Patient Safety, Patient Advocacy: In Pediatric Nursing, A Tricky Balance

CT Scan ink and watercolor on paper 2014 by jparadisi

I was precepting a new nurse. She’d earned a job in our PICU during her student clinical rotation. New grads weren’t routinely hired, but her competency led to her recruitment. Precepting her was a joy.

This particular shift, we were assigned one of those midafternoon admissions with the potential to keep us overtime: rule out meningitis. The preschool-aged patient had been brought to the ED after having a first-time seizure. When he reached the PICU, however, we were relieved that he presented more like a febrile seizure.

Besides a fever and runny nose, the only other remarkable characteristic about the child was his utterly charming personality. We drew his labs while starting an IV. An antibiotic infusion was started, and acetaminophen administered. Feeling better, and not the least postictal, he played with our stethoscopes.

This was many years ago. There were standards in place that accompanied certain diagnoses. ‘Rule out meningitis’ came with a CAT scan and lumbar puncture.

Both seemed excessive, given the child’s presentation, but there was the order for CAT scan. He sat upright in his crib singing, as my preceptee (we’ll call her Beverly) and I rolled the crib down to the CAT scan.

IV sedation was ordered for the CAT scan, if it proved necessary. I had some in a syringe in my pocket (that’s how we did it in those days) to enable our patient to lie still for the scan.

But he charmed the technician too, who asked me to hold the sedation. Instead, he seated the willing child on the sliding table, and allowed him to glide in and out of the tube several times, as if it were a Disneyland ride. Then he asked the child to lie on the table, and to stay very still with his arms at his sides. The boy did as told, and the CAT scan was completed without trauma or sedation.

Not surprisingly, the results of the scan were normal.

Returning to the PICU, Beverly and I transferred the monitor leads back to the wall unit. She took vitals signs and we reviewed charting the procedure. The parents came to the room.

Soon afterwards, the pediatrician returned and ordered the lumbar puncture. Beverly and I suggested that the procedure was unnecessary, given the child’s lack of symptoms, but protocol prevailed. The parents opted to leave the room.

It was a disaster. The child, who’d adopted us as his newfound friends, willingly curled on his side as Beverly and I hugged him close. But as soon as his skin was swabbed and the tip of the needle pricked his back, he went ballistic. There was no holding him still. He fought as if his life depended it.

It was an entirely different experience than the CAT scan. I don’t know who had more hurt in their eyes, our patient or Beverly. Unable to introduce the needle, the doctor told us to hold the child still. I suggested sedation, but the pediatrician was worried that the child would become too sleepy. “Just hold him still!” he told us.

Agitated, the procedure still uncompleted, the physician left the room briefly. Beverly held the sobbing boy close to her chest, trying to calm him. He curled into her, seeking protection.

“I refuse to participate in this procedure if he refuses to give sedation,” she told me. I saw she meant it.

Beverly was a really good nurse. She deserved a really good preceptor. A good preceptor recognizes an opportunity to teach the most important aspect of nursing: patient advocacy. It was my job to lead by example, using my words to reduce conflict and advocate for what was best for our patient.

This was a long time ago. Although now back in favor, “watchful waiting” was not part of the protocol for this clinical situation. The best I could do was to pursue consensus. The physician wouldn’t agree to forgo the procedure. Granted, the possibility our nursing assessment was wrong held the potential for a devastating result. When informed that neither Beverly nor I would take part in the procedure unless the child received sedation, he conceded.

Beverly held the boy close to her chest, as I slowly pushed enough IV medication to calm him. Obediently, he let us curl him up on his side and hug him close while the physician collected, drop by drop, three small tubes of crystal clear spinal fluid.

The results were normal.

From time to time I think about this little boy, Beverly, and about unnecessary procedures. I wish I’d been a stronger patient advocate, for the boy, and for Beverly. Good patient care is as closely related to art as it is to science. Knowing when to adhere to protocol, or not, in best interest of the patient requires skill, experience, and a bit of luck.

I wish I could see that little boy laughing as he rode in and out of the CAT scan tube again.