Raquel of The Doctor Stole my Stethoscope asked in Moving past competency to comfort if I had pediatric IV tips. I have things I've learned, so I thereby offer them up to the blogosphere. This stuff is for less emergent emergencies. If you have a dead kid or one who looks to be dead soon, spend almost no time looking for a peripheral IV. Skip to an IO. Otherwise, for your run-of-the-mill ER kid (who will be chubby and dehydrated 90% of the time)...
- Give the child some credit. I used to just wrap kids and let the rodeo commence while they screamed their heads off. Why would I reason with a nearly preverbal child? Then as I was doing this with a pretty young child (about 18 months) dad leaned down and said to the child, "Hey. They're putting a straw into your arm to give you medicine that will make you feel better and give you a drink through your ARM. Yeah, it's pretty cool [in response to dubious look from toddler]. Just settle down and they'll be done soon." The toddler was swayed by dad's logic and subsided to mere dirty looks. I learned from this that even very young children should be given the chance at the baby version of informed consent.
- I'm extremely concrete and honest with kids. My speech goes something like, "You don't feel good, do you? To make you feel better, you need medicine that goes into your arm. I'm going to stick a needle in your arm and then take it out, but a little straw will stay in your arm for the medicine to go through. It will hurt! But not for very long. I'm going to be as fast as I can, fast fast fast, while you hold still like a rock. You can yell as LOUD as you want, but you need to hold still or we'll have to do it TWICE. Can you hold still while we do this?" Kids are generally honest. A fair portion say no, they don't think they can hold still. And a fair number start screaming at "needle" and everything else seems to become "wah wah wah," so the rodeo starts. But a lot more than I'd think ponder the situation and decide yes, they can hold still. Either way I now give them the respect and chance to absorb the information and decide how it's going to go. I recently had a mom get pretty ticked when I told her child, "I'm going to put a needle in your arm and it's going to hurt" because she felt I was meanly scaring the child, but the child accepted my terms and held absolutely still (this child turned her arm around to check out her armboard and said, "That looks pretty good"...hehehehe). I told her afterward why I do that ("if you were your daughter, would you rather be lied to or given a truthful description of what was about to happen to you? ...if I told her it wouldn't hurt and then it did, she would never trust a medical professional again"), and she agreed it made sense. (I remember being in preschool and have a doctor tell me a shot would "pinch a little" before horrible burning pain scorched my arm, and I still remember the shock and rage I felt.)
- Which brings me to parents. With peds, parents are your patients too. I offer them the option of leaving the room while we do painful things to their kids. Why? Because the child will sense their distress and get more upset, because it doesn't help ME to have a hysterical parent, and because if they leave, the child sees me as the bad guy and mom as the soothing presence. If mom holds child down, child feels betrayed. If mom swoops in afterward to soothe child, mom remains mommy, who makes child's owies feel better. It seems barbaric to many parents to NOT be in the room soothing a child having a painful procedure, but there is compelling logic behind it and I really push for it. If parents stay in the room but make things worse by screaming at me ("I SWEAR TO GOD YOU BETTER GET THIS THE FIRST TIME" upsets the child and distracts me), they will be removed for the remainder of the procedure. I just say, "Mom, you need to step out right now. You aren't helping your baby by staying in here." And 99% of moms agree and step out. The other 1% are tricky: then, in addition to taxing procedures on a screaming, upset, sick child, I have to decide whether I have done something inadvisable that needs to be modified or whether security needs to come take mom out because she's interfering with something that needs to be emergently done, thus endangering the child. Either way I have to stop what I'm doing, thus delaying care.
- You thought I'd be talking about technical stuff, right? Getting an IV in a kid is mechanically the same as getting one in an adult. You just have a smaller target. Your holder has a harder job than you do. Babies and toddlers are both strong and oddly able to twist at just the right micro-angle to cause the vein to disappear. So find a good holder. Wrap the baby in a sheet like a burrito with just the arm out that you need. Get everything ready. Get blood cultures for good measure because you KNOW the kid will need antibiotics and you'll need them eventually, right? Don't automatically go for a 24 unless it's a tiny little baby; they kink and clot. Other than that...pediatric veins have a nasty habit of spasming when the needle enters, so stick it like you mean it. Find the vein, take a deep breath, and DO IT. Baby veins aren't typically valve-y, so if you think you've hit one your 24 is likely kinked---don't try to push through your valve. Pull out to the skin until you see the kink, then twirl the catheter slowly and float it in.
- I find that singing "The Itsy Bitsy Spider" has magical effects at quieting babies. I'm pretty sure it's because they're distracted by thinking, "why the hell is this nurse singing badly on top of all the other horrible things happening to me?" It's superstition, but what the hell. I was having trouble with an IV recently and said "someone sing The Itsy Bitsy Spider!" Mom did, and I got flash immediately. I'm telling you, The Itsy Bitsy Spider is where it's at.
- Practice. If you are bad at and/or afraid of pediatric IV starts, tell your charge nurse those things and ask to be directed toward any opportunities that arise.
- Finally...if you apologize, do it only once. Parents get mad if you miss and the first impulse is to say how sorry you are. Because you ARE sorry. You don't want to hurt a kid. But you didn't mess up on purpose, it's difficult to start IVs on sick children, and this outcome is an unfortunate one and not an error. More sorries = more anger because parents think you are sorry because you messed up. "This is a difficult situation, I imagine you're upset and scared, and I'm sorry this is happening today to you and your baby" is a good compromise.
I have finished my long treatise on pediatric IVs. Readers, add commentary! I'm not an expert, which is why I have so much to say on the topic. I've had to put lots of thought and practice into this because peds aren't really my area.