ambulance for a luxated patella?

[craff1]

I'm working as a sub-teacher while I finish my pre-nursing regimin. Yesterday a high school girl stood up only to fall back down by her desk. She had a luxated patella. I sent a student to get the nurse to come w/ a wheelchair and ice pack. (No phone or intercom, isn't that lovely?) Nurse came. (She is an MD from Pakistan or something, hasn't been certified to practice medicine in the states so is a school nurse now.) She was pretty well panicked by the situation. She wanted to call the parameds to the classroom. (She thought they would reduce it there at school.) I said wheel her to the office and call the parent (mom works in a hospital). I didn't think they would reduce it w/o pain meds, and didn't feel that the situation was emergent enough to warrent an ambulance. What was the proper course of action?

[P_RN, ADN, RN]

Well a locked knee is an orthopaedic emergency. I suppose that if the girl were in enough pain that EMS MIGHT be handy so that she wouldn't have to wait out in triage forever. But I think your suggestion is fine as long as Mom can get her seen asap.

[super nurse 2]

i don't know if a luxated patella is the same as a subluxated patella but my daughter had the latter. she had been outside playing basketball. i called an ambulance. we hit a bump in the road on the way to the hospital and it went back into place. fortunately i was on my day off from working icu in the hos. so the orthopod. trusted my judgement. as it turned out she had internal bleeding, which he aspirated, and she had to be in a cast for 4 months. when in doubt call the ambualance. they have the appropriate equipment and splints which mom probably doesn't have.

[RNed]

It is always difficult to determine what the parent would say regarding the injury, when that parent is a nurse of other health professional. However, it is probably better to be on the safe side.

I think the clue here is how the patient is responding to the injury more than anything else. If in extreme pain and signs indicated a serious injury or if serious trauma was involved EMT access would be appropriate. However, if the patient is sitting and not showing physical signs of extreme pain and one witnessed the trauma, which was minimal as described, I would have called the parent for a guide to the next coorifice of action.

My daughter stubbed her toe here at the house. Serious stubbed toe, black and blue swollen and for all practical purposes broken. Being a past x-ray tech and present ICU nurse, I iced it, I taped it next door to the good toe and sent her to school. No ER, no x-rays but fairly certain she had broken it.

She goes to school comes back and relates a senario of teachers and the school nurse concerned over parental neglect. Took a week dealing with this and the school and finally had to tell them to call CPS if they were that darn concerned.

I am not sure what is the best coorifice of action, in today's atmosphere, you are darned if you do and darned if you don't. It sounds as though you took appropriate actions in securing additional help and that is what counts. Sometimes there is no right or wrong answers. You got help and that was the right thing to do.

[WashYaHands]

(She is an MD from Pakistan or something, hasn't been certified to practice medicine in the states so is a school nurse now.)

OUCH!!!! :) I feel so......reduced.

Most schools with RN's or LPN's have protocols for such emergencies. The protocols include a plan of action and school nurses should develop a prearranged plan with contacts made in advance at a doctor's office or ER.

There is a degree of judgement call based on the students response to the injury and the mechanism of injury. If the student was calm, handling the pain, and additional assessment did not indicate circulatory or other problems, I would have applied ice and sent her to an orthopod immediately (with parental permission). If the students response was adverse or my assessment revealed additional problems, I would have called EMS for transport.

Parents must always be notified of injury, but if they are not available, treatment should never be delayed, especially in ortho injuries. Reducing the patella/joint should never be attempted at school by the nurse or any other school staff.

[CEN35]

and they are unbearably painful.......but generally (if i had to make a guess 99% of the time) they don't involve neuro-vascualy compromise. despite the "hitting the bump on the road" story........they don't usually fall back to place so easily. she definately needed pain meds.........before it shoud be reduced.......and let's face it legally? because of that 1% chance strectch of neuo-vasc issue poppping up? she would need a post reduction film anyways.

me :)

[Enright]

I have had multiple subluxed patellae over the years, both knees. I've learned to manipulate them back in. However, my first time was at 14 playing basketball in school. It is very scary when you do not understand; it also hurts exquisitely. The school nurse sat with me until an MD came (who just happened to be in the building). He reduced it.

Had the MD not been there, an ambulance would have been appropriate. I was scared out of my mind. As an adult I know better and can cope but a child may not have experienced this before. Since this is not an uncommon happening at school, it would help to have a protocol.

Back to the MD functioning as a nurse....huh? We have a separate body of knowledge. I recall when there was a glut of MDs in the 90's they would apply for DON jobs for which they were "not qualified".