Infant Motrin? I think Not

This week I read an article by Novak and Allen: “Prescribing Medications in Pediatrics: Concerns regarding FDA approval and Pharmacokinetics”. The pediatric population is one that I am familiar with and enjoy working with the most. That being said this weekend I was exposed to some other than stellar medical care which made me think about what I would do if the tables where changed.



Brief story: I was working as an agency nurse this weekend in an ED and was asked to give a 10 week old Motrin (weight based dose 5o mg po) due to fever. Motrin is a drug that I have been taught not to give under 6 months of age. So I decided to one assess the patient myself then make a decision on the order. I went into the triage area to find a 10 wk old baby wrapped in numerous blankets. I asked the parents to unwrap the child and have only a light blanket to hold the infant with. I then passed by the triage nurse (engrossed in her computer, charting I am sure) and spoke with the ED MD who had written the order without assessing the child. I asked if he knew that the patient was a 10 wk old child. And he said yes and he felt comfortable giving the medication. I handed him the drug and asked if he wanted to administer it. To which he replied he never does. I explained that the child was wrapped in many blankets and suggested rechecking the temp after being unwrapped and doing a physical assessment and history. I then informed the busy triage engrossed in the computer (still charting I am sure, although she had no patients to triage) that I was not comfortable giving the drug nor would I. I then tried to pull up information regarding Motrin use and infants. As I suspected the FDA has not approved its use for those under age 6 months.

Fast forward to this article. Several key points where discussed. One of the first statements included that “Off-label” use of medications still required rationale scientific theory, sound medical judgment or data from controlled trails. This is of key importance to me. I highly doubt a nurse who is engrossed in her computer did a sound history enough to understand when the patient actually last had Tylenol or thought to unwrap the infant from the many blankets before urging the MD to give her a verbal order, to which she felt too busy to administer herself.

Novak and Allen also point out that although the Harriet Lane book is often differed to for appropriate children dosing, although  some medications described are also not approved by the FDA.

I reviewed my own pediatric dosage handbook by Lexi-comp and again it stated the safety and efficacy had not been established for infants younger than 6 months. Not that this information alone would stop me, but say the infant had an undiagnosed Patent Ductous Arteriousus. The lack of assessment and random administration of a drug without complete history and assessment puts the patient at risk.
At the end of the article this simple statement was made: "prescribing medication to children is one of the most complex and potentially dangerous functions pediatric advance practice nurses perform” (Novak& Allen, 2007, pp.69). I realize that my time on the ED floor is coming to an end, and that I will eventually be on the other side of care. But what seems most important to me is actually assessing the patient and determining the efficacy of treatment. In addition I think referring to professional colleges who have more sage knowledge in specific areas is also important. Never forget your resources. As far as my role currently as an ED nurse, I will continue to question orders I feel where written without precedence and hope that I can teach other nurses who may not be as vocal as I to also use sound judgment and assessment.


Novak, E. & Allen, P.J. (2007). Primary care approaches: prescribing medications in pediatrics: concerns    regarding FDA approval and pharmacokinetics. Pediatric Nursing, 33 (1), 64-70.

Taketomo, C., Hodding, J. & Kraus, D. (2009) Ibuprofen . In Taketomo, C., Hodding, J. & Kraus, D. (Eds.), Pediatric Dosage Handbook (pp. 899-902) Hudson OH: Lexi-comp.

Did I win the hearts and minds?

I wrote this while preparing to leave Iraq after a long year. I re-read it today.

On March 7th 2005 I volunteered to deploy to Iraq. I felt in my heart that it was what I was called to do. It wasn’t my job to defend our country or help another country re-build. My heart called out to me that I need to be in Iraq to take care of soldiers. You see that’s what I do. I am a Nurse. A long time ago I found my profession, which allowed me to care for others, which in turn gave my heart a personal reward of fulfillment. My mind and heart’s only wish was as any Army nurse, to care for and protect soldiers. So for me, my choice did not feel like a heavy burden or pain. I felt excitement and pride, a sense of fulfillment because I had made a choice to be in the Army. A choice I made because I wanted to care for soldiers.


Soldiers, brothers, sisters, family.


In June 2005 a rumor was spread that I would deploy. My excitement was met with mixed trepidation. My family, although proud of all I accomplished, was scared. Fear…I had not felt that emotion until the moment I caught my mother’s eyes. I was immediately torn…serve in what I felt was my duty, but with a strain upon those I loved.


In September 2005 I deployed to New Orleans to help with the Hurricane Katrina aftermath. I had the opportunity to have a taste of what life would be like. I worked in the EMT (Emergency Room) built from a tent at the convention center. I grew to understand and appreciate my co-workers, while having the opportunity to give back to my country and community in some of the most challenging experiences. With that growth and knowledge a glimpse of what was to become the for bearer came..."Politics”.


