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nicole.schoolRN nicole.schoolRN (New Member) New Member Nurse

Asthmatic emergency

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I have a student that has severe asthma. When she has an attack, I immediately give her a nebulizer treatment which is the only medication that I have in my clinic. Let me tell you, her attacks are scary! She wheezes, has contractions and my pulse ox reader normally registers her O2 at 94-95%! After treatment, contractions and wheezes are gone but her O2 usually doesn't get much higher than 97%.

Last week, she came in for a treatment in the early morning but returned an hour later, having another attack. Mom was working as a sub so I immediately paged her. After an assessment I offered to call 911 but mom was hesitant. Mom did give her an inhaler, and it helped a little bit. I called her pediatrician because I knew she needed help but I didn't want to overstep mom and call 911 without her permission. I'm a new school nurse and still get anxious about those kind of things...

Long story short, Mom took her to the pediatrician after the student calmed down a big and she was admitted to the hospital for a couple of days. Mom stopped by the clinic this morning with an update and informed me that the next time this happens, I need to call 911 immediately, not her but 911. I was taken back seeing how I suggested that last week and she said no.

Anyways, I'm curious when would you call 911 for an asthmatic patient? I don't want to be put in that situation again. Now thinking about it, I feel like I should call 911 on her initial attacks because they are so bad! Help..new school nurse and I'm second guessing everything!

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When I hear "severe" asthma it usually means the condition is not managed properly or the management plan is not consistently followed. I believe the best treatment for acute episodes of bronchospasm is an albuterol MDI used with a spacer...not a nebulizer treatment.

Don't 2nd guess yourself about not calling 911. Under the circumstances you describe I would not have called either. But now you know what this parent wants you to do so go for it.

I still think there is some management/compliance/lack of teaching/understanding issue at play here.

Good Luck, welcome to the farm!!

 

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15 minutes ago, nicole.schoolRN said:

Mom stopped by the clinic this morning with an update and informed me that the next time this happens, I need to call 911 immediately, not her but 911. I was taken back seeing how I suggested that last week and she said no.

 

I agree with Old  Dude, there has probably been a history of lack of education/compliance. I'm wondering if mom got an earful from the pediatrician she's relaying to you what the pediatrician told her. 

Don't beat yourself up over this. This can be a tough gig. But, never second guess yourself about calling 911. 

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You showed immense self control with that mother. I would have been much more transparent that my call was 911 and you overrode it. I would have reminded her that my training is this and sometimes you should defer to that.  Go with your gut, your critical thinking is your friend. 

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1 hour ago, OldDude said:

When I hear "severe" asthma it usually means the condition is not managed properly or the management plan is not consistently followed. I believe the best treatment for acute episodes of bronchospasm is an albuterol MDI used with a spacer...not a nebulizer treatment.

Don't 2nd guess yourself about not calling 911. Under the circumstances you describe I would not have called either. But now you know what this parent wants you to do so go for it.

I still think there is some management/compliance/lack of teaching/understanding issue at play here.

Good Luck, welcome to the farm!!

 

Yup - and she did not improve with her inhaler or the albuterol in your clinic.

And you learned some things: 97% PSO2 is apparently WNL for this kid. It may be that s/he lives at 95-96% (again, I'd get heartburn but if that's uneventful for the kid, so be it).

What did her lips look like? Was she leaning forward in a position of comfort? Sternal retractions? None of the above? In the eight years I've done this, I've learned that the PSO2 is only one tool in my arsenal.

Don't even think twice about mom.Mom is a grown-up woman. Mom made the decision, not you.  Mom may be embarrassed and perhaps got a scolding from the doctor because see OD's first sentence - nebs are the last line of defense.

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So, my background is in acute care pediatric pulmonolgy. Several thoughts:

- First, you did great. Don't doubt yourself if you think 911 needs to be called. The parent can always refuse transport if they get to the school in time. At that point, it's between EMS and mom. That's just you calling for back up.

- I'd recommend getting an asthma action plan (AAP) from the pediatrician. These allow you to do back to back treatments up to three times. Typically, I call the parent to pick up the student if it's looking like they will require a third treatment. That's what I'm comfortable with though. You could require a parent to come when a second treatment is needed. Either way the AAP still allows you to give additional treatments, which is extremely helpful in these situations.

