Too many attempts at a spinal tap?

Nurses Safety

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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.

Specializes in Maternal - Child Health.
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.

it is a nurse's job to advocate for her patients. that includes notifying a resident that s/he needs to contact an attending for assistance and guidance when a procedure is unsuccessful after the first or second try. or contacting the attending herself if the resident declines to do so. i'm glad to hear that the resident(s) didn't kill the patient. but that is a far cry from "doing no harm". do you realize that even healthy term infants are born with immature immune systems? (and this wasn't a healthy term infant, or it wouldn't have been getting a spinal tap.) do you know the risk of introducing an infection to a neonate by sticking a needle into its spine numerous times?

if you were a hospitalized patient who needed a spinal tap, would you allow a resident to try unsuccessfully 5 times without insisting that the resident call for help? i seriously doubt it. please don't subject a helpless infant to such treatment, or criticize a nurse who attempts to intervene on the baby's behalf.

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doctors and nurses are supposed to be guided by a set of ethics.

this would also include teaching hospitals.

a pt's well-being would certainly supercede any learning opportunities available to staff.

moe, your concerns are valid and merit further investigation.

who cares whose pt it was???

if we see someone else's pt being mistreated, we're supposed to look the other way, because it's not our pt???

good grief.

what's next?

leslie

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Did the residents use proper technique? Did they do anything that was illegal or grossly unethical? From what you have said, no. You have nothing to report. For all you know, it was just a difficult stick. This whole "advocating for my pt." is bullcrap, it's just another doctors vs. nursing turf war again. You're in a teaching hospital, for God's sake. Let the resident's learn and let the attendings teach. You get more than one or two tries on procedures and you're allowed to make mistakes. Get over yourself.

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Specializes in High Risk In Patient OB/GYN.
This whole "advocating for my pt." is bullcrap, it's just another doctors vs. nursing turf war again. You're in a teaching hospital, for God's sake. Let the resident's learn and let the attendings teach. You get more than one or two tries on procedures and you're allowed to make mistakes. Get over yourself.

Are you a nurse?

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I totally agree that someone should have called the attending. Having had a 2 week old in need of PICU treatment for a blood clot of her IVC, there was no way the nursing staff tried to stick my girl more than twice for anything, blood work, etc. If there was a problem the attending was called. She was at a a top-notch teaching hospital and I expected residents to try procedures. But not 5 or 6 times! I wasn't even a nursing student back then, but I totally trusted those nurses to advocate for my daughter when I couldn't be there with her.

There is definitely a line that should not be crossed whether you are a nurse or doctor. That child could not advocate for him/herself and the nurse is there to do that. It is not bullcrap as previously stated. Advocating for patients isn't about a turf war, it's absolutely about quality of patient care.

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Did the residents use proper technique? Did they do anything that was illegal or grossly unethical? From what you have said, no. You have nothing to report. For all you know, it was just a difficult stick. This whole "advocating for my pt." is bullcrap, it's just another doctors vs. nursing turf war again. You're in a teaching hospital, for God's sake. Let the resident's learn and let the attendings teach. You get more than one or two tries on procedures and you're allowed to make mistakes. Get over yourself.

Obviously, you are not a nurse....or you are a horrible nurse. Which is it?

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Google "silas2642"....he/she is a student doc. That explains everything!

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Specializes in High Risk In Patient OB/GYN.
Google "silas2642"....he/she is a student doc. That explains everything!
It does.
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Specializes in Peds Cardiology,Peds Neuro,Pedi ER,PICU, IV Jedi.

Okay, working in peds for 12+ years I have NEVER seen a resident attempt any more than twice without A- getting the needed CSF or B-calling the senior / fellow/attending. There's really no reason for it. If you don't get what you need (because you weren't successful with the LP) you're going to treat the patient for bacterial whatever anyway. It does help to better guide your treatment plan, but in the meantime what you're going to do anyway will be fine.

Five was wayyyy too many attempts by residents. It may not have been their fault completely...we all know that these patients have to be held in a specific way to allow the facets to separate, allowing for easier access to the cord. So perhaps someone wasn't holding right...who knows? But to answer your question...YES, 5 is too many. And the father in me would have walked right up to the doc and told him just that. "Don't do another thing until we talk to the attending."

vamedic4

tornado warning in effect:o

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Specializes in Peds Cardiology,Peds Neuro,Pedi ER,PICU, IV Jedi.
Did the residents use proper technique? Did they do anything that was illegal or grossly unethical? From what you have said, no. You have nothing to report. For all you know, it was just a difficult stick. This whole "advocating for my pt." is bullcrap, it's just another doctors vs. nursing turf war again. You're in a teaching hospital, for God's sake. Let the resident's learn and let the attendings teach. You get more than one or two tries on procedures and you're allowed to make mistakes. Get over yourself.

