Tuesday, March 28, 2006

You Got To Know When To Hold 'Em.....

Holy cow!

I never saw this in Microbiology!

Just a bunch of stressed out student nurses trying to cram in it into one summer session going five days a week for five hours a day.

Mr. Graham Positive here was nowhere in sight.

Then again, I took Micro so long ago that if he was in my class he'd be wearing Angel Flight pants, a silk shirt open to the lower sternum showing (hopefully) chest hair and gold chains, as he walked to his desk in platform shoes and feathered hair a la Barry Gibb.

I think I need a cold shower.

hhhhhhhhhhhhhhhhhh


Ah, it isn't often that I feel a "rant" coming on but there is something that I feel very strongly about.

Maybe it makes me a heartless nurse.

Perhaps it makes me a bad mother.

The issue?

I cannot stand it when conscious sedation is ordered for children who have a laceration.

I am old-school. I believe in wrapping them like a mummy, placing them in a papoose and holding them during the suturing. It's faster, the pain stops after the lidocaine injections and the child is then up and ready to go immediately.

For the uninitiated, "conscious sedation" is a term used when a patient needs an especially painful procedure done. An IV is placed and they are given medications that (1) reduce the pain (2) sedate the patient and (3) cause amnesia so the patient doesn't remember what the procedure was like when they wake up.

During the procedure the patient is placed on a cardiac monitor, oxygen, a respiratory therapist is present in case there are airway problems, reversal agents are kept at the bedside in case of emergency, and the patient has the IV as previously mentioned.

It is a wonderful way to get patients of any age through procedures like reducing shoulder dislocations or fractures or hip prosthesis dislocations.

It also ties up one nurse with one patient for however long it takes that patient to recover. The patient is never left alone. The drugs are short acting, but recovery can take as long as one hour for some patients, depending on how much medication they were given and how fast they metabolize it. Vital signs are taken every five minutes during the procedure and then every 10-15 minutes after until the patient is awake, able to tolerate clear fluids, have vital signs near pre-procedure levels and can ambulate.

Is this really necessary for a child with a one-half inch laceration on his forehead?

Ah, I hear the chorus now....

From the parents: "But it is so traumatic on my poor child to hold them down!"

They'll get over it. I not only remember getting stitched at the age of three I still have the scar!

It does not "scar"you psychologically for life. Getting stitches is a part of life. Are we raising a generation of wimps for whom a boo-boo is a life altering trauma?

From the ER docs: "It's hard to hit a moving target!"

Then your nurse doesn't know how to hold. I developed the (not-patented) chest hold many, many years ago where the child couldn't move his head if he tried. Let's just say that it involved removal of my scrub jacket and namebadge, leaning over the gurney, placing my chest on one side of the head and using my arm to surround the top of the child's head and holding it against my chest.

Works every time.

ddd

Just a couple of my personal beliefs.
  • Every person getting conscious sedation, including kids, gets an IV whether or not the doc believes it is warranted. Emergency situations are rare, but that patient is my responsibility, too, and my derriere is on the line if we aren't prepared for them.
  • If conscious sedation is ordered, I feel it is the doctor's responsibility to explain to the parents exactly what that entails, including oxygen, monitoring, IV medications, etc. Just telling the parents that the patient will sleep through the procedure is not enough. They shouldn't have to hear that from the nurse who is having them sign that they have received informed consent.
End of rant.

Now, to end on a positive note:

Emergency room physicians are second only to plastic surgeons when it comes to stitching lacerations on patients of any age. I've seen some beautiful repair work by ER doctors in my time.

24 Comments:

At 3/29/2006 04:32:00 AM, Blogger John Cowart said...

I'm not a medical professional but i know the difference between major surgery and minor surgery.

Minor surgery is anythng they do to somebody else; major surgery is anything they do to me.

PS; I always love your postings.

 
At 3/29/2006 05:24:00 AM, Blogger Flea said...

No argument about conscious sedation, here.

As for the guy at the scope: man, I wouldn't get near a microscope with my socks off!

best,

Flea

 
At 3/29/2006 07:53:00 AM, Anonymous waynetta said...

Has the gentleman at the microscope lost his Howie coat?
Is it in the wash?
I think we should be told...

 
At 3/29/2006 08:28:00 AM, Blogger Tara's World said...

its not my eyes, that guy was nekkid right? Heck of a body though, however he should be worried about germs ummm all over his ...stuff.

 
At 3/29/2006 10:19:00 AM, Blogger Jeffrey said...

I had my head stitched up when I was about 5, and I remember very little, and have no idea if I was sedated (in 1975-6?). I do know, however, that a female nurse pushing my head into her chest would have been highly effective on a number of levels. ;)

How often is conscious sedation used for minor procedures, for kids? Is it pervasive in your hospital, in California, nationwide? What's the reason for it? Fear? Laziness? Have younger doctors been taught to do things that way?

