A wild preschooler with some sort of problem that I can't remember came in with her mom. I'm writing this at nearly 0400 since I can't sleep and, despite being an adept blogger who has four years experience making up fake diagnoses for her patients, I don't really feel like conjuring up much of a tale about this one.
The kid was not sick. That's all you need to know. Anyone can pick out the sick vs. not-sick ER kids in like four seconds, three of which consist of removing the child from under his or her blanket and taking off their hat, snowpants, scarf and mittens so you can actually see them. 90% of kids that go to the ER are of the 'not sick' variety in my humble estimation, maybe even more than that. When I get Alzheimer's, I think I'll just be repeating the "you can give your child Children's Tylenol and/or ibuprofen for fevers at home" speech over and over until I die. My clothes'll be on backwards and my Depends full of hemorrhoid-laced C-diff bowel movements, but I'll remember that speech until my last week or so til I slip into unconsciousness.
But I digress.
Of course, since the child is clearly not sick and could be discharged based on assessment alone and this is not acceptable to most parents, the doctor orders a blood draw and urine sample to check for...well....beats me. No fever, no medical history. Yawn. Back in the early days of the blog, I'd get more pissed over these types of things. Now it's just like, the blood draw ain't going away, best to just get it over with. Hell, I already checked the peds phlebotomy tray for tourniquets--of which there were none, of course-- and searched for 10 minutes for one for it because I knew an unnecessary blood draw was coming.
Drawing blood on a preschooler resembles a 2-on-1 adults-to-children wrestling match where the ultimate goal is a pin without movement of any extremity that would interfere with said needle draw. One adult holds both arms down. As fast as humanly possible after the pin is initiated and the ref runs into the room for the count, while maybe using an elbow to push on a kicking leg, I stab a small-gauge needle in and extract the minimal amount of blood necessary in the shortest period of time and conclude with, "Wow, all done. You did such a great job, sweetie!" no matter how insane the child behaved and quickly give him or her a [sucker, sticker, stuffed animal, popsicle]. If this were dog training, it would be like giving a treat to the dog right after she craps on your dinner plate, but you have to do it because then the kid calms down and can brag about how "big" he or she was for the blood draw.
No matter what "My Visit to the Hospital" books you have or if you demonstrate it on a stuffed animal or not, you can't explain blood draws to kids and make 'em say, "Sure, lady, go for it, sounds like a great thing, this whole needle-stabbing thing to check for signs of infection, electrolyte imbalance or some type of blood-cell abnormality despite my lack of concerning symptoms to make my mom feel better. I'll volunteer my arm for that any 'ol day! My best veins are in the antecubital site on the left arm, if you are interested, come to think of it." In fact, if a three-year old didn't throw a fit and accepted a blood draw without meltdown-level protest, I'd be worried enough to consider that the child really is sick.
So, anyway. Wild kid + Me + Mom + Arm-holder.
Kid predictably starts screaming bloody murder, the arm holder holds the arm sorta still for me while I kinda hit the mini kid-sized AC. The wild pigtailed monster moves a little bit and I readjust the needle to try to get good blood flow through the tiny needle. It's going at the rate of a traffic jam in the Himalayas, but it's going. I'm really not even paying much attention to the screaming or what mom's up to. I'm just dead-focused on the target and the task. It doesn't do me any good to do anything else but draw the blood.
Then out of nowhere: "TAKE THAT NEEDLE OUT OF MY KID RIGHT NOW! STOP THAT! TAKE THE NEEDLE OUT! YOU'RE HURTING HER!!!"
YEEPS! Mom just screamed in my ear!! I jumped a bit and then repositioned the needle back in the antecube. "Ma'am, she's three years old. She's scared. I need a little more----"
"TAKE THE NEEDLE OUT NOW!"
Yeah, I'll ignore the fact that literally screaming in a domestic-violence volume-level at the person drawing blood while a child is already screaming bloody murder is about 0% helpful. Moving on.
I take a 0.00000002 second glance at my tube and note that the 2nd tube had only minimal blood, not enough for the CBC. If I remove the needle now, I'll have to redraw her (shoot me) or give some sort of CSPAN-2 speech to the doctor about why the CBC isn't needed and how it should be removed from the 2011 Tax Bill or order list, or something, neither of which sounded appealing.
"Okay, ma'am, just let me grab a gauze and a piece of tape."
So I turn towards my IV tray, which was amazingly stocked with gauze, and took a couple extra seconds to grab one and then a second or two to grab a piece of tape then slow-mo'd my head back to the child's vein and removed the needle.
Whew! If it didn't hemolyze, it's just enough blood.