:trout:

The above is one of the quickest ways I've seen to get your ass chewed off by an attending physician. So YOU go up and tell the attending "well, Dr. So and So, we attempted the LP five times without success". He or she will probably have some nice words of wisdom to share with you, and probably not in the nicest tone.

Part of the "learning" that goes on in teaching hospitals is KNOWING when enough is enough. That comes with experience...and in the story the OP shared with us..it applies 100%.

vamedic4

no more tornado warning

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Specializes in Orthopaedic and eye.

I think it should be highlighted to your unit manager as we being the advocator of the patient should do something for the patient....can you imagine that the patient is our loved ones.....would you able to tolerate such an unexceptable practice.....or even speak to the resident who had done this to the patient....cheers sot75

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LONGGGGGGGGGG reply (you've been warned)

Several years ago I required a spinal tap.

At the time I was a nurse I was working at the hospital in to which I had been admitted, and it was a teaching hospital.

I was asked at the time if I minded if the House office (i.e.: most junior Doc on the pole) did my tap, under-supervision from the Senior House officer (2nd most junior).

In the spirit of teaching and knowing the Reg (senior doc, one step down from consultant) was stuck in A/E (ER). I agreed.

They attempted the tap six times over a 90-minute period.

Right the reason I bring this up is the differences

ME:

-I gave consent not only that

-I gave informed consent

-After the second attempt they said they were going to stop and get the Reg i.e. they acknowledged that they needed guidance.

-I was the one who insisted they continue (the results of the tap would determine care, and if it was -ve I was out of there)

-The nurse assisting expressed concern that I was consenting due to 'peer pressure' i.e.: was an advocate. When I explained my reasons she was still concerned but happy I knew what I was consenting to.

BIG POINT : I was aware compliant and helpful, it still bl**dy HURT like HELL.

BABY:

-Unable to consent

-Parents not informed, did not give consent. Although another poster did comment that it may have been discussed with the parents. But IMO if one of my family was having a tap I'd like to be around to hold a hand etc. But maybe they couldn't cope with it.

-Unable to express pain clearly due to age

-Unable to refuse due to age

-They did not acknowledge their failure, it may have been as simple as a bad position but until they asked for help ....................................

As for Silas's comments

-since you weren't responsible for the patient, I would say that you don't really have anything to report.So if I witnessed someone abusing a patient if it's not MY patient I shouldn't worry. Sorry it doesn't work that way.

-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. Two things here, first while I'm sure there are some nurses out there who take joy in putting residents in their place, they are few and far between, most of us are to busy doing our job.

As regards patient in danger of side effects: well if they weren't experienced in doing taps, would they know or recognize the side effects?

As I said this procedure HURTS..............................

And they are inflicting it on a one-day-old baby????????? And only giving sugar water. I was on opiates by the end of it and still in pain.

Secondly my job is not doctors assistant it is NURSE. And expressing concerns about a patient's treatment is a part of my job see below.

NMC Code of Professional Conduct ..(Nursing and Midwifery Council November 2004) states that as a Nurse I am ' personally accountable for ensuring that you promote and protect the interests and dignity of patients and clients, irrespective of gender, age, race, ability, sexuality, economic status, lifestyle, culture and religious or political beliefs.

It also states that 'You must act quickly to protect patients and clients from risk if you have good reason to believe that you or a colleague, from your own or another profession, may not be fit to practise for reasons of conduct, health or competence.

Five attempts indicates a certain lack of competence to me?

-This whole "advocating for my pt." is bullcrap, it's just another doctors vs. nursing turf war again. You're in a teaching hospital, for God's sake. Let the resident's learn and let the attendings teach. You get more than one or two tries on procedures and you're allowed to make mistakes. Get over yourself.I have been in Nursing for over 17 years now and have never seen this 'doctors vs. nursing turf war' I have seen Nurses who on occasion are a PIA towards Doctors and go out of their way to second guess them. In the same way I have seen Doctors assume that Nurses are there to run around after them and tidy up their messes.

In other words I have seen a small minority act unprofessionally, not exactly a turf war. The only people that I have come in contact with that believe there is a 'turf war' are the unprofessional ones.

Now maybe you feel that you have been unfairly treated or that the Residents in OP post are been unfairly maligned, but as a Nurse I really don't care the patient is my prime concern, not teaching, not 'turf wars' not someone's ego.

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