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Exercising Restraint

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During my four years in the emergency department at Henrietta Egleston Children's Hospital in Atlanta, I learned a lot about how to keep all kinds of kids still for all kinds of different procedures: infants for lumbar punctures, toddlers for extraction of sundry objects from ear canals, teenagers for nasogastric tubes, and everything and anything in between. Each size of child, each procedure and each individual kid requires a different technique and approach. Throw in each doctor's idiosyncrasy, and holding kids still so that terrible stuff can be done to them with as little damage as possible -- physical, psychic and metaphysical -- becomes a real art form.

For Dr. Krause's lumbar puncture (LP), we sit the kid upright, stand in front, clamp elbows with thumbs and thighs with fingers, keep the head down with chin or cheek and adjust spinal curvature per the doctor's specifications. For Dr. Welch, we lay the child on their side, stand in front, grasp the back of the thighs with one hand and the back of the neck with the other, bend like a pretzel and adjust accordingly.

It didn't hurt that I had a couple of decades of aikido training in which I learned the ways the body likes -- and doesn't like -- to bend.

Of course, some procedures benefitted from various forms of conscious sedation. Here, too, it helped to know which doc was doing the procedure. Extensive suturing for Dr. Mehta? EMLA cream in the waiting room, followed by topical lidocaine-epinephrine-tetracaine (LET) solution in the procedure room, IV ketamine and morphine and subcutaneous epinephrine buffered with sodium bicarb. Dr. Johnson for a fracture reduction? IV versed and fentanyl, and an inflatable tourniquet with distal block.

On one particular day, Joey came to us in severe respiratory distress. I think he was about two years old. They brought him right to the trauma room from triage. Of the 10 signs of pediatric respiratory distress listed in the Pediatric Advanced Life Support (PALS) textbook, he was exhibiting 11. Tripoding, retracting, flaring, grunting and lousy pulse ox you name it, he had it. And he was getting tired. What happened next is one of the reasons that, if you have the option, you should strongly consider transporting a really sick kid directly to a dedicated pediatric facility.

Dr. Zempsky, one of the attending physicians on duty walked into the trauma room, took one look at Joey, and went into stat mode. "Grab me a bunch of 60cc syringes and a big angiocath," he told one of the nurses. "Guy, hold him like we're gonna do an LP," he told me. I sat Joey upright on the edge of the bed with his legs dangling over the side. The doctor pumped up the bed to about waist height. I was facing Joey, cradling him with my left arm under his knees and right arm around his shoulders. His eyes were half closed, his breathing rapid and shallow. He was so tired, he was ready to give up, to just drift off. We were cheek to cheek and I could hear his breathing start to slow down, to become shallower. Still, I expected that when the doctor stuck that big needle in his back, I would have to hold on tight. I was wrong. He was just too far gone.

The doctor listened to Joey's back, cleansed an area over his lower ribs on the left side, injected a little bit of lidocaine subcutaneously, and inserted the angio over a rib and into the left lung. He removed the needle from the angiocath, attached the syringe, and began to draw out a stream of off-white puss. He filled one 60cc syringe, then swapped it out for another. He filled that one and swapped it out again. Joey began to relax. His breaths became deeper, slower. I don't remember how many syringes the doc filled, but I remember being astonished to see that much junk coming out of such a little chest.

By the time the doctor had finished draining as much fluid as he could, Joey's head was resting on my shoulder. His eyes were closed; his breathing was slow and relaxed. His color was good. His pulse ox was 100%.

Sometimes, when things go right, restraint can melt into a hug.

For more on pediatric patient care, visit our special patients topic page.

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