In my past days as a phlebotomist I've had on occasion a child where it took 6 people to get his blood. He promptly got up when I finished and started kicking his dad screaming how much he hated dad. I've also had a couple of kids who sat quietly with very large eyes never moving an inch while I drew their blood. Sisters that were like 2 and 4 I think. I too always do the crowing of how "great" they do even when they don't. However I was completely unable to manage that a couple of months ago when I had an 8 year old sit there screaming swear words at me and threatening very convincingly to kill me for the entire draw. I was simply speechless. Of course after him and his mom left my words to a co-worker were "that's a serial killer in the making."
ReplyDeleteoh my. i knew i was not a nurse for a reason. now i know what said reason is! yikes...
ReplyDeletehappy new year honey!
smiles, bee
xoxoxoxoxoxo
Well, with any luck, you cured the mother of the need to bring the little dearie in for every bit of bad behavior and sniffle she has. More likely, this will result in a notation of assault and battery in your "permanent record".
ReplyDeleteWait until they get their "Patient Satisfaction Survey"...
ReplyDeleteScary... I am waaayy old and my parents trained me and my siblings to cooperate with medical procedures by the "or else" method (you WILL sit still OR ELSE). But even my stern mother intervened when I was a sick kid (high fever + dehydration) and the hospital sent a very nervous student to the floor to start an IV. Mom had been a phlebotomist and I think it reached the point of her saying, "give me the damn needle or get someone up here who has actually DONE THIS BEFORE..."
ReplyDeleteGood grief, I've drawn blood on feral cats that were better behaved.
ReplyDeletebattynurse: that 8-year-old would have been me, except that at that age I didn't know any swear words yet.
ReplyDeleteTo this day, it takes about 35mg of diazepam PO to make me hold still for a blood draw. Any less, and either the phlebotomist or I am leaving on a stretcher. Or both.
I always hated sticking children and learned quickly that I could not rely on parents to hold. Most of the time, on out-patients, I would ask that the parents leave the room and I would have a couple of my co-workers to hold. In those days the parents would actually leave the room, because we were medical people and they really didn't want to watch anyway. I imagine today that parents insist on staying nearby so that they can monitor the procedure for possible law-suits...
ReplyDeleteAt least in my day, the kids were awed enough by the hospital and all the white lab coats and uniforms that they were initially cooperative -- until the needle pricked their skin. But we were prepared for the tussle and immune to their cries and screams. Parents did not interfere, but would yell at the kids, not us, and would not even think of telling us to stop.
The best-behaved kids were those with chronic diseases who had been through all of this many times and knew that they were whipped. They knew it was better to just get it over with. I felt so bad for them...
GRRR... Reminds me of my oldest drama-mama daughter. Trying to get her to stand still for a spine x-ray when she was 4 years old... She was scared to death for the procedure. Wouldn't stand still, Took a bit of sedation, lots of bribery and 3 DIFFERENT trips to the x-ray lab over a week period before they were finally able to get her to stand still long enough to get a good x-ray. Then it was "Oh, was that all?" Now she is a pro at x-rays, some 6 years later - She was diagnosed with juvenile scoliosis at a young age( is a patient at a Shriners Hospital)
ReplyDeleteShe is still pretty wimpy when it comes to getting flu shots/ immunizations...
The other daughter I have? Piece of cake. A dream for a patient. Doesn't flinch and is very cooperative.
I'm sad/happy to say that I was that screaming kid growing up, needing 5 people to pin me down (though thankfully without the crazy parents). How times have changed.
ReplyDeleteA coworker of mine who worked for years in pees taught me the best trick: have someone hold good pressure up against the olecranon process by the epicondyles. On kids, if you press there on an extended arm, it is nigh unto impossible for the kid to bend their arm.
ReplyDeleteYou still have to watch out for their teeth, though...
Ha! Thank you, iPad autocorrect for changing peds to pees...
ReplyDeleteFor crying out loud how moronic can some parents be? Keep your 3yo out of the ER if you're gonna freak on the poor nurse over a small blood draw! Get some sense mom!
ReplyDeleteI hope she didn't damage your ear drums and kudos for the clever thinking!!!!
I am probably one of the 2% of parents who actually will hold a child down well enough. I figure if you do it right the first time, you don't have to do it again.
ReplyDeleteMy oldest was the worst for blood draws. No matter what size needle or for what reason, I would hear her entire sad life story for the next 30 minutes after a needle. The worst was when she was 2 and since we had an older home, I asked the pediatrician to have her tested for lead. He ended up doing the draw himself, since they used a butterfly needle for kids that age and he was the expert at it in the practice. But I had to help hold her down..you would have thought we were murdering her.
One of my earliest memories is of a childhood (~4 years) blood draw. First time I had ever seen a black man; African or French accent. I remember the general tenor of the speech: "Young man, we are searching for Blue Blood. Do you know what that is? Would you help us to find if you have the Blue Blood?" Worked a treat in that case.
