Zen and the Art of Laceration Repair

"When we lose our conscious thoughts, our stress and worries will go with them. Stillness and quietude will take their place."

I got an E-mail from Shinga who asked me to expand on my comment about preparing children for painful or scary procedures.

I don't claim to be an expert in anything, but I have found certain techniques to be useful in the course of my practice. I really don't like categories or labels either, but if these maneuvers are related to zen meditation, breathing control, hypnosis, or any other technique that helps people relax, sit still and endure uncomfortable procedures then you can call it whatever you want. These steps are so basic that I would expect most docs and nurses probably use them anyway, but I have received many appreciative comments from family members and staff regarding my "calming effect" on patients, so I thought I'd try to figure out what I do that helps accomplish this.

I'm sure most who read medical blogs are familiar with the standard ways we are taught to put children at ease, so I won't go into detail about those. I don't wear a white coat, I keep a relaxed demeanor at all times, I sit at the patient's level, I smile and talk directly to them in a soft gentle reassuring voice, I avoid making loud noises such as slamming the door or banging the mayo stand, I don't let them see the needles. I take my time with them. I try to calm down the parents, because parents who are freaking out will always make the child more nervous too. I let the parent hold the child the majority of the time, if that is the position of comfort for both.

Most lacerations in kids I prefer to close with Dermabond if it is reasonable to do so, but if there is a significant likelihood of improved cosmetic or functional outcome with sutures or other methods then I will offer various options to the parents. The wound still has to be cleaned though, so they are going to have to sit still and relax a bit, and their fear needs to be addressed in an individually appropriate fashion. Not all kids can be easily comforted verbally.

For certain complicated lacerations and of course all reductions of fractures, I prefer to chemically sedate the child with ketamine, unless contraindicated. If an injury has the potential for complication if not adequately revised, or if the location of a wound requires extensive cleaning or debridement, then I prefer to have the child completely still, pain free, and unaware. My zen mastery, though formidable, occasionally requires some chemical augmentation.

Ketamine turns a scary, painful, psychologically traumatic, and possibly rushed or inadequately performed procedure into a calm easy situation for everyone involved: patient, family, and staff. I despise the "brutaine" technique of just wrapping the screaming kid in a sheet and torturing her, although rarely such an approach is necessary just to get the local anesthesia injection over with in a child who cannot be comforted.

Simple lacerations and "just in case" splints typically only require reassurance. Optimally, I would prefer to have the child lying on the stretcher with the parent at the head of the bed or beside them, holding their hand. I typically prefer to have a trusted nurse who is also gentle, relaxed, and good with kids to stabilize the area requiring attention. If a local anesthetic is required, I tell the child that it will sting just a little bit, but only for a second. Then they won't feel anything else. It'll be OK.

Once all the equipment is arranged, and everyone is situated and ready, I place a hand on the patient and talk to them directly and slowly in a calm voice, telling them to take in a deep breath and let it out slowly. This should be repeated a couple of times so they can allow themselves to relax. Focus their attention on breathing out. "Take a deep breath and let it out slowly.........again." I breathe with them, face to face. "Goooood." Occasionally, some kids are still going to cry when you start to approach their injury, and almost all will cry when you inject the lidocaine. "Deeeeeep breathhhh" I repeat calmly. I still will give them the opportunity to let me inject slowly, because if they can handle the first half cc or so and still stay still, then the rest is much less painful. I've personally never found EMLA to be worthwhile, and kids hate the freeze spray.

If they are too agitated with that approach, then I usually just get the local over with as quickly as possible then back off for a minute. Typically, once the local is in they are able to be calmed with the breathing approach again, and they sometimes will even fall asleep during the procedure itself.

Someone mentioned on another blog about working with a physician they called "Dr. Ativan" because of his relaxing effect on patients. That's my style as well. My personal belief is that if patients' anxiety level can be reduced through relaxation techniques, of which breathing control is probably the most important component, then their procedure will be less traumatic and better appreciated by everyone.

Breathing exercises like the one mentioned above can also help to induce a more relaxed state in oneself, during a stressful shift or when trying to fall asleep for example. I personally underwent a sleep study in which I achieved stage 2 sleep in only 3 minutes. It works....try it.

ADDENDUM: It would be interesting to hear any more "tricks of the trade" others have found to be helpful in calming young patients, including pharmacological agents of choice.