Takeaway
Some medical procedures are uncomfortable and do not go quickly or smoothly. The patient’s well-being and the need to complete the task must both be thoughtfully considered continuously.
Passion in the Medical Profession | October 14, 2025 | 5 min read
By Lealani Mae Acosta, MD, MPH, Vanderbilt University
As a neurologist supervising a lumbar puncture (LP) clinic, my focus is sometimes confined to a three-inch opening in the sterile drape over a patient’s lower back. Since I’m the attending physician who supervises the neurology residents in our LP clinic, that circle is sometimes punctuated by tiny red holes from where I have, or the resident has, unsuccessfully attempted to obtain cerebrospinal fluid (CSF).
The number of holes depends on my and the resident’s comfort level, experience doing LPs, and threshold of asking for help. Having done hundreds of LPs, I have a good grasp of when I’ll be successful and when I need to stop. The residents will sometimes ask for my assistance after a few attempts, at other times, after a dozen or more. When they need help, my job is to take over and find the space to obtain the CSF to assist with the patient’s diagnostic and/or therapeutic work-up.
One such patient was Sylvia, who had a deceivingly straightforward appearance, but whose anatomy proved difficult as we attempted a high-volume LP for a normal pressure hydrocephalus (NPH) evaluation. Sylvia was a tall, lean woman, so I thought the resident would have no problem getting into the space. Her vertebrae were easy to palpate, and our hands could easily span the iliac crest on both sides. For some patients with larger body habiti, we sometimes can’t find the bony prominences hidden under layers of excess tissue, so she seemed like a piece of cake. However, after several attempts over half an hour the resident hadn’t obtained CSF, and he asked me to take over.
“Aren’t you done yet?” Sylvia groaned as I palpated along her iliac crest and back. “I thought we’d be done by now. My shoulder is getting sore from being on my side for this long.”
“I’m so sorry that are you’re uncomfortable.” I did my best to both validate her feelings and reassure her. “We can’t see exactly where we need to go from the surface, so we have to use the landmarks from your body and what we’re feeling when we place the needle. Sometimes we can get it right away, but most of the time it can take many minutes.”
She sighed and grimaced as I palpated along her back. As gentle as I tried to be while traversing where the previous needle insertions had been, she was clearly sore, despite us giving her extra lidocaine. I offered more local anesthetic and she accepted. Her body seemed to churn through it in record time, and it took two extra administrations for the discomfort to be tolerable.
At every angle I navigated the Quincke, I encountered bony resistance. The nurse helping her remain in position adjusted the pillow under her head and assisted Sylvia in pulling her knees further to her chest, but to no avail. The patient understandably found the sensation of me working on her back very uncomfortable.
Navigating empathy
With situations like this, I navigate my options for empathy. I can be so empathetic that I stop the LP completely. I hate to make any patient feel pain, particularly when I’m the one directly inflicting it by inserting a needle in the back. At the same time, I know this will cause further delays in care because we would have to schedule for a fluoroscopy-guided LP on another day. Additionally, we wouldn’t be able to provide post-LP assessments of cognition and gait if the LP is done outside our neurology clinic.
Another option is to remain empathetic with the patient’s overall health and potential for benefit that I know we can best determine if we complete the procedure. Her doctor sent her for our NPH workup for a reason, so she may benefit from improved gait and/or cognition if we can obtain a large volume of CSF.
What I don’t want to do is be so hypnotized by that three-inch diameter of skin that it alone becomes my center of focus, instead of the patient’s well-being. At times, I’ve caught myself fixated on maintaining our LP Clinic’s 92-95% success rate. I have to factor in the patient’s comfort level in being able to continue the procedure. Beyond that, if I become too hyper-focused on that lumbar circle, I neglect to see if the patient’s back is twisted in a way that prevents the spine from remaining aligned or if they’ve inadvertently straightened out and lost that necessary curve to separate the vertebrae.
Open communication is key
After 15 minutes without success, I paused. We could stop and reschedule the procedure. I could try again in the same position. Or we could sit her up, which many patients find easier to maintain and often relieves shoulder pressure.
I said to Sylvia, “We haven’t gotten any fluid yet. We have three options: stop for today; try again as you are; or sit you up and try in a new position. It’s your call.”
“I didn’t come all this way not to get this done,” she said.
So, we carefully repositioned her to sitting while maintaining a sterile field. With the shoulder pressure gone, she was more comfortable. CSF flowed within five minutes. I’m not sure who was more relieved when we removed the needle—Sylvia or me.
Remembering the big picture
Experiences like this remind me to pause and remember what it means to give exceptional care and how best I can empathize with the patient. I can’t lose the forest for the trees: or, in this encounter, the patient for the CSF. Being an empathetic doctor entails both focusing on the task at hand in my narrow sterile field window and remembering the bigger picture of how my actions impact the patient as a whole.
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This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.