911 Debrief

[DEgalRN]

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.

[SummitRN, BSN, RN]

Besides, if EMS was all knowing and said it wasn't asthma and she would be OK, why the #### did they take her for evaluation?????

The reason they "took her to the ambulance for evaluation" is because they are professionals and if you call EMS they owe the patient a prudent and thorough examination.

And because the vast majority of EMS agencies do NOT have the latitude to recommend no transport after evaluation, even with an ALS ambulance. They are bound by protocols, and dad would have had to sign refusal of care paperwork. Unclear if that is what he ended up doing?

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.

Why would you need to measure it? It would be an "unnecessary test" even in the hospital with this patient in the given scenario. RR60, SpO2 100% you don't need an iStat to presume resp alk. What you do need to do is consider the obvious resp alk in the big picture as an explanation for the patient's otherwise concerning symptoms of "light headed" and likely additional unspoken symptoms etc that would provide positive feedback to the panic attack.

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.

Fair enough. But you are basically arguing for calling 911 for all anxiety attacks if the patient also has asthma in their hx.

I think a better answer is to change the rules of this game. I think it silly that most school RNs don't have O2 or albuterol. Is it not crazy that an EMT can give albuterol in most states, but a licensed RN at a school isn't even supplied with it for emergency use? Why? The RN has 10-20x the education vs the EMT (and 1-2x that of the medic) and at a higher level. A single ambulance response would pay for years of supply of that capability.

Really?!?! This is why responding to a "school nurse" post when your specialization is something entirely different, is a bad idea. ... What I would hope you do understand is every asthmatic patient is not going to present in a textbook fashion, and even with a "mild attack" where SPO2 is 100% without broncho or O2, things can change in the blink of an eye, quickly resulting in an asthmatic about to crash.

You too are presenting a logic that demands all anxiety attacks patients should result in calling an ALS ambulance if the patient has asthma. A lot of things can change in a blink of an eye, so your logic also easily argues for 911 for any mild asthma without an inhaler? Maybe all asthma period? Maybe have an EMS unit on standby if you have asthmatics in the student population?

Sure the reasonable line is somewhere in there.

If the school RN cannot differentiate that they are on the safe side of the line, then by all means call 911. The OP asked for evaluation of the situation and in retrospect, it appears to have been an anxiety attack in the setting of mild asthma based on the OP's own description and the Paramedic's evaluation.

I do find it humorous that I am getting flack for "commenting outside of specialty" but here we are questioning the paramedic's workup of "anxiety attack vs severe asthma attack" with a conclusion of anxiety?

So which is this? An emergency? So we don't trust the emergency professionals? Or is this not an emergency so we don't trust the emergency professionals?

[JenTheSchoolRN, BSN, RN]

The reason they "took her to the ambulance for evaluation" is because they are professionals and if you call EMS they owe the patient a prudent and thorough examination.

And because the vast majority of EMS agencies do NOT have the latitude to recommend no transport after evaluation, even with an ALS ambulance. They are bound by protocols, and dad would have had to sign refusal of care paperwork. Unclear if that is what he ended up doing?

Why would you need to measure it? It would be an "unnecessary test" even in the hospital with this patient in the given scenario. RR60, SpO2 100% you don't need an iStat to presume resp alk. What you do need to do is consider the obvious resp alk in the big picture as an explanation for the patient's otherwise concerning symptoms of "light headed" and likely additional unspoken symptoms etc that would provide positive feedback to the panic attack.

Fair enough. But you are basically arguing for calling 911 for all anxiety attacks if the patient also has asthma in their hx.

I think a better answer is to change the rules of this game. I think it silly that most school RNs don't have O2 or albuterol. Is it not crazy that an EMT can give albuterol in most states, but a licensed RN at a school isn't even supplied with it for emergency use? Why? The RN has 10-20x the education vs the EMT (and 1-2x that of the medic) and at a higher level. A single ambulance response would pay for years of supply of that capability.

You too are presenting a logic that demands all anxiety attacks patients should result in calling an ALS ambulance if the patient has asthma. A lot of things can change in a blink of an eye, so your logic also easily argues for 911 for any mild asthma without an inhaler? Maybe all asthma period? Maybe have an EMS unit on standby if you have asthmatics in the student population?

Sure the reasonable line is somewhere in there.

If the school RN cannot differentiate that they are on the safe side of the line, then by all means call 911. The OP asked for evaluation of the situation and in retrospect, it appears to have been an anxiety attack in the setting of mild asthma based on the OP's own description and the Paramedic's evaluation.

I do find it humorous that I am getting flack for "commenting outside of specialty" but here we are questioning the paramedic's workup of "anxiety attack vs severe asthma attack" with a conclusion of anxiety?

So which is this? An emergency? So we don't trust the emergency professionals? Or is this not an emergency so we don't trust the emergency professionals?

But EMS has a direct line to a hospital, with back-up to communicate symptoms to in order to help make any determinations. They have a wealth of medical equipment that school nurses can only dream of. Most school nurses do not have any other medical professional to consult with. We don't diagnose. We are the only medical professional in our building. Some of us have school physicians for some orders like stock epi, but they are not a person who is typically available for a consult the second we need one. And some of us don't have a school physician at all.

I don't call 911 for all students with asthma that may be presenting with an anxiety. The OP had an escalating situation. I had one as well that I described above. Mine ended up being anxiety AND asthma, with albuterol that was used and failed. Anxiety and real asthma symptoms can go hand in hand. I've handled many, many a panic attack without calling EMS, and some of those students also had asthma. I don't have O2 or stock albuterol. You may think it is silly, but that is how it works currently in most schools. We are trying, but many, many schools out there don't even have a school nurse or one that works for entire school day.

