Thursday, June 11, 2009

Fly Like A Butterfly...

Last night a mother came in with her 9 year old who had just been stung by a bee.

He had had allergic reactions to stings 3 times in the past and was already showing some hives on his face, neck and arms. Very mild swelling to his eyelids was also starting to appear.

I was at triage and we were slammed but he was a priority so I whisked him into the department and poured some liquid diphenhydramine (benadryl) down his gullet before you could say "histamine response".

Mom was a nice, middle aged woman. We chatted about the risks of stings and the fact that she might want to look into an epi pen and liquid benadryl. Kid was sniffly and upset but not getting any worse. Mom told me last time he had a reaction it took 3 nurses to hold him down for the injection. I said he may not need one today depending on how the benadryl took effect (it seemed to be working).

Doc and med student saw him and he ordered an I.M injection of benadryl. I drew it up and went in the room to give it.

The child completely flipped out, running and hiding behind his mother, screaming, crying.

Mom just sits there with her hands folded in lap,

"oh Honey...the nurse is busy, let her give you the shot, remember we talked about where we will go eat after?"

Kid continues to freak out. I do not have time for this little episode...I walk away and tell mom to get him settled and I'll return with some more nurses. In the meantime I talk to the doc and see if we can give some oral ranitidine or maybe more oral benadryl...he is responding to the P.O meds so is an injection necessary? It is not going to be easy, I explain. But no, he says it will not absorb fast enough. Fine.

I come back with our male site leader and nursing student and ask them to hold with mom's help.

Mom continues to be useless at disciplining or calming child. The two other nurses are trying to hold him, I attempt to wrap him in a sheet which completely doesn't work.

Now kid is ballistic. Freaking out, screaming, kicking and punching as hard as he can. I am bent over trying to hold his hip still so I can give him the injection in the glute. In the process I get a kick to the abdomen (with shoes on, thanks) and punches/flailing arms to my upper body. My two colleagues are also getting kicked and punched by the child. Mom is the most impotent disciplinarian I have ever encountered. Her child is assaulting three health care professionals and all she's doing is saying, "oh, don't do that, stop it, come on....donnnn't...".

Finally I get the injection in after telling the kid to stop several times (and calling him a brat--I couldn't help myself). We walk out.

I was trying to mix some gentamycin up for a septecemia patient and my hands were shaking to the point I could hardly hold the vials. I have never been so furious at work in my life. Not only was I angry for being assaulted but I was also extremely upset that the mother didn't even apologise or discipline the child. Plus, the staff all just brushed the incident aside.

I was shocked at how upset I was actually. I was fighting tears over the whole thing and I couldn't figure out why I was so emotional after the event. When I had calmed down I returned to the room. Sat down and looked him in the eye. I apologised for calling him a brat. He evidently hadn't even heard me but accepted my apology anyway. He apologised for kicking and punching me. I offered, "friends?" and we shook on it.

I told him, sometimes at work people punch me, scratch me, kick me, even bite me.

"They BITE you???"


I went on to explain that we are nurses who are trying to do our jobs and it is very upsetting when the people we are trying to help are trying to hurt us. He said sorry again and said he wouldn't do it in the future. I walked out of the room, but have to admit, I couldn't bring myself to say what I wanted to the mother.

When I got home from my shift I took a long walk.

It was a beautiful night, just dark but still the warm air was hanging heavy. I was trying to unravel the nights events in my mind and look at my reaction to everything a little more objectively.

Why did only one co-worker ask me if I was alright?

Why did that mother not react to the way her child was acting?

Why is nursing the one job where being assaulted at work is an accepted job hazard?

I don't care that it was from a 9 year old. The whole event was unacceptable but I was unable to articulate it at the time. Or take the appropriate actions to deal with it. The "suck it up" mentality is very clear in nursing.

By the time I got home my lower back had completely seized up due to my poor body mechanics during the wrestling match avec needle. It's still very sore today despite my early morning hot yoga class in an attempt to work it out. I was in pain all day today at work but no, of course I didn't fill out any incident forms or make any complaints. Yeah, what am I going to say, "kicked and pulled by 9 year old, now suffering from lower back pain." Right.

To think about the monotonous regularity with which these events occur in the nursing profession makes me wince.

I just needed to vent a little.

Next time you see a nurse, give her hand a shake for all the sh*t we have to put up with. And then, when she sits down...give her a nice little shoulder rub (really get to those traps...).


Keet said...

I'm telling you, tranquilizer guns. It's the way of the future.

No really, tho', the doctor should have ordered some oral benzo's to calm the little shit down. 0.25 of ativan would have slowed him right down, and you could administer the IM into a nice relaxed buttock, instead of a soon to be big time needle bruised tense little bum.

My hindsight is 20/20 take on such things. We don't tranq enough people in the ER. It's not like johnny-nine-year-old-needle-phobe is going to get addicted.

Albinoblackbear said...

"We don't tranq enough people in the ER."

