Needle phobia in minors (UK)

[Guest]

I'm not exactly the world's greatest needle phobia expert - so comments are invited on this one. I received the following e-mail:

"I need your advice on a desperately urgent matter. My 13-year old daughter has bad teeth, needs urgent attention because of the danger of septacemia, but has a morbid phobia about needles. We have tried every thing we can think of. What she needs is to have gas without an injection first, but we are told this is not possible, even though we are willing to sign any disclaimers. Our real fear is that she could die without attention. Please advise what we can do."

 

[Guest]

Hi all, Happy New Year

There are 2 questions to cover here, important one first.

It can be possible to do a GA without an injection, but you can't possibly absolutely guarantee it.

Sometimes, very rarely, during the induction of the anaesthetic, the anaesthetist NEEDS to get IV access. Immediately. Or preferably sooner than that

If that happens then you don't want to be in the position of trying to persuade a reluctant 13 year old to let you do it.

So as a dentist who uses GA a lot, I will never ever give patients (or their parents) the impression that it is possible to have a GA absolutely and definitely without needing to use a needle.
I will say that it's very unlikely and I'll explain as above, but if the patient is still insistent that they won't accept an injection under any circumstances, then I'm afraid that I can't help them. Maybe that's what's going on here.

Second point. You can't sign away your right to proper treatment. Doesn't matter what disclaimers you want to write up.

 

[Guest]

So what would you do if you were the parent of a 13-year-old with generalized needle phobia in danger of septacemia? Or as a dentist, how would you go about getting IV access? The situation appears to be quite urgent.
Any ideas appreciated - Thanks

 

[Guest]

They would get "the speech"...
"Listen, I can't guarantee that you won't need to have an injection at the hospital. We will make every possible effort to avoid it but it might have to happen. If I need to give you an injection, it will be to save your life. It will be a last resort, but if it needs to be done, then it really, really needs to be done. I'm sorry, but that's the way it is. I'm a dentist not a magician. Is that acceptable for you?"

If after that they still won't accept a GA, then it's really difficult. I've never encountered anyone who has refused treatment after "the speech", but it'll probably happen tomorrow now

You ask how I would go about getting a line in if it was an absolute emergency and the child was refusing? If it's a 13 yr old that I judge capable of witholding consent, then nothing happens, if she dies it's her choice. That's the law here in Scotland and I respect it.
If I judged her incapable of witholding consent then she would be restrained using the minimal force possible to allow me to get the IV in.
Again that is the law here.
Interesting discussion

 

[Guest]

What would you do if it was your kid? I know I'm putting you into a corner here... but hypothetically? Assuming you weren't a dentist. I know it's a tough one to call.

 

[Guest]

I'd like to put tuppence worth in here if that's ok? because I once was that 13yr old girl sort of and fortunately (or unfortunately seeing as how my mouth is now) nothing bad happened but nothing was resolved and I think if you can overcome these issues young you are going to save yourself years of suffering.

Gordon with the greatest respect (I quite like you ) whilst your 'speech' might work for 99% of the population and I wish it would work for a 100% it wouldn't have worked for me at thirteen and it wouldn't work now I would just accept I was going to die and that it was all my own stupid fault. In some ways I have been waiting to be so ill that the decision was taken out of my hands as in 'doctor she's unconsious and will die if we don't remove this tooth,' so they take it out I survive and wake up healthy wealthy and wise well at least one of those things! but it hasn't happened and I've been in pain for a decade on and off and it's no way to live your life and this child if helped could avoid all that.

I endangered my own childrens lives as a result of my fear of needles non of this stuff is logical or anything, normally I'm sensible and relatively intelligent. Fear of needles doesn't come from nowhere or maybe it does. I remember my mother (probably with the best will in the world) saying to me at an early age 'I'm not going to lie to you because then you wouldn't trust me you are going for an injection and it will hurt not a lot but a bit' I suppose all I heard was 'hurt' so they chased me round the surgery and held me down and it did hurt and any injection I had as a child followed that path. My youngest just finished her course of pre school vaccinations she has no fear and is quite ok with the whole deal. How have we achieved this? Well I'm out of the equation because if you put me in the same room as a needle any child would sense danger was afoot. So the bloke who is cool takes her along an injection in this house is called 'a poke' it works she's happy, relaxed, it's over before she registers any pain and she's very proud of her 'pokes' we never said it would hurt and we never said it wouldn't she made her own mind up and I'm not going to argue with her

For the child lc is talking about I would say maybe she needs to be in charge, outside of the need for treatment I would be trying to do stuff like getting her to put the numby gel on herself and try holding the needle giving herself a poke with it nothing to do with treatment or the possibility of death with just a sensitive person helping her figure it out herself without this huge pressure that she is no doubt under, worried people make you worry. I also think that avoidance stuff like using gas just brushes the problem under the carpet and I am the kettle calling the pot but she needs to be able to have injections for all sorts of reasons (you should see what I do all day and I'm not vaccinated against tetanus). I'm rambling a bit but might be worth contacting the Maudsly Hospital in London they do good behaviour modification stuff there and I'd say the whole issue needs looking at rather than just her need for dental treatment.

