This is the 106th #WILTW
For those working with acutely ill and injured children there aren’t many more important things we can do than relieve distress and pain. Sadly though there are times when procedures need to be performed in Emergency Departments which will not be completely pain free.
Clearly every effort is made to ensure that the management of fractures, insertion of sutures or removal of foreign bodies is as comfortable for the child as possible. Standard text books will list some analgesic agents and those with any experience will ensure they have a repository of distraction techniques and preferably a play specialist[1] with them. The real life situation is a little more complex and, as with any task, a little preparation can go a long way to improving everyone’s satisfaction with the process. One of my recommended follows in Paediatric Emergency Medicine is Brad Sobolewski (@pemtweets). This week Brad wrote on draining abscesses in children.
His post started with the factors that will impact on a child’s tolerance of the procedure. The list was actually relevant to many procedures and it got me thinking about the unconscious processes that I go through performing them.
The sequence can neatly be described by P.R.E.D.I.C.T
Personality – maybe the most important component. What is the child like? What makes them tick? What are their fears? Do they know what is going to happen? This may be obvious but sometimes it does take some unpicking (and why play specialists are worth their weight in gold). Some children and young people are very rational, and others less so, especially when they have been through a traumatic event to bring them to the Emergency Department in the first place. From 18 month onwards you can get a sense of how children may react; this information is invaluable
Relatives (or carers) – I’m always mindful of one of our play therapists quotes “as calm as you are is as calm as she’ll be“. Anxious parents can make for anxious children.
Experiences of the child – If one thing is going to change your approach it will be the parent saying ‘the last time this happened we had to…’ Children remember like elephants. This is why it is so vital any procedure is as pain free as possible. One poorly performed blood test makes all subsequent blood tests 100 times more difficult. Make sure you are aware of past history.
Duration of the procedure – Some manipulations may take seconds whereas an embedded earring may take much longer (and why a good nerve block sometimes essential!). A schoolboy error is not to plan for a long procedure because you are overconfident (see below)
Interruption – while sometimes procedures have a time critical element; not all do. Ensuring you are aware of other potential distractions in the department is important (there may be lots of procedures happening simultaneously at any given time on a busy evening!)
Confidence of success – Plastering a child with a deformed forearm is unlikely to go wrong. But if you don’t fish out the small plastic ball from the ear canal at the first attempt its not always a simple next step. I always tend to think about will happen if things don’t go to plan. What are your get out strategies and what other techniques or pain relief might be needed?
Team – My final thoughts revolve around who I have available to achieve the best outcomes. A play specialist is always invaluable, as are nursing and associated staff experienced in minor procedures in children. Sometimes less is more for the frightened child, conversely a couple of ‘holders’ (noting that brutacaine is not an acceptable approach) are necessary.
So P.R.E.D.I.C.T’ing your procedure is important and I think relevant to all children including those with development delay or a neuro-disability.
What have you learnt this week #WILTW
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[1] In the United State Play Specialists are called Child Life Specialists I think