ITS A BUSY WEDNESDAY evening
in the emergency department at St. Louis Childrens Hospital. The
attending physician has juggled it all on this shifta 10-year-old
gunshot victim, arm and face traumas, and a vomiting, pregnant teenager.
And yet, as the night unfolds,
the pace quickens.
The flashing light that signals patients arriving by ambulance
swirls at a steady beat. In the midst of the traumasand the distress
and anxiety that accompany pediatric emergencies for patients and their
parents Janet D. Luhmann, MD, assistant professor of pediatrics,
is struck by her next patients calm composure.
Michael Williams stoically sits with his arm in splint,
handcrafted by his dad out of Home Depot paint stirrers and duct tape.
The 9-year-old explains that he broke his fall with his wrist while playing
soccer: I screamed really loud because my arm was shaking with pain.
Judging by the swan neck-like shape of his forearm, Luhmann
suspects both of its bones are broken.
We might have to twist and move your arm around during
X-rays, so were going to give you some pain medicine thatll
make you better, but you may feel a little silly, she tells her
young patient. Michael is given oxycodone to make the X-ray manipulations
more comfortable, a preemptive pain treatment that isnt standard
in most emergency departments.
Luhmann was rightboth Michaels radius and ulna
are broken. She explains that the fracture needs to be set or reducedone
of the most painful pediatric emergencies.
To make realignment as painless as possible, Luhmanns
team intravenously sedates Michael with ketamine, a potent sedative and
analgesic. Thirty minutes later, after a dramatic reduction, Michael awakens
and asks the staff who wants to sign his cast first. I had the best
dream, he says. A robot put on my cast. It was cool, and it
didnt hurt.
The fish bone must come outKennedy and resident
Mark Frisch, MD, monitor Columbus McKinney as he inhales nitrous oxide
at St. Louis Childrens Hospital before treatment.
Pain management
Imagineeven as an adulthaving a broken arm set
without pain medicine. National studies of more than 250 U.S. emergency
departments (EDs) reveal that 75 percent of adults receive anesthesia
for fracture reductions like Michaels, while less than 40 percent
of children receive pain medicine for the same procedure.
I cant understand how hospitals can ethically
justify withholding analgesia when a patient is clearly in pain,
says Robert M. Kennedy, MD, associate professor of pediatrics. There
is a lot of confusion about the difference between pain and distress.
People expect kids to cry and often choose to interpret crying as a sign
of anxiety and not pain. But if its an injury that would logically
be painful, we should assume theres pain.
Recent studies by Luhmann and Kennedy that have appeared
in the journals Academic Emergency Medicine, Annals of Emergency Medicine,
Pediatric Clinics of North America, Pediatric Emergency Care and Pediatrics
report on methods they have developed to safely and effectively sedate
pediatric patients during the most painful emergencies: fracture reductions,
significant burns and abscess incision and drainage.
Far too many emergency rooms still opt to restrain children
and treat them with no sedation, says Kennedy.
We cant just tune it out as normal and accept
that kids are going to cry, says Luhmann. By implementing
the most creative and technologically advanced ways to address the issues
children have with pain and anxiety, we can change the current culture
by showing the field theres a better way.
The teams most profound advances have been with the
sedation methods of potent medications such as ketamine and nitrous oxide,
which effectively reduce pain and stress with little cardio-respiratory
depressionthe biggest danger of sedationor other lingering
adverse effects.
David M. Jaffe, MD, the Dana Brown/St. Louis Childrens
Hospital Professor of Pediatrics and head of the pediatric emergency department,
explains that one of the advances that places the School of Medicine at
the forefront of the field is the use of nitrous oxide.
Earlier studies of the drug done at other universities revealed
that when pediatric patients used adult-oriented nitrous oxide machines,
the outcomes were disappointing.
But Luhmann and Kennedy, with the help of John D. McAllister,
MD, associate professor of pediatrics and of anesthesiology, developed
a delivery method designed especially for kids. Now, nitrous oxide dispensers
sit alongside the oxygen machines in seven of the EDs treatment
rooms.
What makes nitrous oxide, or laughing gas, so attractive
is that it offers very effective pain and stress reduction. And, once
the mask is removed, the patient returns to normal within a few minutes.
The researchers have found that nitrous oxide is highly
effective in a number of clinical procedures, such as suturing, IV insertion,
pelvic exams and foreign body removal, which often cause more anxiety
than pain. And kids love the fact that there are no needles.
