Are you calling 911?

lifelearningrn, BSN, RN · Oct 11, 2020

I think you did everything right.

Sometimes the spo2 dips if you're not taking deep enough breaths. Was her breathing labored? Lips blue? It seems all her vitals were fine except the occasional dips in o2.. that quickly rebounded.

lifelearningrn, BSN, RN · Oct 11, 2020

As a parent, I'd be thanking you for over reacting.

ruby_jane, BSN, RN · Oct 14, 2020

That is excellent documentation. It is absolutely normal after a near event to revisit the steps you took in the interest of self-improvement.

First: You had NO way of knowing that the kid did not eat breakfast and SECOND - that's not usually how kids who are hangry present!

What did the breath sounds do when you auscultated? Was she wheezy? I tend to give more credence to a flailing PSO2 if the kid is wheezing. If the kid is not turning blue and not positioning for comfort in tripod position - I feel better about that 93%. As an adult-onset asthmatic I will say that when I need to cough sometimes my PSO2 looks low (like 92) but a few deep breaths and a cough will get it back up. My favorite doc used to tell me never to trust the PSO2. Look at the student. If there's a blue tinge to the lips - that's bad no matter what the PSO2 shows.

Having said all that - the parent was not clear whether the kid had asthma so you could not rule it out. When mom got there the kid worsened and became lethargic (so mom saw that, too). You NEVER go wrong calling EMS. You did not force mom and kid onto the rig. That was a mom call (although I am sure you would have documented the pants off of "mom wanted to drive student herself against advice."

Finally - the auscultation is often the differentiator in asthma versus anxiety. I would bet a cup of coffee that the kid had status dramaticus in front of mom; that the lethargy resolved into relief that mom was there, and let me repeat myself: You and your partner did the best you could with what you had at the time. I would not have called EMS at the beginning but you describe (and hopefully charted) a clear decline with the end result as: We just don't know but we don't want to chance it.

School nurses fly by the seats of our scrubs. There is no shame in getting that OUT OF HERE because we do not have the equipment to manage a sinking ship. Hang in there!

SaracaraRN05 · Oct 14, 2020

I'm a RN with 10yrs experience. I recall from nursing school I can never forget.." From your very detailed post of actual situation, you guys are excellent nurses. " you went with your nurses instincts." The child presented with what described as being in possible acute respiratory distress, reported SOB and chills. No medical hx or meds on file, the parent seemed unsure. In settings like schools you I would believe theres limited resources to assess a child, your " Nursing Assessment" is in my opinion is most important. As a parent, even though the outcome was stable I would be thankful as the kids are like your own when caring for them. Your excellent nurses and compassionate. Good job.

LovingPeds, MSN, APRN, NP · Oct 15, 2020

It sounds like you did a very thorough assessment. This possibly could be used as a learning experience in order to develop a policy plan for these types of emergencies.

From a liability standpoint, if the unforeseen happened and this child did have difficulties, became unresponsive, or stopped breathing on the 3 minute ride to the ED or in the event of a traffic delay in time of arrival under those circumstances, then nursing staff could be held negligent for failing to notify or wait for 'appropriate medical transport'. Especially if the documentation mentions the word 'lethargic' after a child states "I have breathing problems". You have enough to qualify an emergency call for medical transportation.

I have to attend several 'conferences' a year on limiting malpractice liability per my employer to meet requirements for malpractice insurance discounts. They present a lot of interesting cases. This just seems similar to one of the cases reviewed from an office setting where the nurse accompanied a 'sick but stable' child to the ED by private vehicle. There was an accident on the way to the hospital which wasn't far and the child suffered significant injuries in the accident. The nurse and her employer were then sued for malpractice after the family's attorney blamed the 'emergency' for the accident (and their erratic driving) and then claimed that the child's condition was too bad to have been driven by private car and that there was negligence in failing to provide 'safe and timely access to appropriate emergency medical assistance' when they failed to call EMS for transport. It ended in a settlement and the end result of the insurer's recommendation that if a child is 'sick' enough to require medical presence in transport then they really just need EMS transport.

