# Dr's bed-side manors?



## Syk (May 11, 2012)

I had to rush to the hospital yesterday evening after learning my nephew had fallen on a limb which impaled him and broke off. The way my mother and brother were talking it sounded like it had gone through and through.

Once I reached the hospital, I found out it was only a small branch and had gone in his lower leg, around the shin. It had indeed broken off.

When the doctor came in, he was quite nice. However, he held the needle right in front of the child's face, told him it was not going to hurt at all. After sticking him nearly 15 times around the area to numb the location, he began trying to retrieve the limb with forceps. 

Once he eventually figured out the forceps would not work (after the nurse asked him did he want to try from her side of the bed) as the piece of the branch was so deep, he decided to lacerate the area so he could get the branch out easier without damaging the surrounding tissue. He held the scalpel up right in front of my nephews face, and told the nurse she needed to learn how to use a scalpel, that he needed to go deeper than that.

I cannot help myself to think, that this was somehow extremely unprofessional. The sane-logical thinking on my part, is when dealing with pediatrics who are terrified of needles, he could have at least turned around so my nephew could not have seen the scalpel. Or talked to the nurse afterwards to let her know his preferences on depth.

After it was all said and done, I find it a bit hilarious. But at the same time, I think I have learned a personal lesson when dealing with peds.


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## Veneficus (May 11, 2012)

I wasn't there to comment on what happened except to say it is not my way.

In Peds it is taught to show the child the equipment you are using before you use it.


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## mycrofft (May 11, 2012)

I'd show it to him after the Valium and Versed had taken effect.
And,  the doctor didn't "lacerate", he "incised"...on second thought, maybe *that* one lacerated it.


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## Syk (May 11, 2012)

Nah, he "lacerated" it, literally. About an half an inch Vertical/Horizontal, didn't go "In" with the scalpel, not sure why he did it that way, but then again he is the doctor - and it worked. He then continued using the forceps.

And no valium, just lidocaine.


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## Veneficus (May 11, 2012)

Syk said:


> Nah, he "lacerated" it



"You keep using that word, I do not think it means what you think it means."

http://www.youtube.com/watch?v=G2y8Sx4B2Sk


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## Syk (May 11, 2012)

Funny video, and not being a prick but,

tr.v. lac·er·at·ed, lac·er·at·ing, lac·er·ates
1. To rip, *cut*, or tear.
2. To cause deep emotional pain to; distress


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## usalsfyre (May 11, 2012)

Since we're going to go there...



> in·ci·sion  (n-szhn)
> n.
> 1. The act of incising.
> 2. Medicine
> ...



You might want to learn some basic medical terminology, it will help you in the future


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## Veneficus (May 11, 2012)

No worries,

But that is a layman's definition, there are gross physical and histologic characteristics seperating an incision from a laceration.

Medically a laceration is caused by a blunt force which irregularly seperates the skin and in which bridging fibres remain. 

An incision is made from a penetrating/cutting force, leaves no bridging fibres and is longer than it is deep. (it would be then considered a stab if it is deeper than it is long)

A scalpel makes an incision. No matter how many times or what direction you cut in.

Rooting around a wound with forcepts will cause lacerations, which would be considered secondary wounds, but the cuts are still incisions no matter what you do to them after. 

Any lacerations would also be relatively minor in comparison if caused by forceps and would probably more accurately be described as avulsions.


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## Aidey (May 11, 2012)

Syk said:


> When the doctor came in, he was quite nice. However, he held the needle right in front of the child's face, told him it was not going to hurt at all. After sticking him nearly 15 times around the area to numb the location, he began trying to retrieve the limb with forceps.



The patient only feels the first prick. Lidocaine has a predictable coverage area per injection. The injections overlap so that the patient doesn't feel the subsequent needle sticks. 

Also, children are more observant than we give them credit for. I was taught early on to never try and hide something from a child because if they catch you, your job is about to become 1000 times harder.


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## Syk (May 11, 2012)

Well to the flamer, medical terminology does not super-seed common sense. It's obvious everyone knew exactly what I meant, and I'll point out the obvious in your response.

*a. A cut into a body tissue or organ, especially one made during surgery.*

And to further advance this wording, the doctors report states "I made a small incision to the child's lower right extremity and removed the foreign object. I then sealed the *laceration* with Dermabond."

I'm not speaking to a doctor, and I am not writing a pre-hospital care report. This is not my job, this is somewhere to kick back and talk to our peers. Therefore I'm not going to go by a medical dictionary when we are all in the pre-hospital care field and know that a laceration means a cut, an incision means a cut therefor it *WAS* a *CUT*.. Neither of my employers nor the doctors/nurses in the hospitals I have been to have complained about my terminology, therefore I must have a decent enough understanding of medical terminology to have made it 5 years in the industry.

