Sunday, April 17, 2011

Four sticks.

*names, details, etc. changed to protect anonymity. . . you know the deal.
image credit
Middle-of-the-night, Pediatric Ward - Internship 1997.

"I just wanted to go over the procedure before we do it, okay?"

She nodded quickly as she sat in the bedside chair next to the empty bassinet. Her youngish face was pretty, even without makeup. The over sized sweatshirt that she wore clearly belonged to someone else; her tightly folded arms were lost inside of it, barely offering a glimpse of her trembling fingertips. Two moments later, a man came scurrying inside with car keys jingling in his hands.

"Hey. . ." He looked at her first, immediately grazing her cheek with his lips. Then he faced me, fully alert. All business.

"Honey, this is Dr. Draper. She was just about to tell us about the procedure. You know. . .for the fever."

He gingerly sat down next to his wife but kept his eyes focused on me. With a tight-lipped smile he raised his eyebrows and gestured for me to carry on.

I nervously shifted the three pagers clipped onto my lopsided scrub pants and cleared my throat.

"Hi, sir," I extended my hand to introduce myself. My hand is shaking. Why is my hand shaking? Relax. This is a straightforward procedure. We do this all the time. Poke out your chest. Look confident like your resident always looks.

I cleared my throat to fight of my building nerves. "Okay. So the thing, I mean, the procedure that we are going to do on baby Jasmin is called a lumbar puncture. Have you ever heard of that?"

They looked at each other for a moment and then back at me. He spoke first, but more to her than me.

"Kind of like when you had the epidural, I'm thinking?"

"That's what I was going to say," she added.

"Umm, well yeah. . .it's kind of like that. Since she has a fever, we need to get a sample of the fluid that bathes her brain. . ." I realized that this sounded kind of macabre, so decided to revise that statement. "Since she has a fever and she's less than a month old, we like to exclude all kinds of infections. We check the blood, the urine, do a chest x-ray, and then we also look at the spinal fluid. Just to be, you know, safe. We start the antibiotics and send all of these tests to the lab to see if there are any germs that could be causing a serious infection."

"So this is why she needs the . . .what did you call it?"

"Lumbar puncture or spinal tap," I answered the father. "To make sure everything is okay. If no germs grow, we will be a lot less worried."

"So . . . .is it. . .does it hurt her? This test?" the mom queried. "Like, should I be in there with her?"

I internally recoiled at the thought of this worried mother being present as we folded her firstborn child into a fetal position. I saw my wobbly intern hands trying to obtain a sample of spinal fluid and shuddered, hoping they didn't catch it. "Um, well. . .you. . .well, usually we would just have you wait, you know, here in the room."

"How big is the needle they use?" the Dad asked.

I hated these kinds of questions. There was never a right answer or an answer that I felt was authentic. I was thinking, It's a big ass hollow needle with another smaller needle inside of it. But I didn't say that. Instead I simply said, "The spinal needles are special ones for this type of procedure. The ones for grown ups are pretty large, but the one we are using for Jasmin is the smallest one we have available." There. That wasn't so bad. Even if I never answered his question.

Dad rubbed Mom's shoulder and kissed her hard on the side of the forehead. Her nose was red on the edges. She looked like she was going to cry.

"We need to have you sign this consent form before the lumbar puncture, okay?" I slid the sheet over to them on top of the nearby tray table. "There is a very, very tiny risk of infection, uhh, bleeding, and. . yeah. . .mostly those things but it is really, really rare." Based upon my extensive experience. Um, yeah.

They both just sat there staring at the paper with all of that tiny writing on it. Finally, Mom took a pen from her purse and scrawled her signature across the bottom of the page. I wish I could say I felt anything more than relief. Relief that this would be moving on along and that I didn't have to page my upper level resident. Relief that she had signed the consent and especially relief that she wasn't demanding that she be there while it was taking place.

I know. That's terrible, right? I mean, how could even I admit that? How dare I? But the thing is. . . . it was true. I was more than half way through my combined Internal Medicine and Pediatrics internship at this point and I had spent more than nine months trotting behind an upper level resident and working obscene hours. The senior residents had the added complexity of supervision; backing up every failed procedure and emergency and being the one who told their haggard interns to "go ahead home" long before they could. What that means is that my main role models were often emotionally and physically exhausted, so they taught me to value things like efficiency, persuasiveness, and pseudo-confidence.

So that's why I felt relieved. It meant that I would be able to get into that treatment room quicker. That I would get a chance to "get" the L.P. on this baby. And just maybe, if I was able to do it in "one stick" and if the lab reported that the fluid was free of so much as a trace of red or white blood cells, I'd get a three A.M. high five from my senior resident--and a cold ginger ale from the patient nutrition room in celebration of my "champagne tap."

I peeled myself away from that room with those worried parents and then into a pair of sterile gloves, size six-and-a-half. As my senior sat nearby on a stool while eating a bag of microwave popcorn, I coached away the tremor in my right hand before starting. I made eye contact with the nurse who was helping me by holding baby Jasmin in position.

"You ready, hon?" the nurse asked me while tightening her grip around Jasmin's lower legs and nape of neck.

"Okay. I'm ready," I said.

And then, after numbing Jasmin with anesthetic, I commenced to advance the spinal needle into Jasmin's three week old vertebral space. With my resident coaching me from his perch, I forwarded it until I met resistance.

"Pull it back and go up a little. You have to kind of head for the head a little bit," he smacked. Pulling a grease covered hand from his popcorn bag he demonstrated the "proper" technique in the air for me while squinting his eye for effect.

