ouchlessness vs convenience
There needs to be a good reason not to use local anaesthetic preparations in a child whose
condition can wait the hour or so for EMLA to work.
In fact the ability of the triage nurses to predict a doctor's intention to venesect or start an
IV is high.
In the situation where we need to wait, I give the child (or occasionally the parents) the choice,
and see another patient or two in the meantime.
In our department, doctors do all IVs and bloods, and with experience the skin changes induced by
the creams form no impediment to identification and cannulation of veins. The cost of patches or
cream is insignificant.
The conclusion: with-holding EMLA or the like is cruel and uncaring.
We need to remind ourselves that we are advocates for the children for whom we care.
Fellow Ped EM
Sydney Children's Hospital.
> I find it interesting that nurses seem to always feel that anything before
> starting iv's is not worth the effort, that it somehow makes vein
> visualization difficult, and that its just not a big deal to start the iv.
> I find the literature to be contrary to these notions. Quite a bit of
> anesthesia literature finds that a bunch of stuff like buffered lidocaine
> injected, flourimethane spray, EMLA, etc really decreases pain without
> decreasing first and second stick sucess rates in randomized trials. My
> own experience (as one of a few MD's here that start IV's) with older
> children and adults is that using buffered lidocaine is very helpful to the
> patient and doesn't make the iv start any harder. Emla is the same except
> it takes forever. I think that a little combination of resistance to
> change and desensitivation to patient discomfort on the part of the nursing
> staff makes implementation of proven methods to decrease discomfort
> difficult. Also since most ED MD's are horrid at IV starts I've heard the
> arguement often ended by some comment by the nurses that the physicians
> don't really understand and that they're really good and don't need this
> other stuff, etc. When my patients request numbing medicine (since many
> repeat pts have had iv's by anesthesia) I just do it myself instead of
> argue anymore.
> Intersted if anyone's nursing staff has latched onto either emla or
> injected lidocaine or cold sprays/etc...???
> Virgil Davis, MD
> At 08:06 AM 12/21/99 -0600, Jay Pershad wrote:
> >Dr. Fisher:
> >We use it in our ED. I tend to use it mainly for LP's. I still have to use
> >injectable Lidocaine to anesthetize the deeper tissues( ligaments and dura).
> >With Numby, the entire LA can become painless. I prefer it to EMLA for 2
> >reasons. One is, the time to onset, which is only 10 minutes, as opposed to
> >45 minutes to an hour with EMLA. Secondly, the depth of LA is greater with
> >Numby (upto 10 mm as opposed to 5-6 mm with EMLA).
> >The nurses in our ED our divided on it use for IV starts. Some of the more
> >experienced ones seem to prefer to just go ahead and start the IV in one
> >stick. They find that 10 minutes of Numby with its attendant "burning" at
> >the site is not worth it. Moreover, they feel that the Epi in Numby causes
> >vasoconstriction and impedes proper vein visualization.
> >I have not reviewed the data to comment on its success or efficacy. For a
> >very anxious "needle-phobic" patient it may have a role.
> >Jay Pershad, M.D.
> >Lebonheur Childrens's Medical Center
> >Memphis, TN
> >For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> >The URL for the PED-EM-L Web Page is:
> > http://www.brown.edu/Administration/Emergency_Medicine/ped-em-l.html
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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