Whenever the “Ouch” pager clipped on my belt this week goes off, I’ve found myself standing quickly and informing others in the room, “I’ve got to go. There is a child in pain.” I’m not sure they can always tell the comment is meant to be tongue-in-cheek. Often it’s the hyperattentive parent, not the child, that makes me most uncomfortable. Of course I want to help these kids (many of whom are post-surgical or have sickle-cell vaso-occlusive crises), but wow, some of these parents need to tone it down.
For instance: venipunture. If there were a magical way to draw blood without using a needle, of course we would do it that way. Or if we could make do without labs, we wouldn’t drawn them. Naturally, no toddler is going to relish the thought of a vaccine or a needle-stick. But I feel that when we make such a big deal about it, it makes the experience for the child that much more traumatic. Surely there’s a cultural component. I wonder if the African children I saw in Cameroon would be so upset by the mosquito-bite sensation of a blood draw?
On the pediatric pain service, we aim to use multimodal therapy. For one child recovering from a Chiari malformation surgery, today’s plan was opiates, adjuvant medications, physical therapy, and a visit by the clowns.
Many children treated with opiates develop constipation, leading to the necessity of routine and often aggressive bowel regimens. One of my favorite quotations of the day was instructions to the nurses from my attending, regarding a constipated child. “Cotinue the stool softeners and go ahead and try another suppository. If that doesn’t work, then try an enema. Those are more intrusive.” “Intrusive” puts it mildly.
On a creepy note, one of my fellow residents, while reading a chapter in a basic textbook today, asked me, “Who said ‘Practicing anesthesia is practicing medicine of the autonomic nervous system.’?” My response, “I did. I coined that phrase in 1986 while giving a lecture in Chicago.” We both laughed, and then my colleague said, “The quotation has a 1 beside it.” I directed him to look at the endnote at the back of the chapter. Reference 1 was another book produced by publishers based in Chicago, copyrighted in 1986. What are the chances?
Another fellow resident related to me the story of his patient who caught on fire several months ago. The patient was crumping before his heart surgery, so the surgeons sloshed sterile prep on the patient, cracked the chest, and “crashed” onto cardiopulmonary bypass. It’s unclear how the fire started, but in the process of sawing through the sternum, perhaps a stray spark ignited the still-wet alcohol-based cleaning solution. The fire was quickly dowsed with saline, but the patient (already intubated and under general anesthesia) had a couple blisters on the neck and chest. Given the, uh, unusual circumstance in the operating room, an intra-operative dermatology consultation was requested.
The instructions were simple, as the burn was very mild. “Put some silvadine on the blisters….and oh yes, give some extra fluid.” We thought the last piece of advice, though generally appropriate, was cute . Here is a patient on cardiopulmonary bypass, during which we’re continuously draining the patient’s entire blood volume approximately once per minute and pumping the anticoagulated blood back in, carefully maintaining temperature, pressure, volume, anesthetic depth, and anticoagulation parameters. And we’re told to give a little extra fluid.
This is akin to getting a car’s engine replaced, and asking the mechanic to make sure there’s enough windshield wiper fluid.