I think I am going to have a coffee mug made with that quote on it. And on the other side, a photo of you holding a pineapple with your eyes going in opposite directions. :D

Seriously, I agree completely.

Anonymous said...

Tough day at the office!
It doesn't matter if it's a 20 yr old bodybuilder, a 75 yr old grandma or a 9 yr old child, it's still an assault and it's bound to cause an emotional reaction. Perfectly normal!

It's a real shame you didn't get the support you needed from your colleagues though.

Take care.

Anonymous said...

I agree with the tranquilizer gun idea. And add a swift kick in the ass for the mother! That woman badly needs some intensive training on how to be a RESPONSIBLE parent.
I used to know a mother like that. Her lack of control (and lack of concern over what her little monster was doing) damn near got me shot with a .38 caliber hot load.

Bostonian in NY said...

Little kids can be freaking strong...I had a 4 year old that took 4 full sized adults to hold down for an ear exam and blood draws.

Nurses are awesome BTW...

Albinoblackbear said...

Medic--Thank you. Now I feel validated. You're absolutely right.

Anon--Indeed. I am glad that so far none of the poorly controlled children in the dept also had weapons. Yikes. I don't know what a .38 caliber can do but I am assuming it is not good if you're shot with one.

BINY--Yeah, I believe it.

And yes, nurses are awesome. ;)

Dragonfly said...

So sorry to hear that. I was the injecting person for a recent situation like that and it was SO difficult. The first thing was to make sure I didn't get stabbed, and that took a few tries.
It is amazing how strong kids can be in situations like that. (And how fragile in others). If the mother had helped (he was in the Emergency Department for a reason after all) or your colleagues had been more supportive it would have been better. Hope your back has sorted itself out.

Chris H said...

Maybe the law is different where you work. But in the state health system in which I work (in emergency care) this is clearly assault - by the RN on the child. Tacit agreement from the mother is no defence. The child clearly has a mild allergic reaction - just to be able to create that minute ventilation shows that they do not have compromised respiratory function due to bronchospasm. If I found one of my staff behaving in such a manner, and colleagues assisting her, they would all require a detailed discussion on the rights of the child, the actual legal implications of a prescription, and the obligations on the nurse to act professionally and wisely in either the administration or the declining to administer a medication. The situation would be entered on their personnel record. Considering the degree of distress that seems to have been caused (I hope some of it was poetic licence) I would take advice from the professional issues unit of our area health service on whether this needed to be referred to the state nurses board to consider disciplinary action.

Albinoblackbear said...

Dragonfly--Thank you, yes swimming, massage and time seems to have sorted things out in the neck and back department.

Chris-Interesting that you put no responsibility on the doctor who ordered the medication even after my discussion with him regarding the situation...(maybe you missed this part of the post, "In the meantime I talk to the doc and see if we can give some oral ranitidine or maybe more oral benadryl...he is responding to the P.O meds so is an injection necessary? It is not going to be easy, I explain. But no, he says it will not absorb fast enough.")

If giving a child a ventral gluteal I.M antihistamine injection against his will (as ordered by the physician who deemed it medically necessary for the treatment of an allergic reaction) is considered 'assault' by a nurse in Texas, then I can add one more item to my list of "Things That Make No Sense in US Health Care".

Rogue Medic said...

Chris H.,

Where do you draw the line at resisting the doctor's order?

If you speak with the physician and then get no change in the order from an IM to a PO dose, do you state that you will not administer an IM dose of medication for an allergic reaction, because IM injections are barbaric?

Do you only inject IM/IV/SQ for children who will sit calmly and not cry when stuck with a needle? That might limit you to injecting only children who are victims of abuse, who will sit passively through just about anything.

Do you let the noisiest, worst behaved patient determine what is acceptable behavior in the emergency department. This does seem to be your point.

Do you realize that a 9 year old does not have the capacity to make informed decisions?

Do you base all of your pediatric treatment decisions on the ability of the child to cry and fight back? If so, how do you justify giving injections for vaccines, or is that something that you feel should be left up to the opinion of a nine year old - someone at the Jenny McCarthy level?

I do not know why the doctor insisted on the IM injection. From the description it sounds as if it is a case that would have been adequately treated with PO medication. Maybe the doctor knows something I do not. The doctor's explanation may not have been the primary motivation. But the doctor is the one who gets to make these decisions. The nurse, or in my case, the paramedic, may voice objections. Outside of a danger to the patient, there is not the ability to refuse that order. The kid is crying is not a danger that seems to justify this. I agree that the child does appear healthy enough, but again, it isn't my decision unless there is a danger.

I do not believe that is different in Texas.

The main problem with this case is not the doctor and certainly not the nurse, but the parent. This is not acceptable behavior from a 9 year old, maybe from a 2 year old, but this child is long past 2.

Fortunately state laws are beginning to reflect the rate of assault and battery on EMS personnel. Laws are being passed making it a felony to assault EMTs. The states need to do the same for everyone in the hospital. Working in a hospital should not make you a punching bag/kicking bag or even a bite stick.