The moment you decide they're sick enough to need a nurse with them while being taken, you've already decided they need close medical monitoring. It would be best to just make the call and wait out their arrival in the nurse's office rather than risk the unknown in a vehicle on the road away from any supplies that may help you in case of emergency.

Good job handling a tough situation! Glad the kiddo was okay.

DeeAngel · Oct 15, 2020

Sounds like the parents are bugged about the cost of the ambulance....

cmh1118, BSN · Oct 15, 2020

On 10/11/2020 at 6:02 PM, lifelearningrn said:

I think you did everything right.

Sometimes the spo2 dips if you're not taking deep enough breaths. Was her breathing labored? Lips blue? It seems all her vitals were fine except the occasional dips in o2.. that quickly rebounded.

Thanks for the assurance. No blue lips, no labored breathing. It definitely did improve her O2% when I made her take deep breaths. It never stayed low, only when she stopped the deep breathing.

cmh1118, BSN · Oct 15, 2020

On 10/14/2020 at 8:58 AM, ruby_jane said:

That is excellent documentation. It is absolutely normal after a near event to revisit the steps you took in the interest of self-improvement.

First: You had NO way of knowing that the kid did not eat breakfast and SECOND - that's not usually how kids who are hangry present!

What did the breath sounds do when you auscultated? Was she wheezy? I tend to give more credence to a flailing PSO2 if the kid is wheezing. If the kid is not turning blue and not positioning for comfort in tripod position - I feel better about that 93%. As an adult-onset asthmatic I will say that when I need to cough sometimes my PSO2 looks low (like 92) but a few deep breaths and a cough will get it back up. My favorite doc used to tell me never to trust the PSO2. Look at the student. If there's a blue tinge to the lips - that's bad no matter what the PSO2 shows.

Having said all that - the parent was not clear whether the kid had asthma so you could not rule it out. When mom got there the kid worsened and became lethargic (so mom saw that, too). You NEVER go wrong calling EMS. You did not force mom and kid onto the rig. That was a mom call (although I am sure you would have documented the pants off of "mom wanted to drive student herself against advice."

Finally - the auscultation is often the differentiator in asthma versus anxiety. I would bet a cup of coffee that the kid had status dramaticus in front of mom; that the lethargy resolved into relief that mom was there, and let me repeat myself: You and your partner did the best you could with what you had at the time. I would not have called EMS at the beginning but you describe (and hopefully charted) a clear decline with the end result as: We just don't know but we don't want to chance it.

School nurses fly by the seats of our scrubs. There is no shame in getting that OUT OF HERE because we do not have the equipment to manage a sinking ship. Hang in there!

Thank you so much for your response and reassurance. I was thinking that myself, about the status dramaticus once Mom showed up. No tripod position, honestly she was just laying down quietly and looked peaceful for the most part. It would just dip when she didn't take some deep breaths, and as soon as she did it would jump back up into high 90's. I appreciate the reply!

cmh1118, BSN · Oct 15, 2020

10 hours ago, LovingPeds said:

It sounds like you did a very thorough assessment. This possibly could be used as a learning experience in order to develop a policy plan for these types of emergencies.

From a liability standpoint, if the unforeseen happened and this child did have difficulties, became unresponsive, or stopped breathing on the 3 minute ride to the ED or in the event of a traffic delay in time of arrival under those circumstances, then nursing staff could be held negligent for failing to notify or wait for 'appropriate medical transport'. Especially if the documentation mentions the word 'lethargic' after a child states "I have breathing problems". You have enough to qualify an emergency call for medical transportation.