So I said tuppence should have said tenners worth hope no one minds

 

[Guest]

What would you do if it was your kid? I know I'm putting you into a corner here... but hypothetically? Assuming you weren't a dentist. I know it's a tough one to call.

I honestly can't say. It's outside of my experience with my own kids, who apparently have no morbid phobias about anything except tidying up their bedrooms

If the dental problem is as serious as they are making out, then I'm afraid that they have to bite the bullet and deal with it, and deal with the consequences later with a therapist if necessary.

Putting my dentist hat back on, I'd load the child up with benzos before she got anywhere near the hospital and she wouldn't remember if she'd had an injection or not. In fact she'd be doing well to remember she'd even been to the hospital...

 

[Guest]

I'd like to put tuppence worth in here if that's ok? because I once was that 13yr old girl sort of and fortunately (or unfortunately seeing as how my mouth is now) nothing bad happened but nothing was resolved and I think if you can overcome these issues young you are going to save yourself years of suffering.

Very good point.

Gordon with the greatest respect (I quite like you ) whilst your 'speech' might work for 99% of the population and I wish it would work for a 100% it wouldn't have worked for me at thirteen and it wouldn't work now

Eh, thought I'd come to Gordon's rescue here, not that he needs it ... I'm sure "the speech" doesn't occur in isolation, and only comes into play when other things have failed. It can be difficult to convey the full context of a situation on a message board.

I endangered my own childrens lives as a result of my fear of needles non of this stuff is logical or anything, normally I'm sensible and relatively intelligent. Fear of needles doesn't come from nowhere or maybe it does. I remember my mother (probably with the best will in the world) saying to me at an early age 'I'm not going to lie to you because then you wouldn't trust me you are going for an injection and it will hurt not a lot but a bit' I suppose all I heard was 'hurt' so they chased me round the surgery and held me down and it did hurt and any injection I had as a child followed that path.

Being chased and held down and then given a painful injection would do that to you. Especially the being held down bit.

For the child lc is talking about I would say maybe she needs to be in charge, outside of the need for treatment I would be trying to do stuff like getting her to put the numby gel on herself and try holding the needle giving herself a poke with it nothing to do with treatment or the possibility of death with just a sensitive person helping her figure it out herself without this huge pressure that she is no doubt under, worried people make you worry. I also think that avoidance stuff like using gas just brushes the problem under the carpet and I am the kettle calling the pot but she needs to be able to have injections for all sorts of reasons (you should see what I do all day and I'm not vaccinated against tetanus). I'm rambling a bit but might be worth contacting the Maudsly Hospital in London they do good behaviour modification stuff there and I'd say the whole issue needs looking at rather than just her need for dental treatment.

So I said tuppence should have said tenners worth hope no one minds

That's what message boards are for, otherwise I would've engaged in private e-mail correspondence ! I find your thoughts on the matter extremely interesting and thoughtful, especially since I've never experienced real needle phobia. Great tip about applying the numbing gel yourself and giving yourself a little poke (without the needle at first, I suppose), too - I'm planning to put up a sort of questionnaire/self-test thingy on the website in the near future, and would like to use your suggestion, if you don't mind.

London might be too far away in this particular instance, but I do think you've mentioned something really important here. Realistically, it's not going to be possible for anyone to avoid needles for the rest of their lives, and the sooner this is tackled, the better, because phobias don't usually improve spontaneously (quite the opposite, in fact). From reading both yours and Gordon's comments, right now I'd be inclined to say that the situation might be too urgent to allow for behaviour modification treatment - and the current concern is to ensure someone's survival. So I'd say, go the benzo route, knock 'em out, do what needs to be done. Then really sit down and find a long-term solution. The problem is, it's all too easy to forget about the latter once the situation lacks urgency.

 

[Guest]

Putting my dentist hat back on, I'd load the child up with benzos before she got anywhere near the hospital and she wouldn't remember if she'd had an injection or not. In fact she'd be doing well to remember she'd even been to the hospital...

Is it safe to use a large dose of benzos followed by general anaesthesia? If it is, it sounds like a runner...

