“Can you help me with this?” one of my colleagues asked me, late Friday afternoon.
“ I’ve got a patient with a big abscess on her thigh. The parents tried treat it at home and she freaked out. I don’t do them if they’re this big. I don’t do lidocaine. And they don’t want to go to the ER.”
I do “do” lidocaine. Lidocaine is the local anesthetic that dentists or surgeons use for numbing the gums, or the skin. Otherwise, filling a cavity, or incising and draining an abscess, would be torture. But the injection itself burns. And more than that, the anxiety associated with getting a needle put into a very tender spot on the body may make the entire procedure impossible.
Since I had only one more visit for the day, a “virtual visit” for medication follow-up, I said yes. I went into the room with my trusty nurse Danielle. I will call this 7-year old patient Misty.
“Hi Misty,” I said. “I’m Dr. Dave. I hear you’ve got a big boo boo on your leg”
Misty was in no mood for talking. She was already terrified. In fact, she showed her fear by kicking the dressing tray that we had placed on the table onto the floor.
Her mom hugged her. Misty hugged her “lovey”, a Curious George doll. The abscess on her right thigh, had begun several days earlier as a pimple, and grown. This is typical for methicillin resistant staph infections (MRSA). Misty had never had an infection like this. Neither had anyone in her family.
Her parents had tried to squeeze pus out themselves, which is very painful. Now Misty was afraid of anyone touching it.
I examined the abscess. It was a big one, 5 x 5 inches, but “pointing”. It would drain easily, and she would feel a lot better afterwards. I talked to her mom, telling her that in the ER, they could give Misty a chemical anesthetic called “conscious sedation” so she would be basically asleep for the procedure. But her mom to did not want to go to the ER, with the potential for a long wait, and exposure to the growing number of Covid patients in our community.
So, if I was to do the procedure in the office, I would need Misty’s cooperation. She was a big seven year old. And my number one rule for office procedures, whether they be immunizations or incisions and drainages (called I & D’s) or anything else, is I do not have my patients experience the trauma of being held down.
Since children are often in a regressed state when they are fearful, and Misty was not in a mood to listen to me, I addressed Curious George, as if Misty were a pre-schooler.
“Hi Curious George,” I said, remembering his books from my childhood, “I hear you broke your leg once, when you were playing. It was crooked. But you knew what to do when the doctors were fixing it so it didn’t have to hurt too much at all!”
Misty looked as curious as Curious George. I looked at them both.
“I heard that you took some really deep breaths, and then you squeezed this squish ball really tight!
I said, showing a squishy stress ball with little protusions that lit up when the ball was squeezed.
I gave the ball to Misty.
“Now I’m going to clean your skin with some cool brown soap that may help you not feel it as much,” I explained to her. (Notice I said “may” because I don’t like to tell my young patients things that aren’t true.)
Now, I said, to her, and to Curious George, “Squeeze and take a deep breath in and out!”
As she did that, I began to slowly inject the lidocaine, as Danielle and her mom gently held her hands. I can’t say Misty did not feel it, or even that she did not cry. But she remained still. And the cry was more of a whimper, for only a few moments. I was able to easily achieve total anesthesia, make an x shaped incision with the sterile scalpel, open up the cavity with curved forceps, and drain a considerable amount of pus, which I sent for culture. Because the cavity was large, I packed with with sterile iodine containing gauze. Then Danielle cleaned up the wound and put on a dressing.
Misty’s mom and Misty were pleased with the experience. It had saved her an emergency room visit.
I had done a successful I & D. I would give her antibiotics and have her follow up in the office, to have the packing removed.
Most of all, Misty learned that she could use her imagination, and her breath to help herself get through a scary and uncomfortable experience —- a great life lesson. With the help of Curious George!