In Jan of 2006 my close friends and I knew that we would indeed be deploying to Iraq. Our mission was not as we had hoped for; instead we would be taking care of soldiers and Detainees at Abu Ghraib. We were to win the hearts and minds of the masses and reclaim our countries good name, after the negligence of others had tarnished it. I remember leaving my mom at the airport, tears in her eyes. I had caused her pain and now I was to have a mission I dreaded.


A thousand questions pass through your mind and your heart. The “what ifs”, came to life in my dreams. Two wounded...one a US soldier, another a detainee…who do you care for? What if they both have serve wounds? What if you can care for only one? What if one will die? How do you decide? “Remember your ethics training” the empty voice repeats over and over again. “Remember the Geneva Convention, remember the rules of triage” the voice continues. But what about my heart? What if? What if it is me? What if I can’t make that choice? What if I do make that choice? Who will know but me? The truth lies deep inside.

Politics, media, mis-representation, smiles, nods, handshakes, thank you for… yes thank you. We came here to win the hearts and minds. Did we? Twenty four hours into our new lives, “Two marines IED”, my medics voice...breathe in Michelle…breathe out, “you have four inbound, detainees”, breathe in, “Ma’am we have four waiting for sick-call”...breathe out... “Ma’am there’s a call”…breathe Michelle.


I slept the first night with exhaustion. I awoke only once to the sound of Chinooks…more patients I thought. My days seemed to mix. Busy...slow…there was a fair amount of US solider trauma, detainee trauma, aches and pains. No tough choices.


“Smile”, a whisper went into my ear. “Hello Sir”, “Yes”, “We’re good Sir”. Politics, reviews, tours. We closed the infamous Abu Gharib. We moved from one small FOB to a smaller fishbowl, straight in the heart of politics and garrison life. The day we separated from our small home, I felt saddened with the knowledge that I would see fewer and fewer soldiers and more and more politics. It wasn’t just me that felt the change. Almost instantaneously people’s lives were surrounded by “evaluations” and “accomplishments”. With this came a strain of confinement. Winning the hearts and minds became more painful.


Can you give 100% of compassion and care to someone who may have hurt your brother, your sister? Can you do it for one day? How about two days? Ten? How about 150? My friend did. Day in and day out she gave. While I was sheltered in the Emergency Room, I watched as my friend gave and cared. She did it and it hurt. My momentary emergency room triage, evaluation, patch work, was nothing compared to her work. That work changed all of us. We all grew apart and together like an enigma. Pulled at two polar extremes. Our defense at times was to lash out against ourselves. We did it for the anguish, pain, frustration and fatigue we felt. The confusion and strain of our jobs caused a roller coaster of emotions, upsets, and heart aches.

In a job like ours it would be easy to allow the weight of the world, of “politics” to weigh your heart and mind down. “They” say that under stress people band together. We did, my friends and I. We made a mafia of friends. We gave each other strength and encouragement. We found ways to laugh and have fun despite our fishbowl.

The fishbowl, you see, is we now lived. The eyes of the world were on us, even though our neighbors to our left and right had no idea who we were, or what we did. It was this fishbowl that proved to magnify the “politics” that surrounded our job.

Our year is almost complete. Although it sounded like a jail sentence, it was a life experience. We as a collective group watched as mortars flew over our heads and landed 75 meters from our hearts. We felt the sting of “CS” gas, and the scare of M9 rounds clamoring around us. But with that there was more. We learned about the culture in which we were submerged. Both US forces and Iraqi alike. We cared when others might not have. I know now more than my peers will ever learn in their “school books’ and spoon fed educations. A fact that to this day causes me to pause while I listen to them make claims of knowledge and understanding.

I learned also about something others may never truly understand. I learned about Philia, a love for my friends. I love my friends as my brothers and sisters. I understand now, how our lives will forever be intertwined. I also learned how to listen to my own heart and soul. I lived and experienced, I made history. And with all this is the knowledge that by no means did I do any more or any less than my peers. I just simply did.

What lies next in the chapters of my life? The next “what if” to ponder. If there was a word that meant more than a simple “thank-you”, more than gratitude, above the simple and equal to the gratefulness that overfills my heart. I would give it. First to my family, then to my friends. To my co-workers, fellow soldiers, to my brothers and sisters.

It has been five years since that point in my life, and so much has changed. I am forever grateful for my journey. My life constantly gives me the tools to succeed. God, my family, my friends, my mentors and even random

patients teach me every day. And for that I say from my soul, Thank you
~m