I think I mentioned last night that I initially resisted when the ER doctor said he wanted to admit Caden and put him on IV antibiotics. My initial reaction had more to do with protocol than anything else. Oh by the way…the protocol changes depending on where you are in the hospital and who your doctor is for a particular shift. I am pretty convinced that there is little the hospital can do for Caden in a regular hospital room that we can’t do at home or at least in combination with home medical supply (for oxygen) and daily visits to the pediatrician when injections are needed. Tonight I had a conversation with a resident that sealed my opinion.
I want to set the stage first. Earlier in the day Caden’s IV failed. The IV was the method for delivering the antibiotic (Rocephin) last night and some extra hydration today. Since Caden has traditionally been a very difficult stick for IVs Sherry asked if they would forgo the IV and simply administer the Rocephin by way of injection(s). She assured them that we could add water and electrolytes by g-tube for hydration if needed. The staff agreed and Sherry probably sighed with relief since the injections would likely come later in the night when I was back at the hospital. This would save her from having to watch/hold Caden while he got a new IV. Anyway…I showed up at about 10pm and Sherry said the Rocephin was on the way. She had carefully choreographed the routine for me. They (nurses and assistants) were going to get vitals, give fever meds and Tamiflu via feeding tube, and give the injections all in one visit to Caden’s room to minimize the amount of disruption to his sleep. About an hour later the nurse came in with the vitals cart and the fever meds. She said that the day shift must have forgot to order the Rocephin injection because it still had not shown up. I agreed to go ahead gathering vitals and giving Caden Tylenol and Tamiflu via g-tube. We were mostly able to get this done without waking him too much. I noticed that Caden did not have the Lidocain patches on his legs. Normally Caden would get Lidocaine on his skin at least twenty minutes prior to an injection of Rocephin. As a matter of fact the ER even did Lidocaine on Caden’s hand before giving an IV and I did not even have to ask for it. The nurse just looked at me as if I had just asked her for the square root of 841. She said she would check into it. About another hour later a young whipper snapper resident popped into Caden’s room. No mask, no gown, no gloves by the way even though we are in an isolation room. Our conversation went something like this:
Dr. Whipper Snapper: Good evening sir I am Dr. Whipper Snapper. [extends hand to shake]
Me: [Shaking hands] good evening Dr. Whipper Snapper how are you?
Dr. Whipper Snapper: Good…so…about the request for Lidocaine cream. Has there been indications that this has helped him in the past?
Me: Uh…well I really don’t know. He has had the cream in his skin for every Rocephin injection I can remember and there have been quite a few.
Dr. Whipper Snapper: Well the cream will probably do very little to help. The majority of the pain on these deep muscle shots is caused by the medicine entering the muscle tissue so the initial stick will barely be an issue with this type of shot. The cream will do very little to ease the pain.
Me: So if it will take away any of the pain then why not do it? Is it an inconvenient to put the patches on? Are there adverse side affects? What is the problem with using the cream?
Dr. Whipper Snapper: No it is not about inconvenience and there are no real side effects to be concerned about. It is just that I don’t want to do something that is futile. Do you know if the lidocaine helps at all?
Me: I have not had Rocephin with and without the topical cream so I really could not say. I would have to test the process both ways to be able to say for sure. Caden’s limited verbal skills have prevented him from articulating his preference.
Dr. Whipper Snapper: Understand. So can we forgo the cream?
Me: I will say that I am more concerned about how the medication is reconstituted than whether he gets cream on his legs. I have seen the difference between Rocephin reconstituted with sterile water verses Rocephin reconstituted with lidocaine. The pain for Caden is considerably more severe if the Rocephin is not reconstituted with lidocaine.
Dr. Whipper Snapper: Oh…Uh yes…that makes sense. I will check into how the prescription is written and make sure it is mixed with lidocaine instead of sterile water.
Me: Thanks. I am willing to forgo the cream as it will likely wake him up to put the cream on. If he were already awake then I would say that we should go forward with the cream.
Dr. Whipper Snapper: Okay. Is everything else okay?
Me: I lowered Caden’s oxygen to 3/4 of a liter. His O2 sats were 100% at 1.5 liters. He is still hanging near 100% even at 3/4 liter.
Dr. Whipper Snapper: Oh yes. That’s great. We want to wean him off the oxygen. Let me know if you have any questions.
Note: The names have been changed to protect the guilty.
Still not sure why it was so important for Dr. Whipper Snapper to come in and have a conversation over the Lidocaine cream other than what he said about not doing something he saw as futile. Since he did not volunteer that he had tried Rocephin shots with and without Lidocaine cream I will assume that he has never tried it either. He did not seem to even blink with agreeing with me on the reconstitution issue even though he was not sure if it was ordered that way. If he has such a keen sense for what is futile and what is not in terms of comforting a child, why would it not be common knowledge and practice to order Rocephin injections reconstituted with Lidocaine liquid to ease the pain for children? His job in the ordering the Lidocaine cream would have only required him to put pen to paper. Instead he got up and came to visit me to have this conversation over something that he had no objective evidence to support. Subjectively I will agree that the initial poke seems to pale in comparison to the burn of the medicine deep in the muscle for Caden. I gave in with the hopes that I have gained a little ground with him in case I need something later. 😉
Caden is doing pretty well considering the circumstances. While you get monitored all too closely in the hospital there is little to no chance of getting rest. Caden is on about 3/4 liter of O2 and his saturation numbers are at 97% while sound asleep. If he keeps this up then we might be able to blow this popsicle stand within the next 24-48 hours with the doctors’ blessings.
Well…”the Rocephin is on the way” meant that it would be here in 4 1/2 hours. That is right. It is now 2:48am and Caden is finally back to sleep after 2:30am injections of Rocephin.  I could have driven to the ER from home, got the Rocephin injections, and been back home in bed. ARGH…inpatient hospital protocol brought to you from room 727 at the Medical University of South Carolina Children’s Hospital.
Oh…Caden seemed to do okay without the Lidocaine cream ahead of the injections.