I have to attend several 'conferences' a year on limiting malpractice liability per my employer to meet requirements for malpractice insurance discounts. They present a lot of interesting cases. This just seems similar to one of the cases reviewed from an office setting where the nurse accompanied a 'sick but stable' child to the ED by private vehicle. There was an accident on the way to the hospital which wasn't far and the child suffered significant injuries in the accident. The nurse and her employer were then sued for malpractice after the family's attorney blamed the 'emergency' for the accident (and their erratic driving) and then claimed that the child's condition was too bad to have been driven by private car and that there was negligence in failing to provide 'safe and timely access to appropriate emergency medical assistance' when they failed to call EMS for transport. It ended in a settlement and the end result of the insurer's recommendation that if a child is 'sick' enough to require medical presence in transport then they really just need EMS transport.

The moment you decide they're sick enough to need a nurse with them while being taken, you've already decided they need close medical monitoring. It would be best to just make the call and wait out their arrival in the nurse's office rather than risk the unknown in a vehicle on the road away from any supplies that may help you in case of emergency.

Good job handling a tough situation! Glad the kiddo was okay.

Thank you, this is a wonderful response. I appreciate you sharing about the malpractice/liability standpoint. That makes a great point about medical presence and EMS transport. I think in the heat of the moment we thought, OK she literally just declined while Mom is right here, it will take an ambulance minutes to show up, the hospital is just right down the street, etc. I totally understand it could have gone bad on the drive there and luckily didn't. I think it was more of "I'm here, I'll accompany her if you'd like" and Mom jumped at it. Looking back is when we thought of all the "what if....."s . Hindsight is of course 2020. I appreciate the reply and it definitely was a learning moment.

Guests · Oct 15, 2020

You followed your nursing instincts and the family should be grateful. I will never forget, many moons ago when I was a fresh in the field PNP, I had a baby come to me for his 6 month well visit. It was middle of Winter and he had a snotty nose and just looked sort of "off". Per Mom, he had been slightly more clingy, but was taking his bottle fine, peeing, pooping, active, etc. When she took his clothes off I noticed he was retracting and on auscultation he was wheezing. SPO2 was 95%. I ended up nebbing him twice in the office and he continues to wheeze, but more than anything else, he just gave me a bad feeling that I could not really explain. I consulted with my attending and said that I did not feel comfortable sending him home. After going back and forth for a while the attending told me to go with my gut and if I thought he needed to be admitted he would start the admission (I could not admit as a PNP). Long story short, I got a lot of push back from Mom and the unit saying it was "ridiculous" to admit a baby with a 96% SPO2 and in no acute distress. I maintained that something was not right. He got up to the unit and within an hour, crashed and coded ?. Spent a week in the PICU and was Dx with RSV. If I had not followed my nursing instinct, my guess is he would have crashed and coded in the car on the way home and lord knows what the outcome would have been. Things can go downhill VERY quickly. You did the right thing.

JenTheSchoolRN, BSN, RN · Oct 15, 2020

4 minutes ago, MHDNURSE said:

You followed your nursing instincts and the family should be grateful. I will never forget, many moons ago when I was a fresh in the field PNP, I had a baby come to me for his 6 month well visit. It was middle of Winter and he had a snotty nose and just looked sort of "off". Per Mom, he had been slightly more clingy, but was taking his bottle fine, peeing, pooping, active, etc. When she took his clothes off I noticed he was retracting and on auscultation he was wheezing. SPO2 was 95%. I ended up nebbing him twice in the office and he continues to wheeze, but more than anything else, he just gave me a bad feeling that I could not really explain. I consulted with my attending and said that I did not feel comfortable sending him home. After going back and forth for a while the attending told me to go with my gut and if I thought he needed to be admitted he would start the admission (I could not admit as a PNP). Long story short, I got a lot of push back from Mom and the unit saying it was "ridiculous" to admit a baby with a 96% SPO2 and in no acute distress. I maintained that something was not right. He got up to the unit and within an hour, crashed and coded ?. Spent a week in the PICU and was Dx with RSV. If I had not followed my nursing instinct, my guess is he would have crashed and coded in the car on the way home and lord knows what the outcome would have been. Things can go downhill VERY quickly. You did the right thing.

It is stories like this that always have me go with my gut. It is also why I try and listen very carefully when a parent says they have a gut feeling something is up with their kid. Because you know what - that gut feeling is often right.