Calling 911

[moreoreo]

How many times have you called? Have you ever called and then questioned yourself? Particularly when you were new to school nursing?

I have been working for nearly four months. Just as I was starting to get comfortable, I had my first "emergency" (a broken arm. I have to admit it was my first time ever seeing a broken bone, it wasn't the worst break but the student was in a lot of pain). I have called EMS three times in six weeks due to recess injuries, the last time being today. Today's arm, I am not even convinced was broken, but the student was in such distress she was wailing the whole time she was in the office. Mom was driving in from another town and twenty minutes in, I called the paramedics because we were needing to remind her to take breaths and she was starting to look out of it. (I am very familiar with the student as she is a "frequent flier" and have seen her cry before.) I guess I am looking for validation because once she had left (medics waited for mom so she could decide whether to transport in her car or have ambulance take care of it--she opted for ambulance) I was reeling for a while because I felt like I had made the wrong decision.

We are so inundated with visitors (sometimes up to 24 in an hour) during recess that I worry that maybe feeling stressed overall pushed me to call. Students continued to stream in while I was trying to focus on her and even though her injury wasn't an emergency, I didn't feel comfortable with her overall presentation. I had help of my health aide and a secretary during most of this time but the situation was somehow more stressful for me than the other times when there was clearly a broken bone involved because I had doubts--I didn't want others to think I had overreacted considering her arm itself did not look horrible.

I remind myself that I would rather do too much than too little, but I had thoughts of quitting today not because of the amount of work or stress involved but simply because I wonder if I am really cut out for this.

I've felt overwhelmed because along with the students I called ambulances for, I have had a good handful of others during this short time who are now in casts and slings from recess injuries, and I am overall jumpy from constantly writing incident reports and following up with parents and am still struggling with the independence and liability associated with this role. I am going to discuss in detail with my superior tomorrow and that usually helps me feel better but I trust you guys too and could use some helpful criticism. Thank you!

[DEgalRN]

You're fine! You also have to remember you're in a school. There are going to be times that you may need to call even if they're not "emergencies" simply because you don't have the ability to handle the symptoms or the liability is too great.

To answer your question, I've probably called an ambulance 10-15 times in the past 2 years? I had a kid with cardiac issues, with no emergency plan in place, despite me pleading with his mother, so he was probably 5-7 of the calls last year (sorry mom, your kid has known cardiac issues, and is c/o chest pain and difficulty breathing, I don't have an EEG or the ability to draw labs). Plus I've had intractable abdominal pain, one attempted suicide, an overdose, epipen use, uncontrolled asthma attack (that's how I got my inhaler for the girl!), and a handful of other situations.

[SassyTachyRN]

My first year, I called I think 11 times. I had a kid with uncontrolled seizures who I called on 9 times for seizures over 5 mins, no emergency meds in clinic or care plan from doc. The other two... one epi pen use, one resp. distress after two albuterol tx's not successful.

The last few years, just a handful. Few more epi pen uses, a dislocated kneecap and what I thought was acute appendicitis because the kid was writhing in pain and tossing and turning and crying and screaming, so I called. The kid had a uti and constipation....

[OyWithThePoodles, RN]

I called 911 once last year and got in trouble for it by the principal. She didn't feel that a broken arm warranted a 911 call. I called because the kids arm was u-shaped. He was hysterical. Would not let anyone touch the arm to try and secure it. I thought that mom might have a hard time safely driving 40 miles to the pediatric hospital she wanted with a bendy arm and a crying kid.

She said next time I called 911 I needed to let her know. So this year when I had a barely responsive teacher I told her first. Some people just want the power.

[SassyTachyRN]

I called 911 once last year and got in trouble for it by the principal. She didn't feel that a broken arm warranted a 911 call. I called because the kids arm was u-shaped. He was hysterical. Would not let anyone touch the arm to try and secure it. I thought that mom might have a hard time safely driving 40 miles to the pediatric hospital she wanted with a bendy arm and a crying kid.

She said next time I called 911 I needed to let her know. So this year when I had a barely responsive teacher I told her first. Some people just want the power.