- Old Dude is right. An MDI with a spacer, taken properly, is just as effective as nebulizer treatments and they work faster. In the children's hopsital, as soon as a patient was down to q1 or q2 albuterol treatments they would use an MDI (even if the dose required was as much as 8 puffs).

- 94/95% honestly doesn't freak me out so much. Obviously they can't stay there, but it's not like their brain isn't getting enough oxygen. For me, it's more about how they look and how their lungs sound. How much are they "working?" Now, if a kid is sitting at 96% for a half hour and looking tired, with tight lungs (not much wheezing) that scares me a lot more than the talking/happy kid at 94% that just came in with wheezing only on auscultation. The pulse ox is just one tool, like Ruby said. Use your assessment skills first and foremost. (Side story, I had an 11yo who would sat 98% right up until he would crump to the 70s and nearly need intubation. He would present with a tight, intermittent cough, little to no wheezing with adequate sounding aeration, and 98%. Fast forward to post 3 treatments each 20 minutes apart and he's actually legit wheezing upon auscultation. This kid was THAT tight with sats of 98% the whole time.)

- My threshhold is 92% or below. That gets an immediate call to 911 while I'm doing the first treatment. 93-96% is treat and reassess, then call if symptoms don't improve and a parent can't get there in less than 10 or 15 minutes (obviously, if there is massive WOB going on this is a grey area between observation and immediate 911 call). 97% and above is normal. And by 97%, I mean solidly 97, not dipping to 96 with ambulation/talking. 

- Finally, to reiterate, don't EVER feel bad for calling 911. You are alone. You have to triage and call when you are feeling out of your ability to care for the student in an out of hospital setting. Parents are going to be pissed, or they will make you seem like you overreacted or underreacted. At the end of the day though, you need to do your best to keep your patient safe, not keep the parent happy. 

Welcome to our weird little world! We are here if you ever have any questions and are happy to have great nurses around!

Edited by pedi_nurse

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The second you even consider calling 911 is the moment you should start dialing. I'd rather have a pissed off parent than a dead kid. 

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5 minutes ago, Wuzzie said:

The second you even consider calling 911 is the moment you should start dialing. I'd rather have a pissed off parent than a dead kid. 

This every day of the week!!!

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i agree - this is sort of a gut, have to be there type thing.  You will get a feel for what is normal for your kids and unfortunately, it may mean erring on the side of caution and having a few parents getting their dander up because you called EMS.  But like pedi_nurse said, if the parent comes to the school while EMS is there, they can always sign off on treatment and transport.  I'd much rather explain why I called than why i didn't.  You may feel differently the third, fourth, eighth or fifteenth time you see a kid in the same scenario, but if your nurse spidey senses tell you 9-1-1, then don't second guess yourself.  

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We use a Clinical Respiratory Score rubric and you get either a 0, 1 or 2 in 6 categories. The highest score is a 12 with 8-12 being considered severe to life threatening. A sat of 90-95% gets you a 1. So I agree that it is an overall picture and not just one thing.
I also agree - if you think about 911 then go with your gut. 

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Personally, I would have stood my ground. "Mom, based on my assessment, your child needs immediate evaluation. We can call 911 or you can transport him / her to the ER immediately. What is your choice?"

I would also be demanding an asthma action plan and necessary medication / supplies listed on that plan. No, next time you need to verbal info from that mom!!! 

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I had a similar asthmatic emergency yesterday as well! The 6 year old was coughing and wheezing like her normal attacks but about an hour and half after treatment was back having trouble again. I called Mom to take to the ER, I felt like she would be fine to wait, but then about 20 minutes later I noticed she was just not right and sats had gone from 95% to 88%. Immediately I called 911 and really freaked out grandma who had arrived just then to get her. They ended up transporting her to the hospital. She was released last night and is at home today. Even in my sixth year as a school nurse, I still can get a little hesitant about when to call. I do need to remember the minute I even think about dialing 911 that I should just call. That's a great thought! I keep kicking myself that I didn't call for her earlier yesterday but I'm glad I did, even if parents are mad about it.

It is a very different world to work in the school setting, but I feel so much better hearing about everyone's experiences. Helps me not feel as alone. :)

 

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