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Tuesday, March 20, 2012

Simply love them: using lidocaine to anesthetize the skin before arterial punctures or IV insertion

Lately I've been doing hospitalist shifts at a busy medium sized hospital that serves a complicated and pretty sick population. Patients frequently have lots of life threatening medical problems that interact in unpredictable ways, putting them at high risk of dying when they get an acute illness. When they come in they are vulnerable and scared and sometimes angry and difficult. I am sometimes needed in more than one place at a time, which makes it imperative that I figure out some way to make the interaction work so that things will move smoothly in the direction of helping the patient start getting better.

What has been working particularly well has been the approach of deciding ahead of time to love them, and then talking to them and hearing enough of their stories that I can develop a respect for where they are in their lives. When a person is truly vulnerable, there is just nothing like love and respect to buy cooperation. And it is also much more fun for me, because then I look forward to my interactions with them.

Occasionally there is a patient who is really bound and determined to make staff cry or one who lies about everything in order to manipulate caregivers, but they are not very common, and sometimes, if everything goes just right and I've eaten my wheaties and drunk my green tea and worn just the right earrings, love and respect can win those over. I saw one of these folks just tonight and he was incredibly irritating, made me miss dinner, told me almost nothing that seemed like it was probably true, but I kind of like him now and if all goes well we will have a great visit together tomorrow and he won't monopolize all of my time telling me stuff that strains belief.

Some of the things we do to patients in the hospital that make them the most sad and also irritable and uncooperative are related to sticking them with needles. Needle sticks just plain hurt. They don't hurt much for very long, but they keep being repeated at random intervals, and two kinds of needle sticks are particularly painful. When a needle goes into a vein, that hurts but not much, but when a needle goes into an artery it really aches. Arteries are deep and surrounded by nerves. People who are critically ill get many arterial punctures in order to find out if their oxygen and carbon dioxide levels are normal and also to monitor their acid-base balance. They are often delirious when it happens, but it still really hurts, and they remember the hurt when or if they recover. When an intravenous catheter (an IV) is placed, a plastic tube with a needle in it is put in a vein, but often it takes awhile to find the vein, and during that time the needle is digging around in the flesh. Ow. Both of these procedures can be performed after injecting some numbing medicine with a tiny needle that really doesn't hurt much at all. The numbing medications is usually lidocaine, which can burn, but can also be nearly painless if 1 part bicarbonate is added to 9 parts lidocaine, buffering the slightly acidic solution. It hurts even less and works faster if the buffered lidocaine is warmed to body  temperature. If buffering the lidocaine is not possible, a slow injection, over 30 seconds, works almost as well. Patients like being numbed first. I know I would.

Many organizations have published in favor of anesthetizing for arterial punctures (http://ajcc.aacnjournals.org/content/15/6/595.full is a review of this literature.) Most places that I have worked do not anesthetize arterial punctures routinely, mostly because it takes longer and partly because the operators (nurses or respiratory therapists) have been taught that a stick for a stick doesn't make sense. Except that it does if it is your wrist or the wrist of someone you love. It is even more rare to anesthetize for the placement of IV's and this is a much more common procedure. (http://ajcc.aacnjournals.org/content/17/3/265.full.pdf goes over this literature.) Arguments are often made that it takes longer to do it this way and that these procedures are often done in a big hurry, but if it were done all the time, the equipment and medication would be easily available and I'm positive it wouldn't add more than a couple of minutes to the procedure. Physicians also routinely cause discomfort with aspects of our physical exams: we make our patients cold, we poke them too hard and we leave their bedclothes messed up. Some discomfort is unavoidable in hospitalizations but being gentle and mindful can go a long way to reducing it.

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