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Before the Shot.


Norman Rockwell, the fabled American painter, had a firm grip on more than his camelhair brushes; he had a grip on the American spirit. Rockwell was fond of saying, "If a picture wasn't going very well, I'd put a puppy in it."

One of his most memorable renderings was that of a young boy with his pants down, standing on a chair in a doctor's office. While the youngster is carefully reading the diploma on the wall, the doctor is seen in the background preparing a syringe. It's obvious an injection is in the boy's very near future. Not only was this one of Rockwell's most memorable paintings, it was also one of the most reproduced and distributed. During the 1930s right up until the 1980s and beyond, just about every General Practitioner had a reprint hanging in the office. It was and still is found on calendars, mugs, prints, lampshades, wallpaper, and pillows. It was called "Before the Shot, A Study for the Doctor's Office." There is no telling how many young people it influenced into becoming doctors.

Norman could have done more for "us" (us being physicians and dentists working in the field of developmental disabilities) if he had bothered to paint another heartwarming scene in a medical setting. How is this for a Rockwellian scene?

Doctor's examining room, white walls with one open window showing that spring had sprung outside. A mother--young, pretty, blonde, wearing a blue cardigan, pearls, and a pleated skirt--is sitting on an armchair with her eight-year-old son, who is wearing dungarees (this predated jeans) with a five-inch cuff, a Brooklyn Dodgers T-shirt, and a coonskin cap. The young boy's head is turned away from her. He's not crying, but he's not happy. It's obvious he would rather be back home in his backyard or settling down to watch Lassie on the family's black and white Dumont with rabbit ear antennas. The mother has her arms lovingly wrapped around her son's torso while the doctor, in his long white coat, steadies the boy's head with his left hand and begins to raise his right hand with a shiny otoscope to examine his ear.

Sweet. Touching. Memorable. Familiar. Rockwellian. American.

This scene is well known to mothers and fathers around the world. Mothers and fathers have been helping to position, stabilize, and protect their children in medical and dental procedures since William Jenner first vaccinated James Phipps, an eight-year-old boy, for smallpox in 1796. You can bet young Jimbo had to be held for that historic ordeal.

Injections, eye baths, earwax removal, throat swabs, applying iodine, cutting off a cast, examining a tooth, removing adhesive tape, even cutting hair, or clipping toe nails have never been pleasant undertakings. Even when the pain was perceived but not felt, it wasn't pleasant. The reassuring yet firm stabilizing intervention by a mother or father did the trick. In fact, for the parent not to have held their child would have been considered "unparental."

In situations where the parent was unavailable, when the child was brought to the emergency room from a sleep-away camp or from school, the doctor would ask his or her nurse or dental assistant to play that role and compassionately and momentarily restrain the child.

Jump cut 40 years later. Same scenario except the child, in addition to having excessive earwax or a broken tooth, also has Down syndrome, cerebral palsy, autism, or any number of conditions associated with intellectual and developmental disabilities. Only this time the dentist and dental assistant, performing the same short duration stabilization are charged with physical abuse, improper use of physical restraint, and possibly assault. The scene becomes more Orwellian than Rockwellian.

This scenario of a dentist or physician facing charges of employing physical restraint on a child or adult with a disability stands as a formidable reason for clinicians to avoid caring for patients with complex disabilities. Sadly, many dentists and physicians who have cared for our population for years have decided that the potential liability is reason enough to exclude them from their practices.

For clarification purposes, I am not referring to the use of restraints (of any kind) that are used for the convenience of the staff or because of time saving or financial considerations. I am not speaking of restraints that are used as a first measure before documented trials of desensitization. I am specifically referring to the use of short interval stabilizing maneuvers, including the appropriate use of a papoose board when applicable in critical medical or dental procedures. Of note is that a thorough physical examination (including inspection, palpation, and auscultation) constitutes a "procedure." It often necessitates that a parent or assistant firmly hold a person's arms while they are pushing down on the abdomen to ascertain any abnormality. Without this the examination becomes ineffectual and invalid.

The use of the word "appropriate" in the appropriate use of restraints and stabilization is key. The astute clinician appreciates that any restraint is part of a multi-tiered approach to compassionate care. The need for familiarity with desensitizing, distracting, and acclimating techniques must always be the first generation of patient care. For the patient with intuitive or learned fears, sensory issues, low pain thresholds, discomfort in strange environments, apprehension with strangers or an inability to process the ongoing activity, the need for "steady as we go" needs to be incorporated into all practice cultures and regimens.


This cannot be approached as a "punch list" with half heartened trials and immediately moving onto the next "step." These initial steps are ideally repeated over time in a variety of settings. Even if the medical records demonstrated that previous attempts at desensitization were fruitless and that a restraining maneuver worked well, the dentist or physician has an ethical obligation to begin anew. It is not unusual that contributing factors (pain, time of day, setting, personal approach, uniforms, medications, hydration, bowel or urinary needs, hunger, temperature, music) will result in a different response from the same approach that was unsuccessful weeks before. Again, this requires a unique culture on behalf of the physician, dentists, and staff. Of course in a life-threatening scenario, the immediate concern is the "fast and furious," life-saving intervention.

Obviously some medical procedures carry different risk-benefit considerations. A four second intra muscular buttocks injection is different from a four second whirl of a high speed dental drill in the mouth. Both have potential for misadventures if the clinician cannot be assured of a safe, stable, and secure window of opportunity.

The ultimate restraint is, of course, sending the patient with a developmental disability to the operating room under general anesthesia. While under certain conditions this has its place in the clinical arena, it has its calculus of risk.

There is a greater risk in this story, and that's the risk of deferred, deprived, or denied treatment. This is the single biggest consequence of backing clinicians into a threatening corner regarding their ability to employ purposeful, compassionate stabilization.

Parents, caregivers, program administrators, advocacy groups, human rights and ethics committees, direct support professionals, and patients with special needs require education regarding the use of stabilizing and restraining protocols. They must appreciate that these procedures are being used in the continuum of the least restrictive environment with the end point being the best possible treatment outcome.

The dean of modern medicine, Sir William Osler, was fond of telling his residents, "Do the kindest thing and do it first." That adage should drive the clinician's decision to employ the "kindest" maneuver that insures the quickest, safest, and most effective doctor-patient transaction.

As Androcles found out, sometimes the rewards of firmly holding a limb while you remove a thorn announce themselves years later.

Rick Rader, MD, Editor-in-Chief

Director, Morton J. Kent

Habilitation Center

Orange Grove Center, Chattanooga, TN
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Title Annotation:ANCORA IMPARO
Author:Rader, Rick
Publication:The Exceptional Parent
Geographic Code:1USA
Date:Apr 1, 2008
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