Ouchless (Pediatric) ER

From the Washington University (St. Louis) Record:

At one time, pediatric emergency medicine physician Robert M. "Bo" Kennedy, M.D., could guess, without even looking, how many patients were waiting for treatment in the St. Louis Children's Hospital Emergency Department. The loud cries of these frightened children, many of them in pain, always tipped him off.

With his trademark intensity, Kennedy decided they could do better. So in his research projects, he began to focus on alleviating children's anxiety and suffering from the moment they enter the hospital. Thanks to a range of regimens that he has developed in collaboration with colleagues in anesthesiology and psychiatry, the noise level in his department has noticeably tapered off.

"I really think that we have worked hard to become the 'ouchless emergency department,'" says Kennedy, who is also an associate professor of pediatrics. Along the way, some of his innovations have changed emergency room treatment worldwide.

"Bo Kennedy is simply one of the finest pediatric emergency physicians in practice today," says David M. Jaffe, M.D., head of the division of pediatric emergency medicine. "He is passionate about alleviating the pain and anxiety of children in the emergency department and has become a leader in clinical investigation in this area. Bo was here before our division existed, and we are fortunate to have benefited from his many contributions over the past 20 years."

Among the treatments that Kennedy has pioneered is the use of buffered lidocaine — injected with tiny, 30-gauge needles — to blunt the pain of starting an intravenous line. Even sleeping babies only stir a little but don't awaken when he hooks them up.

Another is the combination of two drugs, ketamine and midazolam, which he tested in children with forearm fractures who needed a painful bone realignment. The results were clear: ketamine worked better and caused fewer breathing complications than earlier drug combinations. Over time, the staff began using IV-administered ketamine for a variety of serious procedures, such as treating burns.

"But there were more minor procedures, such as suturing lacerations, where we really only needed a local anesthetic and lighter sedation," he says. "Using ketamine seemed like using a sledgehammer when a tack hammer would do."

Working with colleague Janet D. Luhmann, M.D., assistant professor of pediatrics, Kennedy began to take a fresh look at nitrous oxide or "laughing gas," often used in dental procedures. In small children with facial lacerations, was it as effective as midazolam or did the two work best together? The nitrous oxide had joyous results.