So I tried again. And again. And again. Until finally, my resident was forced to dust of his salty hands, wash them, and then put on his own pair of sterile gloves. Eventually, he pulled out that inner needle and clear spinal fluid dripped from Jasmin's tiny back. I then took his place, collecting four separate tubes of the water like liquid to send to the lab.

The nurse strategically placed one band-aid over the four tiny puncture wounds just above her gluteal cleft. One bandage for the four "sticks" that Jasmin endured.

I still remember following my resident out of that room and to the nurses' station where he went right on chomping on those kernels while dictating how I should label the specimen. The main thing I felt was disappointment with "not getting it"--that is, needing to have the upper level step in and successfully complete the procedure. Not so much as a thought about the fact that somebody's baby just had just gotten stuck repeatedly in her back. That was my concern--not Jasmin. So much for that high five and that ginger ale toast.

Jasmin was handed back to her parents swaddled tightly; she had fallen fast a sleep after her marathon of high pitched crying from being held into a jackknife position by a nurse vice grip and being prodded with a needle. Four times. Mom and Dad hugged her and kissed her. And later thanked us even. They were none the wiser.

After that, we went to go eat the Chinese food that the medical student had squared up during our jaunt in the procedure room. I'm pretty sure we didn't speak much of Jasmin again. That is, with the exception of a reference to her being unusually chubby for a three-week old, explaining why "maybe you found it tough to feel your landmarks."


Today Zachary was playing "hide and seek" without notifying us that we were supposed to be seeking. He was crouched under a blanket on the bedroom floor, and my two hundred-plus pound husband unknowingly stepped right on top of him causing him to let out a high pitched yelp. As soon as Harry realized what happened, he quickly scooped crying Zachary up rubbing his face and repeatedly kissing the tiny finger that he'd trapped beneath his shoe. I scooted beside them on the couch and joined into the consolation. We both hate seeing either of our children in pain.

That's what got me thinking of Jasmin.

Today I am reflecting on how different my perspective has become on caring for human beings now that I have children. I feel sad when I think of how often during my training we habitually depersonalized ourselves from our patients; especially during procedures. I'm not saying that we didn't care. We did care. But somehow the culture during those days of unmonitored duty hours led many of us to operate outside of ourselves; going through the motions when we were tired and compartmentalizing the people from the procedures. Even children.

I have cried on more than one occasion while watching my kids get immunizations. When I imagine those parents and their worried faces, and then when I recall how easy it was to separate them and Jasmin from that lumbar puncture. . . . I cringe. I cringe even more when I recall the countless other Jasmin's I encountered along the way. I'm ashamed of that to this day.

Oh, and that horrible consent process I subjected them to? Uggh. That's an entirely different and equally disturbing story for another time.

All I can say now is that I am really happy that this part of medical training has evolved. A lot more time is spent humanizing our patients and respecting them as people more than objects. I recently read this reflection written by a current Pediatric resident blogger and knew it for sure.

And thank goodness for that.

Yeah. Zachary's smushed finger ended up being fine. But I still wonder how those parents felt when they took off that band-aid and saw those four needle marks on Jasmin's back.

My baby: Puts a lot into perspective.


  1. I still remember when my daughter got her first lumbar puncture at five months of age (she had developed pseudo-tumor cerebrii from the wean of ACTH/prednisone for infantile spasms). What I remember most is that I wasn't "allowed" to be with her for the first one. I still feel resentment -- especially since she landed up having several more, and I was there for those. It was surreal to not be involved -- terrifying -- in way that far surpassed the anguish of witnessing it.

    Thank you, again, for sharing your stories and for your honesty.

  2. I am so very grateful that you are a doctor. I could write an entire essay on how you personify what I think a physician should be.
    But for now, just...thank-you. I say that for all of your patients and for those of us who are fortunate enough to have found you here.

  3. Funny...I think I found you through six year med. I've been reading her blog for a long time. I'm glad I found yours as you add a level of beauty, humanity and love to the "medicine". God bless you and thank you.

    Patty Harral

  4. I share so many of your thoughts and sentiments. Thanks for your reflections, which serve as a reminder of how much I owe to my children. I am a better human being each day because of them, and I will be a better doctor because of them. It is an immeasurable debt I owe them and one I hope to be able to repay at least a little bit of it by giving them my unconditional love and support for as long as I have breath in my lungs.

  5. Yes me too! I was a pediatric resident in 1997, possibly up at 3 am performing (attempting to perform) the same procedure, a LP, - just in a different city. I often (?daily) have this same my children have changed my perspective as a pediatrician. I became a better physician with the birth of each child...every day I am so grateful for that. Every day I am learning more. Of note, my third (and youngest) child has Down syndrome - so we experienced many procedures, doctor visits, hospitalizations, etc. It is quite a different experience to be on the other side, a parent. Like you I teach at an academic institution. I work with residents and medical students every day. I do hope that you are correct that the current generation of residents understand the importance of respect and compassion for patients and families. Some days I am doubtful (of note I could not link to the referenced blogger). I think one of the most important lessons we must teach is that of compassion and respect - humanizing our know what it is like to "walk in their shoes".

  6. OMG! That pediatric resident blogger ( just ended her blog! Bummer!

    Awesome comments--glad others relate. Really!

  7. I shake my head at myself when I remember the advice I gave to a mother of a child with an omphalocele who was having behavior issues in the ICU. Who the H was I to give her advice???? My little 26 yr old self. Honestly, I apologize to that woman in my head frequently. I hope she went home and laughed at my audacity. Thank God we live and learn from our children.


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