Wednesday, 30 April 2008

A needle in giant haystacks

So, I've moved departments...again.

I'm now inhabiting the world of acute paediatrics. This is a world of snotty noses, red ears, high temperatures, and needle fear!!!

I hate needle fear. It's one of the big things you have to get used to when you start life as a paediatrician. In adults, taking blood is a routine procedure for most. Putting drips in means a bit of discomfort for the patient, but most cope with it fine.

With the kiddies, the opposite is the case. Some stoical characters just bite down and accept that you've gotta do what you've gotta do. But most of them, understandably, hate it. It's tough being a sick kid. I never had a drip, but I remember needing eyedrops as a nipper, and nearly tearing the house down in protest. So, I do feel their pain.

James was admitted from A+E this week. 8 years of age, with a bad tummy bug. Big strong 8 year old, so was only just barely requiring an admission to the ward. No real dramas. I thought he would be OK with some controlled oral rehydration, and an overnight stay. But my consultant wanted him on IV fluids. No worries.

James' mum is hyper-anxious. As a result, James is also extremely anxious generally. The thought of having a needle put in her son's arm made James' mum VERY anxious. This, in turn, made James VERY VERY anxious. This sets off a sequence of events that is replicated in paediatric departments the world over, and is intrinsic to the smooth running of the time-space continuum. It goes as follws:

I missed the cannula. Obviously. He jumped as soon as the needle touched his skin. The tiny nurse holding this giant's arm for me was no match for his startled reflexes, and the vein was destroyed. He screamed. This was a scream that only paediatricians and dogs can hear. It is a sound so high pitched that it has the potential to shatter stone. It is the sound that comes from all "treatment rooms" in paeds wards every day.

Mum started crying. Then she got angry. She started asking questions like "have you done this before?" and "are you going to get someone else to try?". There is always a look of shocked disbelief when you tell them you're going to try again. "AGAIN???" they shout? As if the need for intravenous fluids is dependent on your ability to get a cannula in first time. It is important to point out that this NEVER happens when the kid is tough, and accompanied by his even tougher granny. This only ever happens when you're putting a line into a "precious" child.

So, by now, both mother and child are in tears. They are both pissed with me. They both think I'm an idiot. I try again. Success. I remove the sharp bit of the cannula and throw it away. Just need to tape it into place now. James is still wriggling. The poor nurse is slowly losing this battle. I tell him the needle is out, and there's only a soft bit of plastic left in his arm. I tell him the worst is over, and he'll be back in his bed any minute. He doesn't believe me. Hell, his mum has seen me throw the needle away and she doesn't believe me. I am he-who-has-lost-our-trust, after all.

He's shaking. Convulsing. Trying desperately to get that drip out. Backup is summoned in the form of more large, stronger nurses. Too late. He's reached round and grabbed the drip and pulled it clean out.

The baby jesus cries at this point.

Mum looks at me, with red eyes of rage. I'm the culprit. It's true that i should have had more backup, but I never thought he was going to pull the cannula out while I was taping it into place.

So, at this point, all confidence in me is lost.

As always happens at this point, the consultant is strolling past. She's a friendly lady, so she pops her head in to see if everything is going OK. She sees the mess. The blood, the screaming child, the sobbing mother. The dimwit registrar.

So she offers to take over. I jumped at the chance to get away from a situation i've been in a few times before, but always fail to take control of, or to stop it getting out of control. So, the boss picks up the needle, and slides it effortlessly into a nice vein on James' arm.

Does he cry?? Does he hell. Does he try and pull it out?? Ditto. He smiles at her and says "That was much better than before".

So, all is well with the world. Another registrar has been made to look like a twat, without any damage to the patient. This is one of the main reasons that we are employed.

Interestingly, the procedure stressed James so much that he immediately demanded comfort food in the form of jelly and ice cream. Tolerated it beautifully.'ve guessed it. No need for IV fluids.

But at least the time space continuum was preserved for another day.


  1. Ahhh yes.... the bosses/superiors are always that much more.. well. superior! My patient with an acute abdo today had a 3/7 Hx of abdo pain when I asked and only 1/7 when the surgical registrar asked. So frustrating! (I missed the drip on her too... :P )

  2. Re "As if the need for intravenous fluids is dependent on your ability to get a cannula in first time."
    Gotta love the ability of Murphy's law in times like this.

  3. One of my elderly patients said to me when I was admitting him that he had nausea and that was the sole reason he came in. Denied chest pain, SOB, palpitations, dizziness, leg swelling-everything else. Repeatedly. I gave him some Omeprazole and antiemetics and he improved. The next day, in front of my consultant, he gave a history of CHEST PAIN-no nausea at all. I was gritting my teeth as the consultant looked at me and said slowly "there's been a little bit of confusion in the story here". Grrr. Fortunately, as he was elderly and diabetic I had done ECGs and cardiac enzymes to outrule an atypical presentation of an MI. Thank God. I hate when patients do the changing the story thing! Yours sounds more stressful though....:)

  4. Hi polly. it's always the same isn't it. Glad someone else has been missing cannulas this week ;)

    Dragonfly, I believe that "Murphy's law and how to alter it" should be a final year module in every medical school in the world.

    Ellie, we've all been there. From another angle, I once told a patient on a surgical ward we were doing some investigation for his tummy problems. he asked what illnesses we were testing for on the scope he was having. I mentioned several, including crohns. He seemed happy enough with this. On the ward roud next day, he asked the (very nasty) consultant "so why do I need to have a scop, if we already know I have crohns disease?". The boss looked perplexed....The man points at me and says "that guy there says I have it". Nice.

  5. I'm not a doctor, so hope you dont mind me butting in here. I do however, work in a busy dublin hospital and I see everyday how the registrars are undermined and made to look the fool, when sometimes, and marginally sometimes, they can make a better 'people person' than the consultant or the SPR. hell, I've even seen some interns live up to that. But I think the reality is that if your not the consultant, pppfff, your no good. when some can really be better.
    I love working in this health system. I have the dearest privilege of managing the waiting lists for this particular hospital, but I feel for the doctors. They are under so much pressure to remember everything.
    Maybe the OP should ahve asked James' mother to leave the room. difficult with an 8yo who wants his mammy?? Hell, I dont know. I'm not the doctor.

  6. EashtGalwayWoman12 May 2008 at 14:48

    I had a needle phobic son . All his draws were tough. Our routine was this. The phlebotomist used EMLA cream. He sat in my lap as they put in the needle. We had a placement procedure that involved me putting his legs between mine and me crossing my ankles - his legs are then immobilised. His arms are put in an x with me "hugging" them close to his tummy. Thus the arm is wide open to the needle but he is mostly immobilized. Then you chat to him in his ear reassuringly. He feels more hugged than straitjacketed. It worked very well. He is 8 now and is brave. Can sit in the chair and be a brave guy.
    Of course with a worry nut mother it mightn't work but with a steady parent it works just fine.
    My second son is a heart kid. He has tons of blood draws. He is much braver but does give lip ie "you're not even the boss of me!" to the phlebotomist. He's 3.

  7. Hi Sayek, i always give the parents the option of leaving the room. Many take it. it's always better all round, as it gives us one less streessed out person to worry about. But most insist on being in the room. I love it when the old tough grannies come into the room. They stay really calm, and it definitely rubs off on the kids.

    Eashgalwaywoman, it's funny you mentioning the blood taking position that you guys use. I think every paediatrician has their favourite manouvres for taking blood. but TAKING blood is fine. That's very easy. The problems is getting a drip in is usually much harder in a kid than just getting some blood. I hate drips wayyyy more than I hate just taking blood.

    Dr. Thunder