As an emergency medicine physician I frequently have to perform procedures on patients (or provide sedation as a consultant performs a procedure).

Of the procedures we perform in the emergency department and have time to discuss with families, the spinal tap, a.k.a. the lumbar puncture (LP for short), seems to instill the most fear in parents.

I exclude things such as intubation (placing a breathing tube) or thoracostomy (placing a tube into the lungs) — even when we have time to discuss those procedures with parents, we’re often not discussing it so much as telling them why the child needs it (there are exceptions to this of course).

Rogue One — Under The Bright Light

The city was Houston, TX.  The year was 2009.

After a difficult delivery, Rogue One came out having some difficulty breathing.  The obstetrics team called the pediatric/neonatal team to the delivery room.

One of my colleagues from my pediatric residency soon arrived, saw me, and remarked, “I didn’t know you were working on L&D!”

I replied: “I’m not.  That’s my son.”

I was a few months from finishing residency.  I was also in “dad” mode, feeling a bit stunned and helpless.

While his breathing problems were relatively self-limited, due to a confluence of concerns, the neonatal team decided Rogue One needed a spinal tap, aka a lumbar puncture or “LP.”  Due to a combination of circumstances, they were concerned about the potential for a serious infection.

By this time I had performed numerous LPs; I was quite proficient at them.  I was used to being the one explaining how we did the procedure, why it was necessary, and sometimes calming parents fears.

This time I was in “dad” mode, and they had to reassure me and my wife it was necessary.  We were not necessarily given a choice, but I did not protest.  Both of us were well acquainted with the procedure, and they did not spend time explaining it to us.

Having seen enough LPs on other children, I chose not to be in the room.   I know what happens in the room, and I decided knowing was enough.  My wife, recovering from childbirth, wasn’t well enough to attend.

The Worst Medical Show Ever

I’ve watched my share of shows based on doctors.  If you haven’t noticed my Twitter profile pic, I was a fan of the drama ER (until Dr Green died, then it just got silly).  Scrubs is not only the best “doctor” show ever made, it’s one of the best sitcoms/dramas of the past few decades.

My wife, on the other hand, fell in love with Grey’s Anatomy.

While this show causes me significant pain for numerous reasons, I’ve also watched many, many episodes.  Because, marriage.

But even lost in the unfathomable depths of Hades that is a full hour of this show, there is a glimmer of light.  A moment from an episode last season has stuck with me.

For perhaps the only time, I not only understood a character’s motivation, I could empathize with him and agree with him as he dealt with a stressful situation.

One of the many couple’s on the show had lost a child.  The couple still worked together, and had to talk someone else who had lost a child.  The guy decided to share his own experiences as a father losing a child and was able to use that to build trust with a patient.

The female character (I’ve forgotten their names and care so little about the show I don’t feel compelled to Google it) was appalled at him for not only sharing a personal experience with a stranger, but using it to connect with a patient.  She seemed to think it was cheating and a violation of personal information, to use their own tragedy to bond with someone not connected to their child.

Connecting with Parents

Working in an emergency department, I rarely know the patients or families of patients I am treating.  In many cases I only have a few minutes to build trust and convince them I am competent.

With a few years of experience, I’ve become better at building a rapport with parents and patients from the moment I enter the room.

Whenever possible I try to connect with them in ways that are not directly related to the reason for their visit.  I use the logos on their clothing to start a discussion, I’ll talk about sports or Paw Patrol or whatever happens to be on their phone or the in-room television or the kids stuffed animal.

More than once when a teenage patient is well enough to be using their smartphone to talk to someone, I have jumped into the phone conversation and started making jokes and talking to the person on the other end.

And when talking with parents who have brought young children, I liberally mention the fact that I have three young children.  When I’m really looking to break through, I specifically mention I have three boys.

It’s astounding the reactions this receives.  The child I’m taking care of could be getting admitted to the hospital, but mention that I have three boys and suddenly I’m the sympathetic figure.

Apparently just by surviving a short time with three boys and no girls, my wife and I are heroes.

I exaggerate, but only a little.  No, having a girl will not balance things out.  No, we’re not trying for number four.  Yes, it’s loud.  All the time.