The post I made with the definition was not to be a prick to Veneficus, he has actually been very helpful to me.

Long story short, an _incision_ is a _cut_, is a *laceration*. Point blank, *period*.

And before you flame someone, let me point out one thing, punctuation is also beneficial, you might want to use it if you're going to be up tight with medical terminology and use it in an attempt to insult someone.



> You might want to learn some basic medical terminology, it will help you in the future


 ^ Needs a period.

Now that I got that out the way, thank you for the details Veneficus, as I said before though - it wasn't an attempt to insult ya, just a way of showing why I decided on that choice of wording.

@Aidey
Thank you for an actual constructive response. Yep, he was just terrified of the needle, going along with what you have stated - he did indeed show him the needle, but informed him it would not hurt which is one thing I was also taught to never tell someone.

I don't think holding the scalpel in his face was the negative experience, more-so making the statement "I'm going to have to go deeper than that" and letting him watch as he pushed the blade out further.


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## usalsfyre (May 11, 2012)

Syk said:


> Well to the flamer, medical terminology does not super-seed common sense. It's obvious everyone knew exactly what I meant, and I'll point out the obvious in your response.
> 
> *a. A cut into a body tissue or organ, especially one made during surgery.*
> 
> ...



Wasn't a flame attempt, perhaps it was a bit blunt, I apologize for that. Maybe I should refrain from posting when not feeling well.

I would make absolutely sure before you do something as seemingly passive aggressive as posting definitions your right, because you never know who's in the other side of the keyboard.


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## Syk (May 11, 2012)

No worries, apology accepted - and I also apologize for my response as I have obviously taken your's the wrong way.

Guess that's the downside to the internet, being hundreds of miles away and never knowing or meeting who you are talking to, or anyone they are involved with, lol.


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## Irish42 (May 11, 2012)

Aidey said:


> The patient only feels the first prick. Lidocaine has a predictable coverage area per injection. The injections overlap so that the patient doesn't feel the subsequent needle sticks.



Eh not always... I learned this a very painful way on my foot.. Granted, the doc who did it to me later got arrested on like 20 counts of endangering the public's health and safety and got sued so bad his great grand kids are still gonna be paying it off.




Aidey said:


> Also, children are more observant than we give them credit for. I was taught early on to never try and hide something from a child because if they catch you, your job is about to become 1000 times harder.



So true. They always seem to give more of an honest answer about things then the adults do.


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## Aidey (May 11, 2012)

Feet, hands and any area with out as much soft tissue are harder because the lidocaine isn't absorbed as well. If you have an idiot behind the needle that is going to change things too, but when all goes as it is supposed to you should only feel the first needle stick.


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## Veneficus (May 12, 2012)

Aidey said:


> Feet, hands and any area with out as much soft tissue are harder because the lidocaine isn't absorbed as well. If you have an idiot behind the needle that is going to change things too, but when all goes as it is supposed to you should only feel the first needle stick.



Sometimes you can even eliminate that first stick feel by spraying some lido in the wound and then injecting from iside the wound outward.

I haven't found anything that takes away the initial burning though. In Europe there is a spray on cryogen that is supposed to numb the area to be injected, but it doesn't seem to work in my observation of patient reactions.

It is important to remember that lido doesn't work on unbroken skin and has a small onset time of action. So it is best to give a minute or two before you start making more holes or messing around. 

In my mind, when dealing with peds, procedural sedation is the way to go. As I understand, versed has the strongest amnestic effect and it is my favorite benzo flavour.

That way not only do you achieve the goal of the patient not being aware of pain, they often don't remember either and in the future are not terrified of going to the doctor because they equate it with pain.

Rather than simply teaching the technique of controling pain for surgical procedures, I think it is important to teach the goals behind why it is done.

Not only does it help to pick the best anesthetic technique on a given patient, it also stops underdosing and the psych trauma of watching somebody cut them up.


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## mycrofft (May 12, 2012)

Incise: use the sharp side of the scalpel.
Lacerate: turn the blade around.

Locals: yeah, proper way is to take your time, numb the area you can make your other injections from, give it a bit to take effect, then give the other injections. Don't go in like a tattoo slinger paid by the job and not by the hour. 

Nitrous works wonders but it's fraught with its own issues, like fire insurance.


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## bigbaldguy (May 12, 2012)

Keep it friendly kids. Good info coming out of this thread lets keep it on track.