So...a way you could help is to advocate for us if you feel it is silly that we don't have certain things available to us in school setting. I don't pretend to understand a day in the life of paramedic just as I don't expect them to understand a day in life for me, either.

[Flare, ASN, BSN]

Actually, Summit, I find your contribution helpful. Because I do not have stock albuterol, I would not be able to do much more than put some O2 on the student, lead them in some breathing exercises, etc. Depending on how the lungs sounded would have really been my driving force. Asthmatic exacerbations are scary for kids. even ones that can be treated in the office - but we all know how it goes - no inhaler available scares the crap out of the kid when they feel like they can't breathe so that makes everything seem magnified. The total outcome is that the child got appropriate treatment. EMS has certainly been on calls that have been less worthy of their time (even if the brunt of this was anxiety - I rode ems for a while people really call for the silliest things from constipation to the flu to sore throat) and the parent sent in the inhaler the very next day. I'd say positive outcome.

[JenTheSchoolRN, BSN, RN]

Actually, Summit, I find your contribution helpful. Because I do not have stock albuterol, I would not be able to do much more than put some O2 on the student, lead them in some breathing exercises, etc. Depending on how the lungs sounded would have really been my driving force. Asthmatic exacerbations are scary for kids. even ones that can be treated in the office - but we all know how it goes - no inhaler available scares the crap out of the kid when they feel like they can't breathe so that makes everything seem magnified. The total outcome is that the child got appropriate treatment. EMS has certainly been on calls that have been less worthy of their time (even if the brunt of this was anxiety - I rode ems for a while people really call for the silliest things from constipation to the flu to sore throat) and the parent sent in the inhaler the very next day. I'd say positive outcome.

Fair point, Flare.

[DEgalRN]

But EMS has a direct line to a hospital, with back-up to communicate symptoms to in order to help make any determinations.

Yep, this is pretty much what happened.

ALS and BLS responded. ALS called in her assessment to *someone* (supervisor, hospital, MD, I don't know?) and got the OK for the student to be transported without her ride along. Originally, one of the first responders originally asked the other responder if they should cancel the ALS response, but it was ultimately decided that they shouldn't since she could receive a breathing treatment if needed.

[OldDude]

Summit, I do appreciate your input and don't disagree with what you are saying. But you never directly addressed the OP's question and the reason for the post, which was to seek opinions about her decision in this situation.

Can I debrief this situation please?

...

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). /QUOTE]

So...what say you about her calling 911 when she did? Yes or no?

[kidzcare]

I just want to thank you all again! You're all giving my the warm fuzzies! It's wonderful to have such a great group of supportive, knowledgeable people to turn to.

Big hug!!

The reason they "took her to the ambulance for evaluation" is because they are professionals and if you call EMS they owe the patient a prudent and thorough examination.

The OP is also a professional who assessed the patient and determined that the symptoms required higher interventions than were locally available.

Let's consider this from the "worst case scenario timeline". Student presents with above symptoms. RN determines anxiety is causing symptoms. Parent called and on way to school to get child. Child leaves with parent and symptoms escalate. Parent begins to race towards hospital but student is unable to be resuscitated. Better to call 911 than wish you had.

ETA- This is no exaggeration. We've all read the stories about otherwise healthy kids dying from asthma and it happened at my school last year (before I started here). Healthy, athletic 12 year old died of asthma attack (at home). I can't imagine how his parents feel in hindsight if they delayed calling 911 because he'd never had a reaction like that before:cry:

[DEgalRN]

And, I feel as I should add, Dad was fine and supportive with me calling 911 (doesn't mean I still wasn't questioning it, obviously!).

[MrNurse(x2), ADN]

The best way to deal with a parent who may question your 911 decision is that an ER deductible is much less than a funeral. Sorry, like the school nurse that "withheld" the girls epipen, had the outcome been poor, the same people saying anxiety should be easy to spot will criticize the nurse should have known the severity. I have far greater latitude in my hospital job than at school. My pt. vasovagaled the other night, I attempted to revive her while a new nurse with me was freaking. I knew I had a minute or two before I needed to escalate care, I would not have done that in a school setting. Does this make me an ineffective nurse? No, it means my resources in an educational setting are severely limited. This is why someone who is not familiar with school nursing should pause before making a judgement.

[Spidey's mom, ADN, BSN, RN]

The best way to deal with a parent who may question your 911 decision is that an ER deductible is much less than a funeral. Sorry, like the school nurse that "withheld" the girls epipen, had the outcome been poor, the same people saying anxiety should be easy to spot will criticize the nurse should have known the severity. I have far greater latitude in my hospital job than at school. My pt. vasovagaled the other night, I attempted to revive her while a new nurse with me was freaking. I knew I had a minute or two before I needed to escalate care, I would not have done that in a school setting. Does this make me an ineffective nurse? No, it means my resources in an educational setting are severely limited. This is why someone who is not familiar with school nursing should pause before making a judgement.

I agree.

Plus, the school nurse, which used to be me, works 3 days a week and there are eleven campuses and no oxygen and no physician.

Better safe than sorry - call 911.

[vikivail26]

This is what I hate about being a school nurse. You are all alone to make life saving decisions. Sometimes you can't win. You did the right thing. I bet she will not forget her inhaler ever again.

[MrNurse(x2), ADN]

I felt silly recommending follow up for my student that bit his tongue, well, he just got 3 stitches. Had I second guessed myself (which I did after) he may have had issues. I had several pediatricians who have backed up my decision despite the student not requiring medical care, that makes me feel better.