. Otherwise, she should continue assisting and do her job-- nursing.

Actually, they never did get it. Futhermore this has nothing to do with putting anyone in their place and everything to do with doing your job as a nurse and being an advocate for a patient that does not have the voice to speak for himself.

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