Just ask 11-year-old Columbus McKinney. After eating a fish
sandwich, he started choking. A gristly bone was lodged deep in his throat.
Initial attempts to remove the bone caused considerable gagging; nitrous
oxide sedation makes the procedure more comfortable.
The nurse offers Columbus an array of flavored balms (cotton
candy, bubble gum, key lime) to rub inside the mask. Youre
going to feel like youre flying, Kennedy explains. And
well know when its working because youll start laughing.
Minutes later, Columbus, with smiling eyes, giggles between
breaths. His previously stressed mom is now laughing at her sons
response to the nitrous oxide.
I had really good dreams, he says as Kennedy
puts the two-inch bone in a jar for a souvenir. Can I take some
home with me?
Big pain, small patients
Its nearing midnight on Sunday when 6-year-old Mallory
VanDorn arrives in the emergency department with a broken arm after falling
off a swing at her home in Rosebud IL.
Before sedating her with ketamine and midazolam, the preferred
method of sedation for painful procedures, the nurse uses the popular
Ouchless IV Technique developed by Kennedy (see sidebar).
Mallorys parents cringe as the orthopaedic physicians
realign their daughters arm. Luhmann strokes Mallorys tawny
blonde hair, telling her to think about her favorite cartoon. Please
dont do that, Mallory whispers during the most painful part
of the treatment.
Thanks to the analgesic and amnestic effects of ketamine
and midazolam, Mallory doesnt even remember the procedure just two
hours later. As she sucks on a cherry Popsicle, she thanks the nurses
and doctors.
Everyone is really nice, and I just felt a little
dot touching me, Mallory says, excited to color her new cast pink.
Every hospital should do this, mom Donna VanDorn
adds. I cant believe shes sitting here smiling, worried
about missing school and softball practice.
Although ketamine may cause adverse affects in adults, such
as psychosis, paranoia and hallucinations, children appear to be relatively
resistant to these effects.
The researchers studies reveal that only 6 percent
of pediatric patients experience the adverse side effects of ketamine
when they wake up. The team is now investigating ways to further reduce
the drugs aftereffects using other medications.
Kennedy, a strong proponent of treating childrens
pain, believes all emergency departments should follow suit. In
the past, we havent had alternatives to help kids through painful
procedures, but now we have the means to reduce pain, he says.
Lack of proper training on safe and effective sedation methods,
insufficient time and a shortage of resources are largely responsible
for the undertreatment of painful pediatric emergencies.
Fear of addiction and a misconception that young children
dont remember painful episodes also pose barriers. Jaffe, who has
published many studies on pediatric emergency medicine over the past two
decades, reports that even short duration of painful experiences in infancy
or childhood may significantly affect a childs subsequent behavior.
One study found that infants with diabetic mothers, pricked
nine times at birth, had much more agitated responses during routine blood
draws than infants who had not been repeatedly pricked. A similar study
found that compared to infants who had received pain medication for circumcision,
those who underwent the procedure without being sedated had higher rates
of agitation when receiving immunization shots three to six months later.
Weve come a long way since I first started working
at the School of Medicine two decades ago, Jaffe says. Back
then, I knew how busy it was when I walked into my shift by the decibel
level of screaming children in the background.
In many ways, people still think of the ED as the
old characterization of the pit, a noisy place where things
are out of control and patients are miserable. Its very exciting
for us to take the national lead for some of the advances in the management
of procedural pain for children.
Now, even when all 28 rooms of the emergency department
are occupied, theres still a quiet sense of order in the midst of
the turmoil and trauma.
Most importantly, theres a lot less cryingbecause
theres a lot less pain.
Not Even A Pinprick:
The Ouchless IV
Nobodyespecially a childlikes to get
pricked by a needle. The 10,000 pediatric patients who receive intravenous
injections (IVs) in the emergency department at St. Louis Childrens
Hospital each year are lucky to experience the popular Ouchless
IV Technique developed by Robert M. Kennedy, MD.
The procedure entails applying a numbing gel to
the IV injection site. About 20 minutes later, a tiny needle of
buffered lidocaine, which is barely felt, further numbs the area.
When the site is completely numb, the much larger IV needle is inserted.
Were trying to export this technique
throughout the entire medical center, says Kennedy, whos
led several studies in which third-year medical students experimented
by starting IVs on one another. The results: The ouchless technique
rated a 1.7 out of 10 on a pain scale; the standard IV start scored
much higher: 6.1.
Ive started ouchless IVs on sleeping
infants without waking them, he says. Thats how
painless it can be.
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