 

[Guest]

I think I agree about the benzos too! as a short term crutch they work although I'd not just give them on the day of the work I'd start a day or so before with a lower dose and gradually increase the dose because I think it avoids the build up of stress and fear you are already calm and relaxed before the situation arises just a thought because it once worked for me

 

[Guest]

Very interesting discussion here - thought I'd add some of my thoughts.

Dental patients can often have either a general needle phobia or a specific dental needle phobia. Many patients quite happily have a needle in the back of their hand or arm for IV sedation because of their fear of dental injections!
It does sound as if this girl has a general needle phobia which makes treatment more difficult. In the long term it is essential that the cause(s) of the phobia is/are identified and addressed or the phobia will likey get worse. Although it is sometimes not that easy and there are many potential causes. I had an interesting case recently of a child of an IV drug abuser -after careful discussion he revealed that he believed that all needles were bad, as essentially needles had ruined his mother's and his life. A half hour chat separating drug abuse needles and medical needles resulted in the patient accepting treatment with no problem.

We are assuming in this case that simple techniques overcome a dental needle phobia to permit a dental injection are not possible at this time and that GA is required. I would therefore agree in this case it is important to get the urgent treatment done asap using 'premedication' (benzos) to facilitate the GA procedure. Certainly it is often helpful for the patient to take a small dose the night before to help sleep and reduce anxiety. Provided the anaesthetist and dentist are consulted with regards to the doses given there is no problem in using premeds prior to GA, or IV procedures.

An urgent referral to a child psychologist who has expertise in needle phobia, prior to the GA procedure would be my first thoughts here. I have done this on a few occassions and believe that it would be invaluable in this case. This could be arranged via the child's General Medical Practitioner - either following a phonecall or letter from the dentist or directly by the parents. However as waiting lists can be lengthy for GA I would be tempted to get this booked asap and try to arrange to psychologist based on the date of the procedure.

Regards,
Mike

 

[Guest]

I am a not really needle phobic, although I am scared of dentists, well not dentists in general, more dental injections etc. I am 16yo.

However my friend is extremely needle phobic, she does not vomit/pass out or anything like that but gets very distressed and sometimes violent a few years ago she went on holiday to America with her family, she suffers from bad asthma and got very ill while she was there and had to be admitted to hospital. To cut a long story short, she needed a drip but she wouldn't let them put it in and kicked 2 nurses in the process, so they left it and tryed to do it in the night when she was asleep, but that didn't work so eventually several of them held her down while the drip was put in. She was about 12 at the time I think.
This scares me, as I like to think I have control of what happens to me if you understand me, which is probably where my fear of dentists comes from as I can't see what is going on.
Do you think what happened is right?

If it's a 13 yr old that I judge capable of witholding consent, then nothing happens, if she dies it's her choice. That's the law here in Scotland and I respect it.
If I judged her incapable of witholding consent then she would be restrained using the minimal force possible to allow me to get the IV in.

How do you judge that? I don't understand, is that not an age limit or something?

Thanks
Karri
x

 

[Guest]

To cut a long story short, she needed a drip but she wouldn't let them put it in and kicked 2 nurses in the process, so they left it and tryed to do it in the night when she was asleep, but that didn't work so eventually several of them held her down while the drip was put in. She was about 12 at the time I think.
This scares me, as I like to think I have control of what happens to me if you understand me, which is probably where my fear of dentists comes from as I can't see what is going on.
Do you think what happened is right?

It's hard to say without having met your friend when she was aged 12 and knowing exactly what her medical condition was at the time. So the best I can say is maybe, sorry if you think that's a cop out.

In your case, you're 16 years old and in Scotland would be treated as an adult. If you were mentally competent you could refuse any treatment you wished. Full stop.

If it's a 13 yr old that I judge capable of witholding consent, then nothing happens, if she dies it's her choice. That's the law here in Scotland and I respect it.
If I judged her incapable of witholding consent then she would be restrained using the minimal force possible to allow me to get the IV in.


How do you judge that? I don't understand, is that not an age limit or something?

No there is no question of age limit. I have to use my knowledge and experience to try my best to decide whether or not the 13 year old is capable of understanding the results of their decision whether or not to accept treatment. It isn't an easy thing to do, but somebody has to make these kinds of decisions and the system is set up to attempt to give everyone equal rights to treatment.
For instance, if you were 15 years old and went to the dentist in the USA with raging toothache, a 100 dollar bill in your pocket to pay him with and begged for your toothache to be sorted, you couldn't have anything done unless your parents were there in person to give their consent. Do you think that's fair?