Our old, like really old, policies stated that the principal had to be informed before calling 911. Most secretaries are still super stuck on that old policy. So when I'm barking orders for someone to call 911, my one secretary is hunting down the principal. She delayed a 911 call by 10 mins last year. I was SO upset with her. I thought she was on the phone with 911, she was outside looking for the principal who was doing a press conference while I had an anaphylactic kid! I ended up pulling my cell phone out of my pocket and calling myself. My medical opinion will always trump informing a principal, which I later told her. I have a license to protect, and lives to protect.

[ruby_jane, BSN, RN]

My medical opinion will always trump informing a principal, which I later told her. I have a license to protect, and lives to protect

^^ THAT!!!!^^

[RobbiRN, RN]

You are right about the independence and potential liability of your role. As others have commented, it is always easier to defend a decision to call than a decision not to. From an ER perspective, there are multiple daily abuses of the EMS system, anything from a homeless guy trying to get food to a 19-year-old with a toothache who doesn't have a car. It's hard to fault a school nurse for calling for a possible fracture, especially if there is a good known mechanism of injury.

It's easy to justify a call for obvious deformity. If there is no obvious swelling, deformity or discoloration, and the child still spontaneously moves the extremity, it's not unreasonable to wait it out and possibly talk with the parents prior to transporting. Some fractures are subtle and don't get discovered for days. At that point every adult involved feels horrible for not getting help sooner, even though the choice to wait was reasonable in most cases. Most children want to be active and will not fake or exaggerate injury for long.

Do you have some kind of triage guidelines in place that back you up for reasonable decisions not to call 911?

[moreoreo]

The girl's arm was indeed broken, but she was back at school and I was glad to see her feeling better. (She definitely had the "body language" of a broken arm... I just wished so much that mom could arrive sooner because I definitely adequately secured her arm for transport, just her distress got to such a high level)

Thank you all so much for your thoughts. One of our principals said recess will probably be fewer children at a time next year, which I'm glad for. I think the recess supervisors are great at their jobs but there are just so many children running around at the same time. None of our playground equipment seems especially dangerous. Each injury seems to be different from the other (except they are all arms) so it's hard for me to think of any ways to prevent them.

I am really grateful to work in an amazing school and district that are pretty trusting of their nurses. My boss herself often said when I first started that if a fever increased again and the parent did not arrive in 5 minutes I should call 911 (we can't give OTC meds without an order and sometimes cool cloths are not enough), so I guess that set my threshold low for EMS from the beginning. At some point last night the fog from the stress cleared and I could see the child's face again and lost my doubts about calling. Reading some of your stories was very helpful. We are all just doing the best we can for our students and I love that I am in a role where my only real worry is whether I helped them the most I possibly could.

[OyWithThePoodles, RN]

Our injuries are usually from the dang monkey bars, falling from, flipping over and hitting heads, ugh. I didn't know it was possible to hate an inanimate object so much until this job. But I complain about them so much that if they mysteriously went missing they would know Sully was involved.

[MrNurse(x2), ADN]

Our injuries are usually from the dang monkey bars, falling from, flipping over and hitting heads, ugh. I didn't know it was possible to hate an inanimate object so much until this job. But I complain about them so much that if they mysteriously went missing they would know Sully was involved.

My wife and I bought our monkey bars. Job security? We have a natural playscape, save that piece. I get far more injuries from falling off logs and such, but nothing major, normally.

[Amethya]

Don't take it to heart. I had 5! (yes 5) 911 calls this year, and my last one the mother didn't want to call 911. It happens, all you can do is stand up straight and keep on truckin'.

[WineRN]

Our injuries are usually from the dang monkey bars, falling from, flipping over and hitting heads, ugh. I didn't know it was possible to hate an inanimate object so much until this job. But I complain about them so much that if they mysteriously went missing they would know Sully was involved.

I hate the monkey bars and we have "the dome" which is this big metal dome the kids climb on, slip through the bars at the top and come crashing down and straight to me

[Tencat12]

I have found that it is a no win situation. Call 911, get yelled at sometimes, don't call 911 get yelled at sometimes.....So. Document the crap out of situations. If you have a reasonable administration that actually would want to sit down with you and discuss what happened in a non-confrontational way, then by all means go for it! I work in a school with trolls for admin, so not an option in my case though heaven knows I've tried.....better to call than not as others have said.