And is that really Flea up there? If it is, where are you wearing your socks these days? Because I flashed back to the 80s for a minute, and the image was probably entirely inappropriate ...

 
At 3/29/2006 11:21:00 AM, Anonymous geena said...

"Mr. Graham Positive here was nowhere in sight." --

BAAAAAHAHAHAHAAHAHAHAHA :)

 
At 3/29/2006 12:54:00 PM, Blogger Kim said...

Thanks John! : )

Jeffrey, it is not something that is pervasive in my hospital - in fact it is quite rare, and I can't speak for the state of CA, but when I worked at a teaching hospital many years ago it was done on EVERY child with a laceration.

I believe it was because it WAS a teaching institution.

Personally I think it is easier on the doctor, which should not totally be discounted when making the decision. Some lacs are difficult and if you want a really good result, you need time and a patient who is still.

Those cases are pretty obvious and often punted to plastic surgeons who will come into the ER (and I've never had one ask for CS).

I've had to stand up in the past when CS was ordered because of a crazy, full department on a holiday with only two nurses on and it was a small lac.

Plus, there are some differences of opinion amongst ED docs on exactly what drugs should be used. Some feel "X" is safe while others have had bad experiences with "Y".

I'm a big fan of CS when appropriate, I've seen it work wonders.

When necessary.

 
At 3/29/2006 02:15:00 PM, Blogger Third Degree Nurse said...

No opinion on the conscious sedation except that I'd rather not give my kid drugs if she didn't need them.

My opinion on the picture? Damn. Why wasn't I in HIS micro class?

 
At 3/29/2006 02:16:00 PM, Anonymous sean said...

I only spent a small amount of time in the Peds Emerge....but I learned SO many different holds. It was definitely necessary knowledge!

 
At 3/29/2006 03:45:00 PM, Anonymous d said...

I sometimes think that when it comes time for me to be a mother, people will think I am a bad one because I have an "old-fashioned" point of view like yours. If that's the case, so be it. I think it's ridiculous to think that every child needs to have conscious sedation for lengthy procedures (I work in medical imaging). I even have one set of parents who come in and insist their daughter gets general anethesia because they can tell them to put the girl to sleep with the gas before they put the IV in. It terrifies me (and the nurse and anesthesiologist) that something will go wrong before they have IV access, but what terrifies me more is that the parents will not bring their child in for these very-much-needed exams because we won't do as they say.

 
At 3/29/2006 04:38:00 PM, Anonymous Difficult Patient said...

Wow--I agree with you Kim. When little Joe was 18 months, the tip of his finger was severed in a door (still makes me cringe)--the hand surgeon had him in a papoose like you said, and I rubbed his head during the procedure . . .he was fine. Later, his sister hit him in the head and he needed would have needed about three stitches. Instead, the doc used dermabond and he was fine.

 
At 3/29/2006 05:31:00 PM, Anonymous Anonymous said...

Great post!

I absolutely concur. Several weeks ago we had a family present, demanding their child be sedated for some routine blood work ordered by their GP (healthy child, just did not want to "traumatize"). Errr.

The nurse definitely provides a key role in education!

KJ (ER nurse)

 
At 3/29/2006 06:27:00 PM, Blogger red fish said...

I work in a clinical microbiology laboratory, and none of my coworkers look anything like Mr.Graham Positive. Thank goodness. It might be too distracting.

When my oldest was 2, she got a laceration above her lip up to her nose. They called a plastic surgeon and gave her CS. I never thought to question it. I assumed it was the standard of care. I did get a little concerned when her O2 sat started dropping and everyone got a little excited, but it only took about 20 seconds for them to stabilize her. Thank God there weren't any more serious complications. I'm curious, is it possible to immobilize a 2-year-old enough to stitch up their lip?

 
At 3/29/2006 06:34:00 PM, Blogger Kim said...

There are definitely exceptions, and this one sounds legit considering (1) the age (2) the fact that plastics was called in and (3) the nature of the wound.

Lips are tricky, as are eyes. Cheeks and foreheads are the easiest, or chins.

Lips are different - you definitely want a repair that is cosmetically pleasing, and no, I can't imagine being able to immobilize a two-year-old with a lip cut by just holding them!

There would be no way to immobilize their lips while they were sutured!

CS definitely has its place and this would have been one of them, IMO.

 
At 3/29/2006 08:52:00 PM, Blogger Mama Mia said...

I agree for the most part - there are definitely a time and a place for conscious sedation for laceration repair - lips in particular are one of those. However a conscious sedation is definitely overkill for a lac that needs only two or three stitches. For these a topical anesthetic like LET (Lidocaine, Epinephrine and Tetracaine) and a papoose hold works just fine.