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## Syk (May 12, 2012)

Yep, it left the nephew feeling "Tortured" in his own words. I agree with mycrofft about Nitrous Oxide, even dentists use it and it could have made his experience with the hospital more beneficial than having him never wanting to go to the hospital or a doctor in general again as was the case this morning for his checkup with his family physician.

To be in this field, it seems like we must care about people, and have the urge to help others - and as much time as doctors spend in school - the money cant be everything, they have to have some passion for helping people somewhere in their hearts. I know for us here in  Mississippi as far as EMTs/Paramedics go - you can become a nurse in the same amount of time, make 6-20 more an hour starting out than a paramedic and have a lot less work-related danger.

I think another thing that weighs in on it, is this was a level 4 hospital, they generally do not do surgeries even minor. With it just being moved from a government hospital to a private with the main branch being a level 2 trauma center - they are talking about starting to do surgeries in the near future so hopefully things will change.

Veneficus - you continue to amaze me with your knowledge. You need to move to Mississippi when you get done with school for about a year and be a consulting physician with our local hospitals and teach them a thing or two about patient care. The problem here, is outside the major hospitals - they are rag-tag and would rather get you in and out opposed to wait until anestisia wears off... well - that or most of the doctors around here should have been vets.

The major hospitals are great though - UMC/St Dominics and Forrest General.


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## FLdoc2011 (May 12, 2012)

Yea, I think a lot of it could just be from the doc or ER there just not seeing a lot of peds.   ED docs do see peds in training but certainly can lose some of their edge dealing with children if at a place that doesn't see a lot of them.

Also, honestly if it was a fairly minor local injury I would not want to place a child under more risk of sedation just for the sake of keeping them calm.   Procedural sedation is not totally benign and if it's just a matter or saving the child the pain of just a local injection then I don't think it's worth it.


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## CritterNurse (May 12, 2012)

I think those docs would cut it as vets either. 

You don't just handle the patient, you have to handle the owners/guardians/pet parents/what ever they want to call themselves. 

In fact, I think pain management in animals can be just as important as in people. With people, you can say "This will hurt a bit, but then it will be better". With animals, you can't. And a hurt animal will fight back with teeth and claws.


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## mycrofft (May 12, 2012)

Nitrous to adminsiter lidocaine to a large area? Priceless.


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## Veneficus (May 12, 2012)

FLdoc2011 said:


> Also, honestly if it was a fairly minor local injury I would not want to place a child under more risk of sedation just for the sake of keeping them calm.   Procedural sedation is not totally benign and if it's just a matter or saving the child the pain of just a local injection then I don't think it's worth it.



For sure, in a minor local injury, local should be more than fine. 

But when you start dissecting deep tissue or expanding the area, I would think it is then time to perhaps escalate the type of analgesic/anesthetic. 

You don't always have to go for a full procedural sedation, and I must confess i was thinking of a deep penetrating wound when I wrote that, but some versed itself can go a long way. 

I aso understand Ketamine is good also, but I have never used ketamine myself. 

My mentor in anesthesia likes to say, "there is no one right way to provide anesthesia, there is no one best way, but you should be comfortable with the way you use."

I think many physicians today, all over the world, significantly over estimate the risks of various procedures. For a variety of reasons. 

I have also noticed that people, including myself, who are not comfortable with a procedure, tend to use it less frequently than perhaps it should be.

Sometimes I cannot decide ifit is from prudent practice or the limits of ultraspecialization. The truth is probably somewhere in the middle.


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## abckidsmom (May 12, 2012)

Veneficus said:


> For sure, in a minor local injury, local should be more than fine.
> 
> But when you start dissecting deep tissue or expanding the area, I would think it is then time to perhaps escalate the type of analgesic/anesthetic.
> 
> ...



I think the truth is about 2/3 of the way to prudent practice. There are just so many things we "can" do that prudent practice says we limit ourselves from being a jack of all trades and a master of none. At least unless it's absolutely necessary. 

And you better give my kid some versed before you go pulling a stick out of his leg.


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## Veneficus (May 12, 2012)

abckidsmom said:


> And you better give my kid some versed before you go pulling a stick out of his leg.



Well you might want to fly over to this side of the pond for your medical treatment then.

Aside from a CT scan the US seems so risk adverse you might not get much more than that.

Even with the plane ticket it will probably be cheaper too.


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## johnrsemt (May 14, 2012)

If the doctor is showing and explaining to the patient what he is doing that is one thing.  but the OP made it sound like he was just holding up the needle and the scalpel; and that is not a good way to do it with anyone much less a child.


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