ReplyDeleteHow come hospitals don't use a numbing cream like http://www.drnumb.com/
ReplyDeleteI'm on the other end of the battle field, so I'll give you my perspective:
ReplyDeleteI took my 1.5 yr old into ER with a split lip. The pimple faced new grad doctor told us that the electric chair like thingie for strapping kids down during stitches was not available for another 3 hours...or I could choose to hold down my kid myself while he did the stitching.
By creating incentive for parents this young doctor:
1) got us out of there real quick
2) made us dads feel "more involved" with the upbringing of our kids.
Yes my kid hated me for 1 hour, but that was quickly undone when I treated him to his first taste of French fries.
wow. an er nurse that actually does their own pediatric blood draws?????!!!!!! WOW!!!!!!!!!!!!
ReplyDeleteCan you come work at my hospital please?????
Danielle, Who does the pediatric blood draws at your hospital? In my ER, all nurses do their own blood draws, unless you can convince a tech to do it, on all patients regardless of age!
ReplyDeleteAs a lab assistant at a hospital, there are a couple of things we've come up with that can help in a situation such as this. I've had my share of drawing from children. This should help those people who run into drawing kids.
ReplyDelete1) Have the child sit on the parent's lap, and have the parent cross their legs over their child. This will not only provide a sense of safety and security for both the child and parent, but will also help secure those nasty feet that tend to kick you.
2) Have your co-worker/other family member who is helping you (if applicable) secure the child's wrist and forearm, ensuring the arm is straight. Have them hold as low near the forearm as possible, close to the elbow, if both of you feel safe in doing so, as it will reduce the "wiggle" if they try to squirm. Make sure their fingers are clear of the site, and instruct them to keep the arm straight.
3) Anchor the heck out of the site you are drawing from (ie. the antecubital fossa), pulling down on the skin with your thumb as much as possible. Some of us are allowed/trained to use the more secure "two-finger anchor", so if you use that method, push that index finger up more. The "tighter" and more secure the ACF is, the straighter the vein and less painful the inevitable poke will be. The skin should be taut. Don't be shy. This step tends to be a big offender. It helps more than you think - I've had a surprising number of kids (and adults!) admit that it didn't hurt afterwards, which is always golden. Proper anchoring will 8 times out of 10 reduce pain noticeably. Save both the patient and yourself a bit of grief.
4) When you've struck gold, let them know! Tell them "it's in", which will help give a measure of relief to the parent. Depending on the child (you'll be able to tell), make a small show of it ("See?"), and sometimes the child might actually be astonished and curious, momentarily forgetting about this needle in their arm. The moment you mention it allows for the building anxiety and panic to dissolve (just remind your helper to keep the arm straight, lest they loosen or let go). Sometimes the parent gets involved automatically too, which helps both of them even more.
5) Since that CBC is collected last, and as such tends to be the hardest to collect as the child is squirming/screaming, the needle is shifting and all that wonderful stuff, use a transparent-topped lavender tube instead of a standard lavender tube. These short/weak draw tubes help as the vacuum isn't as strong as a standard tube and the capacity is less.
On an additional note, the lab only needs slightly less than a pinky's width in a standard tube to run a CBC (a bit more for a transparent-top, as they are visually deceptive and actually hold less than a standard tube), so long as it hasn't coagulated - you do not need to fill the tube even close so long as the blood isn't coagulated. You can also cheat a little more blood into a tube if you're using a butterfly needle (does not apply for IV lines) by withdrawing the needle _with_ the tube still in the holder, as the vacuum will draw that (sometimes crucial) last few needed drops to run the test from the flexible hose/tube.
Other words of wisdom I find have helped is to calmly yet succinctly explain (without being "graphic") of what you're about to do to the parent and to emphasize the importance of keeping him/her secure. We all know how the kid is going to react, but keeping the parent calm and informed helps translate both verbally/non-verbally even a small degree of comfort to the kid through the parent, which can help immensely for some. If at any time before collecting you even suspect difficulty with a vein, hot-pack it for 5-10 minutes. I know we all want it over and done with, and there isn't enough time sometimes, but if there is, take it. You'll save the kid, the parent, and yourself a lot of potential grief later if you didn't.
My daughter had to get a blood draw to find out why she had a fever for several days. Also an x-ray; the blood draw may have been superfluous, since the pneumonia was clearly visible on the chest x-ray and the symptoms were all consistent. But the pediatrician wanted to be sure. If anyone had suspected us of faking her sickness, doubts were dispelled during the blood draw; two nurses held her while the third did the draw, but she barely struggled at all. High WBC, of course, but no bacteria. They put her on amoxicillin and she was fine.
ReplyDeleteThen there's the story of my allergy test. Hoo, boy! I was a little pipsqueak of a kid, and it still took two nurses to hold me down while I struggled mightily as they made all of the scratches in my back for the antigens. But I'm glad they did it, so here's a once-pediatric patient, all growed up, here to thank whatever nurses were holding me down that day!