Chris H, do you work for Press Ganey?

Unknown said...

I believe that the responsibility for the actions you chose to undertake is yours, not the physician. The physician’s choice of medication may or may not have been correct, I was not there, so could be unequivocal in my comments on that matter. Your recommendation of an oral H2 antihistamines is interesting, but I am afraid not well supported in the literature “...There is no evidence to support the use of H2 antihistamines to speed the resolution of pruritus from non-compromising acute allergic reactions. There is some evidence to suggest that the combination of H1 and H2 antihistamines causes faster resolution of the rash and maybe angioedema...” Fogg TB. Semple D. Best BETs from the Manchester Royal Infirmary. Bet 2. Combination therapy with H2 and H1 antihistamines in acute, non-compromising allergic reactions. Emergency Medicine Journal. 25(3):165-6, 2008 Mar. There is only one study in which the use of an H2 antihistamines was show to improve outcome, and they were administered intravenously (Lin RY. et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Annals of Emergency Medicine. 36(5):462-8, 2000 Nov). I would suggest that what appears to be caution in presuming predictable gastrointestinal absorption of an orally prescribed course of treatment by the physician is warranted in a child with an allergic reaction.
I am pleased to say that I have little or no familiarity with US law regarding this matter, and none whatsoever of Texan law. If indeed health care professionals must defer to medical practitioners, even when assault is required to satisfy that prescription, then I am please that I have never even been inclined to holiday in the USA, let alone work in its health care system. I understand your desire to leave the USA health system as soon as possible, and wish you well.
And yes, where I work, refusal to assault a patient to fulfil a prescription is an option. It is something I have both chosen myself, and seen others choose in similar circumstances.

Rogue Medic said...

Chris H.,

Administering medication to a 9 year old child, even by force, is not assault.

If this were life threatening anaphylaxis, would you refuse to treat an uncooperative child?

Chris said...

See, I don't get that. I'm not in the medical field at all, but I have a 6 year old daughter. She's OK with shots, but not with the throat culture swab (and she gets strep a lot). I figure it's MY job to hold her down, not the medical staff. I pin her down, using my arms and legs, and then yell to the nurse, "GO!" and she jumps in with the swab......oh, and this is at the doc's office, of course. We don't go to the ER for a sore throat - like so many do.....

The Mommy Doc said...

Hi Chris. As a pediatrician, we get a lot of screaming infants and children who need shots (vaccines, antibiotics, IVs, etc). Many times, the mother cannot or willnot restrain her child. In these scenarios, with her permission, we hold the child just enough to keep them from hurting us or themselves further in order to administer the shot. I DO think this is necessary for their safety and health. Especially in the case of the antibiotics or the IVs. Often times, the choice of the child (to avoid the short-term pain vs. the ability to see the potential long-term complications if proposed treatment is refused) cannot be part of the decision-making process. You are lucky to have a 6yo who is able to handle shots so maturely, but many, many children her age and older do not accept the rationale for the shot.
Of note, I practice in the US

Albinoblackbear said...

Chris H--Perhaps in NSW they let 9 year olds determine/direct their own health care. Where I work the age of consent is 12, anyone under that age does not have the legal right to refuse or consent to treatment. Thus, if the parent agrees then it is considered consent.

I would never give a medication against the will of an individual with faculties capable of understanding and refusing it. His was a complete overreaction to a basic medical intervention not meant to harm.

Thus we'll have to agree to disagree that I 'assaulted' the child. Or disagree to disagree.

P.S H1 and H2 blockers used in conjunction for allergic reactions is supported in the literature to have greater efficacy than the use of H1 blockers alone.

Rogue--All I can say is, "yes, yes, and yes". And a few more after that...

Chris--First of all, thank you for not taking your child to the ED every time she has a sore throat! :)

I think it is great that you are able to take responsibility for ensuring the 'cooperation' of your child with medical procedures. That being said...I never have a problem with parents who don't want to be in the room when we are inserting I.V's etc. Understandably it can be really difficult for some parents to watch, though often the children are more calm when mom or dad is in the room.

One of my absolute favorite moments with parents in the ED was the first year I was nursing, a 5 year old who we were working up for septicemia. She was really scared about getting the I.V but her mom and dad took up posts at the head of the bed and started singing her Czechoslovakian lullabies while stroking her hair and free arm. The little one started singing along and didn't even flinch with the I.V. It was quite a beautiful thing to witness actually.

The Mommy Doc--I agree, and feel that the crux of the matter lies in the fact that up to a certain age children are not capable of grasping the concepts with regard to their own health and well being.
Especially for something like a vaccine.

Though I have to say there are many adults that fall into that category as well, and the paternalistic approach with medicine is something I try to be sensitive to...

Incidentally, for the thousands of adult injections I've been ordered to give, I can hardly think of any time that a patient has refused...except patients who were committed under mental health acts with court orders for medication administration.