Ouchless E.D.

Better drugs and greater awareness reduce pain and distress in pediatric emergencies.


Michael Williams’ pride in his dad’s homemade splint belied the severity of his fracture. An “ouchless IV” sedated Michael while doctors reset his arm—an otherwise painful procedure.



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.


“In the past, we haven’t had alternatives to help kids through painful procedures, but now we have the means to reduce pain.”





IT’S A BUSY WEDNESDAY evening in the emergency department at St. Louis Children’s Hospital. The attending physician has juggled it all on this shift—a 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 traumas—and 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 patient’s 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 we’re going to give you some pain medicine that’ll 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 isn’t standard in most emergency departments.

Luhmann was right—both Michael’s radius and ulna are broken. She explains that the fracture needs to be set or “reduced”—one of the most painful pediatric emergencies.

To make realignment as painless as possible, Luhmann’s 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 didn’t hurt.”

The fish bone must come out—Kennedy and resident Mark Frisch, MD, monitor Columbus McKinney as he inhales nitrous oxide at St. Louis Children’s Hospital before treatment.

Pain management

Imagine—even as an adult—having 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 Michael’s, while less than 40 percent of children receive pain medicine for the same procedure.

“I can’t 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 it’s an injury that would logically be painful, we should assume there’s 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 can’t 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 there’s a better way.”

The team’s 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 depression—the biggest danger of sedation—or other lingering adverse effects.

David M. Jaffe, MD, the Dana Brown/St. Louis Children’s 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 ED’s 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. “You’re going to feel like you’re flying,” Kennedy explains. “And we’ll know when it’s working because you’ll start laughing.”

Minutes later, Columbus, with smiling eyes, giggles between breaths. His previously stressed mom is now laughing at her son’s 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

It’s 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).

Mallory’s parents cringe as the orthopaedic physicians realign their daughter’s arm. Luhmann strokes Mallory’s tawny blonde hair, telling her to think about her favorite cartoon. “Please don’t do that,” Mallory whispers during the most painful part of the treatment.

Thanks to the analgesic and amnestic effects of ketamine and midazolam, Mallory doesn’t 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 can’t believe she’s 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 drug’s aftereffects using other medications.

Kennedy, a strong proponent of treating children’s pain, believes all emergency departments should follow suit. “In the past, we haven’t 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 don’t 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 child’s 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.

“We’ve 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. It’s 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, there’s still a quiet sense of order in the midst of the turmoil and trauma.

Most importantly, there’s a lot less crying—because there’s a lot less pain.


Not Even A Pinprick:
The Ouchless IV

Nobody—especially a child—likes to get pricked by a needle. The 10,000 pediatric patients who receive intravenous injections (IVs) in the emergency department at St. Louis Children’s 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.

“We’re trying to export this technique throughout the entire medical center,” says Kennedy, who’s 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.

“I’ve started ouchless IVs on sleeping infants without waking them,” he says. “That’s how painless it can be.”