911 Debrief

Specialties School

Published

Can I debrief this situation please?

I had a student come into my office. Audible wheeze, stating she needed to use her inhaler. Thought it was in her backpack, not there. No inhaler at school. Called mom, left a message, called dad, told him we needed an inhaler. She started to hyperventilate (RR 56). 02 from 98-100, congestion in the lower lobes. Pale coloring, no blue color though.

Called dad back, he said he was 15-20 minutes away. Told him I would continue to monitor but if she got worse I would need to call 911.

She was unable to talk in between breaths. And pantomimed that she felt her throat was closing. Said she felt light-headed and dizzy and would not, could not slow down her breathing. 02 still fine.

Call 911. EMS comes. Takes VS, they're all fine, O2 is 100. Put her on oxygen take her down. Paramedic gets there does her thing. EMS basically tells dad it's an anxiety attack, not an asthma attack and she'll be OK, EMS says lungs are clear, but she's got a bad cough.

They still take her out on the ambulance to be fully evaluated.

I know I can only go on my assessment and I could not get her calmed down, but I'm second guessing whether I should have called 911 or waited a few minutes until dad got there (not knowing how long it would actually have taken).

I just feel like there wasn't a good decision that I could make. :notworthy:

Specializes in PICU.

Not a school nurse, ICU nurse, and have been on the receiving end of people who did not call 911 sooner. With a history of asthma and no inhaler or neb treatment available, you were spot on for calling 911. Asthma can and does kill, you do not want to be the one who would later question what if I only had called 911. NICE JOB! and Great assessment!

Specializes in ICU + Infection Prevention.

Well I'll play the contrarian then. This presentation sounds like a panic attack in the setting of mild asthma. Breathing that fast I bet she felt light headed and dizzy! That is a classic symptom of alkalosis (psychologically induced respiratory alkalosis)... I bet she had tingling hands/lips and maybe nausea too. I bet her pCO2 was

Makes me wonder if this patient ended up getting a whif of benzo if the inhaled beta 2 didn't have sufficient psychogenic relief.

Let me bottom line this: SpO2 is far from the top indicator of asthma exacerbation severity and compensation as it is possible to have a near normal SpO2 (92, 94,) in with a moderate or even severe attack given albuterol and low flow O2... BUT... 100% SpO2 without bronchodialators or supplemental O2 does not fit the picture of a zero word dyspnea asthmatic about to crash.

This reminds me of back before I was a RN, was just an EMT, we'd just been given epi pens and called to an "anaphylaxis emergency." I was super excited to use an epi pen. I arrived to a light headed tachypneic tripoded 16 year old with 2 word dyspnea saying she was dying because she was having an allergic reaction, some wheezing... zero signs of anaphylaxis. I didn't give epi. I talked calmly to her, stood down the paramedics, gave low flow O2 to make her feel like she was "getting air," and a slow calming ride to the nearby clinic with no lights or sirens.

But.

I didn't see you patient. You did.

I don't have kids yet, but I'd love to someday. I think, if I were a parent, I would want the nurses and teachers at my kids' school to do what they felt was best, and to (potentially) overreact rather than under react. You have to do what you feel is best and safest for the kiddos you work with. Please don't second guess yourself. Kiddo sounds like they're going to be fine and that's the important part!

On the other hand, what if something had happened to this kiddo's dad on his way to school? Get stuck in traffic because of an accident (or even been in an accident himself)? Dad's arrival at school was a total unknown.

As someone who isn't a school nurse and doesn't have kids (my own two cents, I don't really have an argument behind my opinion), I think you did the right thing.

Specializes in ED, School Nurse.
Well I'll play the contrarian then. This presentation sounds like a panic attack in the setting of mild asthma. Breathing that fast I bet she felt light headed and dizzy! That is a classic symptom of alkalosis (psychologically induced respiratory alkalosis)... I bet she had tingling hands/lips and maybe nausea too. I bet her pCO2 was

Makes me wonder if this patient ended up getting a whif of benzo if the inhaled beta 2 didn't have sufficient psychogenic relief.

I don't doubt that this kid had a bit of resp alk going on. However, in a school nurse clinic we (I am assuming this is universal) don't have the capability to measure pCO2 and pH. And we most often will err on the side of caution with a kid with wheezing/hx of asthma because they can decompensate so quickly. If the student DOES deteriorate and I haven't called rescue, then I have blue, hyperventilating asthmatic kid in my clinic with a stock albuterol inhaler (and some school nurses don't even have this!) and a pulse oximeter. No O2, no steroids, no whiff of benzo, no anything. This was one of the hardest adjustments I had to make when I became a school nurse after spending years as an ER nurse. I know what needs to be done for these kiddos, I just don't have the capability to DO it in my clinic. Hence, the decision to make the call to 911 will happen fast, and sometimes happens in borderline situations.

I think you absolutely did the right thing, OP. I have been in similar situations before as a school nurse and made the same call. Good job!!

Thanks everyone. That's why I love having this group. :) I appreciate the words of encouragement. I'm lucky also that my admins are very good about supporting my assessments for the most part. It can just be nerveracking having to make that decision on my own.

Specializes in Med-surg, school nursing..

I feel you made the right decision. As others have said, kids can go downhill so quickly. Asthma or anxiety, hyperventilating without the ability to calm down is a problem. The kiddo probably would've eventually passed out if not able to calm down. Then it would've been "why didn't you call us sooner?!"

Kid had a hx of asthma, was wheezing, and saying her throat was closing. As a parent I would gladly pay that ER bill that turned out to be anxiety vs. a long hospital stay from an untreated asthma attack.

Just echoing what has already been said: you did the right thing!

I bet the parents will make sure she's got her inhaler from now on.

First thing this morning, she dropped off the inhaler!

First thing this morning, she dropped off the inhaler!

Now that is a great outcome!!!

Specializes in School nursing.

Ditto on making the right call.

I had a very similar situation happen with a student with a history of moderate-to-severe asthma and suspected anxiety (parent and I had been talking, student denied any anxiety at the time). Had rescue inhaler at school, student used it with no effect. Audible wheeze. O2 was 95-97, respiration rate 24+. I was able to reach student's mom, we both tried speaking to and calming student. Mom hung up, on the way to school, but a good 20+ minutes out. Student was stating "I can't breathe" and was pausing between words to try and get a breath. Wheeze still present and audible without a stethoscope. I called 911. Mom arrived at school with EMS.

Student calmed down a little with O2, Mom refused transport and took student into the ED herself. Diagnosis was panic attack and asthma flare-up. Student got treatment for both; mom was not upset I called 911.

We don't have the tools that the ED or even a doctor's office has. It may be a panic attack, but if we are wrong, the kid suffers. And most of us school nurses get to really know our frequent fliers and if my guts says "something's different" with a frequent flier, I always go with my gut.

Specializes in kids.
I agree -call to 9-1-1 was warranted. Kids do a really great job of compensating until they don't and then it all goes to hell in a handbag. I don't want to be the one holding that bag, neither do you.

THIS!!

Specializes in kids.

On the other hand, what if something had happened to this kiddo's dad on his way to school? Get stuck in traffic because of an accident (or even been in an accident himself)? Dad's arrival at school was a total unknown.

Ding Ding, we have a winner!!! anyone of a number of things could have happened to dad on the way, delaying the call to EMS.

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