Not comfortable with my sub...(Warning: Long post)

[KKEGS, MSN, RN]

I cover 2 buildings and each has a full time health aide trained in CPR and first aid. They are both great and I trust them. Today the aide at my elementary school was out and we had a sub. This is the second time she has subbed and the first time (2 weeks ago) she missed giving a daily medication and did not reattach our Type I DM kid's pump after gym class. These instructions are clearly marked in the sub folder. The diabetic kid's parents realized he didn't have the pump at dinner time when they went to do his evening bolus and had to come to the school after hours to get it. Luckily they were pretty chill about it. I, on the other hand, was not.

Anyway, I spoke with our lead district nurse about it and told her that I would observe the sub today. She missed (or didn't check) for what I feel is a classic symptom of appendicitis. A fourth grader came down twice for a stomachache that started before lunch. No fever, no vomiting. She rested and was sent back to class. The third time the teacher called me directly to come to the classroom because she said she's pale and "just doesn't look well." I walked down there and this little one was heading back to the health office with her teacher crying and with her arms wrapped around her tummy. I went through all my regular questions: where? how long? did you eat lunch? gone potty lately? and then palpated her stomach. She had rebound tenderness in her lower right quadrant. I brought her back to the health office and had her lay down while I called her mother who came to get her.

Am I overreacting?

[Scottishtape]

I'm not a school nurse, so take this as you will.

I don't think you're overreacting to the insulin pump not being hooked back up. There were instructions, she did not follow them. It placed the child in a dangerous position.

I disagree with the second part though. A health aide who is trained in CPR and basic first aid should not be expected to know how to properly assess appendicitis in a patient. They have not had that education. The best I would expect would be to have her call you after the child presented for the second time c/o a stomach ache. Stuff like this is why I don't believe there should be "health aides" in school. It seems really dangerous to me.

This aide definitely needs some retraining.

[lifelearningrn, BSN, RN]

I'm not a school nurse, so take this as you will.

I don't think you're overreacting to the insulin pump not being hooked back up. There were instructions, she did not follow them. It placed the child in a dangerous position.

I disagree with the second part though. A health aide who is trained in CPR and basic first aid should not be expected to know how to properly assess appendicitis in a patient. They have not had that education. The best I would expect would be to have her call you after the child presented for the second time c/o a stomach ache. Stuff like this is why I don't believe there should be "health aides" in school. It seems really dangerous to me.

This aide definitely needs some retraining.

These are my thoughts too. Stomachache is such a common complaint and a layperson (even first aid and CPR trained) doesn't generally know how to assess for that. I had a kid with appendicitis earlier this year, and he didn't have rebound tenderness, just general stomach pain w/o other symptoms. This kid is a FF and I almost sent him back to class. The only reason I didn't was because he seemed to be truly in pain and to be on the safe side I called the parents and had him picked up. He had surgery that night. As a trained nurse, I almost sent that boy back to class.

[KKEGS, MSN, RN]

Thank you for your comments! You are of course right. I spoke with a fellow school nurse who reminded me that the aides do not get the critical thinking education that we do in nursing school.

[MrNurse(x2), ADN]

These are my thoughts too. Stomachache is such a common complaint and a layperson (even first aid and CPR trained) doesn't generally know how to assess for that. I had a kid with appendicitis earlier this year, and he didn't have rebound tenderness, just general stomach pain w/o other symptoms. This kid is a FF and I almost sent him back to class. The only reason I didn't was because he seemed to be truly in pain and to be on the safe side I called the parents and had him picked up. He had surgery that night. As a trained nurse, I almost sent that boy back to class.

.

... and the reason why the story about the boy who cried wolf is SO important. I have one who comes every day, sometimes multiple times. It is so tempting to blow him off, but it is always in the back of my mind, what if? Great pick up.

[JenTheSchoolRN, BSN, RN]

These are my thoughts too. Stomachache is such a common complaint and a layperson (even first aid and CPR trained) doesn't generally know how to assess for that. I had a kid with appendicitis earlier this year, and he didn't have rebound tenderness, just general stomach pain w/o other symptoms. This kid is a FF and I almost sent him back to class. The only reason I didn't was because he seemed to be truly in pain and to be on the safe side I called the parents and had him picked up. He had surgery that night. As a trained nurse, I almost sent that boy back to class.

I, too, almost missed appendicitis with a FF. Student visited me with general stomachache, first time rested and back to class; 2nd visit, I did actually palpate his abdomen, no rebound pain. Pain located at belly button. No fever, did report mild nausea. Something odd finally hit with the third visit and student vomited (still no fever, no other typical symptoms, not even reporting stomach pain during this visit, was pale and quiet though). I sent student home, but that odd feeling made me tell mom that if the vomiting continued, to follow up with a doctor sooner vs. later. Student was in the ED that night and had surgery early the next morning.

I'm a trained nurse that didn't even have any concrete evidence, just a weird feeling. And I started by brushing it off as a typical visit the first couple of times, so I can totally see why a layperson would as well.