For the child (or parents) who is/are really frightened or the slightly more complex lacs, a dose of oral midazolam also really helps because it calms the child a bit and helps the parents once we tell them that while the child may be unhappy being held, he/she will not remember a thing.

 
At 3/30/2006 04:57:00 AM, Blogger TC said...

Kim, I agree with you. Anesthesia always comes with some risk and I think people overlook the fact that CS is anesthesia. and tell your docs an IV is not optional. You have to be able to give a reversal agent and/or fluid bolus NOW if necessary. Some ER's I've worked in would only do CS on a kid w/an anesthesiologist present. And for a head lac?

 
At 3/30/2006 10:36:00 AM, Blogger TBTAM said...

Great post! Agree completely. I also have a view of scars that I strongly believe and have passed on to my kids - Every scar is a story. Most wounds don't require a plastic surgeon.

 
At 3/30/2006 11:32:00 AM, Blogger Student Nurse Jack said...

I had my 18-m-o on an ER table in a city away from home - he took a header straight into a park bench's metal arms. It was so hard to see him in pain, but he calmed down quickly. They papoosed him, and he went to sleep, by gum - I assumed it was his body's way of handing the trauma. The lidocaine injection must not have hurt that much. Yes, he has a scar, but it's a battle wound the chicks will someday trace and say "Oh, sweetie. What happened here?" as they gaze into his big brown eyes. He'll love that scar even more then.

CS was never even presented as an option to me (this was in 2002). Is this standard of care now? Asking the patients or their parents which they prefer? And as a nurse, is it hard for you to present these options equally to your patients?

 
At 3/30/2006 11:57:00 AM, Blogger Kim said...

Hi SN Jack, CS is not the standard for all lacerations (although there are "standards of care" that must be met if you do it).

Parents are given the option, always. But if the option is presented as "the child will sleep through it" and no other info is given (ie risks and benefits), then that really ticks me off, especially when they wind up hearing it from me instead!

I tell the doctor to go back in and explain what CS is before I have them sign.

I'm not the one who presents the options because the doc has to evaluate the laceration prior to suturing. So when parents are given all the information I have no problem supporting either decision.

Unless it is for a forehead or chin laceration and then I take it up with the doctor outside the patient's hearing.

But informed consent means that the parents know the child will be monitored, that the medications can cause respiratory depression, even if rarely, that we have reversal agents available if there is any unforseen problem.

In fact, one medication used for CS can cause, in up to 10% of the cases, an "emergence reaction" where the child hallucinates for something like ten minutes. It isn't dangerous, in fact I guess you could say the kid is "tripping", to use an old '60s phrase.
The folks need to know this is a possibility. That is what informed consent is!

So, to sum up, when the parents are given ALL the information and the doctor feels as though it is the best way for him/her to get the best result
AND they are willing to tie up a nurse for an hour to do it because it is that important, then I have no problems.

But tell me it's going to happen for a simple lac to the forehead, chin or extremity and them's fightin' words!

Oh, pardon me...what I meant to say was that I would express my opinion to my physician colleague in a professional manner. : )

 
At 3/30/2006 12:39:00 PM, Blogger Judy said...

I had a head lac sutured when I was 3. I was so "traumatized" that I still remember it.

My parents had the smarts to take me TO MY PEDIATRICIAN instead of to the ER, since it happened during office hours. I thought he was God at the time and I sat perfectly still, no need for any fancy holds. No need for sedation. He told me about his kid (my age) while he put in the 2 or 3 sutures.

What I learned from that is to call my pediatrician FIRST if my kids get hurt during office hours. It saves a lot of trouble.

 
At 3/30/2006 05:22:00 PM, Blogger kimberly said...

That first photo is hysterical! Where DO you find these! LOL! I look forward to these on a regular basis! Since I read your blog often, I am "tagging" you for a fun list which we here in blog land are currently playing..."4 Favorites." You can see the list for which you are assigned to post on my page, http://rnforyourlife.blogspot.com.

All the best, Kimberly

 
At 3/30/2006 05:44:00 PM, Blogger Dream Mom said...

I had my eye stitched up by an ER doc a few years back and she did an excellent job; it left a very, very small scar that is covered up with makeup. It was kind of tricky because of the way it was cut but she was fabulous. You are right, I was on my way in no time.

 
At 3/31/2006 07:21:00 PM, Blogger filmwidow said...

I got stitches in my chin, compliments of a McDonald's cup when I was 3. My only memory of it was the dr asked me to quit talking, to which I replied, 'Quit asking me questions then.' I think they were asking me questions to keep me calm, but I don't really remember being phased by the incident.

 
At 4/01/2006 04:41:00 AM, Blogger Ron said...

If I ever show up at your hospital, please use your "non patented" chest hold! (not that i have anything against being drugged up, but it sounds like it could be fun!

 

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