The Parent Connection

When I am talking with parents a newborn that needs a spinal tap, and the parents are nervous or anxious, I will mention that my first-born had the same procedure when he was only a couple of hours old.  This usually catches their attention.

I can’t quantify whether sharing this tidbit really helps assuage parents fears or puts them at ease when I explain that I would only do the procedure if it was truly necessary, however I do believe it garners an incremental amount of trust that is necessary.

In our ER we let parents stay in the room for procedures if they want to be present. In other parts of the hospital this is quite uncommon (though not unheard of), as parents are not generally allowed to observe their child’s appendectomy, endoscopy, or biopsy — they  aren’t given the option.

In our ER, even when a child is in critically ill or near death and receiving chest compressions or other potential life saving interventions, we allow (and sometimes encourage) parents to be in the room.

Given the chance, many parents make a different choice than the one I made years ago — they frequently do stay in the room for any and all procedures, including the spinal tap.

So our environment presents challenges that other physicians do not encounter.  We not have little connection with the family prior to their visit, and they will be in the room silently judging us (and sometimes not silently) as we perform procedures.

What’s a Spinal Tap?

This link provides a decent overview of the procedure, though this is written for adults.  In young babies, the procedure is a little different in that the baby has to lay on their side (it can be performed sitting in some infants and in some older children and adults).  We often apply a numbing cream in advance and inject a local anesthetic before the procedure.

The baby has to be curled into the fetal position for the procedure, which makes them angry.  Apparently babies love that position in the womb, but hate it outside of the womb.  It is this positioning that often makes them angry — more than inserting the needle in many cases.

I’ve performed numerous spinal taps where the baby screamed when we positioned them this way, only to stop crying the moment we let them relax, without even reacting to the needle itself.

While I am proficient at this particular procedure, not all of the trainees have reached that point, and even experienced physicians such as myself can have a difficult time with this procedure (or any procedure).

Parents can often sense when things are not going well.  When the spinal fluid isn’t flowing and we’re troubleshooting, it’s stressful. If a parent senses we’re having difficulty with a procedure and start commenting, it raises the stress level on both sides.

Which is why I believe it is critical to build trust in advance by all means available — during a procedure I want my focus to be on the patient, not the parent.

If it means sharing a personal story so a parent realizes I don’t go sticking needles in kids backs willy-nilly and that I have some understanding of its importance and how to do it, then I am going to do so.  If that then lets them manage their anxiety and give just enough confidence in me that I don’t have to switch my focus, then the purpose is met even if the procedure is not successful.

The Real Meaning of Grey’s Anatomy

I’m fortunate that the three Rogue Boys are overall healthy.  We’ve gone through many illnesses, a few ER visits, and some outpatient surgeries, but nothing truly life-threatening.

Even had none of them ever had an illness, however, I believe just being a parent helps provide a little bit of a connection.  While Rogue One’s experiences with a spinal tap helps me in very specific circumstances, simply being a father helps the most.

It’s easy to sense when a family is skeptical of our evaluation or advice — in many cases when they are skeptical, they sometimes believe the doctor doesn’t know what they are doing, but more often that they may not have the kids best interest in mind.

While I often wonder at the cognitive dissonance that leads a parent to take their child to the doctor and then immediately question everything they are told, I also recognize why it occurs.  It’s not possible to care for a stranger to care as much about my child as I do.

The parent seeks care because they know their child needs help, but no matter how qualified, the stranger in the white coat simply can’t care as much about the child as the parent (side note — I hate white coats and never wear them).

It’s often that mutual recognition of parenthood — being a part of that club that has cared for their own child  — that builds trust.

More than the “MD” on the badge.  More than the hospital ranking proudly proclaimed on big signs out front.  Sometimes even more than the experience taking care of so many other sick children.  Sometimes being a parent is simply the best credential.

I never tell parents I was not present for the spinal tap.  If I relived that moment I probably would have made a different choice.  After watching enough parents stay in the room, it’s clear that it’s difficult for many parents to bear nearby, even the ones that stay silent.

I don’t regret not being there, but my “dad” mode has evolved over the past 9+ years.  I spend less time stunned and more time trying to be present for their most difficult, stressful, or important moments.

Some things they have to experience on their own, but some things you put yourself through solely because you’re a parent, even if it helps no one.  That’s part of the parent credentialing process, after all.