911 Debrief

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!!

I would have loved to have stock albuterol (hah, it wants to auto-correct it to butterball!) in this instance! I kept looking over at everyone else's inhalers and wishing I could use them.

As I read your post it brought to mind the "Great Crawfish Creep Out". A little darling was teased with a crawfish they were dissecting in Science. She "passed out" in the class room and once she got into our office, she had such anxiety she was hyperventilating. Nothing we could say or do helped. My co-worker actually was trying the nice calm voice and explaining how she was causing some issues. Once she said "blood", girl went nuts. We had been in contact with mom and still called 911 due to the severity of the s/s she was exhibiting.

Given my experience and the asthma aspect (my little darling did not have hx of asthma), you did the right thing. IMO

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.

Really?!?! This is why responding to a "school nurse" post when your specialization is something entirely different, is a bad idea. If the OP had the ability to offer a "whif of benzo" or any other intervention that may be readily available in a hospital setting,( if her assessment called for that) she would have acted accordingly, I'm sure. School nursing is an entirely different beast, when it comes to nursing assessments, care plans, interventions, actions, and follow-up. If you have never been a part of it, there is truly no way you would understand that. 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. The OP absolutely did the right thing.

Really?!?! This is why responding to a "school nurse" post when your specialization is something entirely different, is a bad idea. If the OP had the ability to offer a "whif of benzo" or any other intervention that may be readily available in a hospital setting,( if her assessment called for that) she would have acted accordingly, I'm sure. School nursing is an entirely different beast, when it comes to nursing assessments, care plans, interventions, actions, and follow-up. If you have never been a part of it, there is truly no way you would understand that. 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. The OP absolutely did the right thing.

THIS!!!

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.

Ok, thank you for these replies because I'm sitting here scratching my head trying to figure out where one obtains this "whif of benzo??"

Ok, thank you for these replies because I'm sitting here scratching my head trying to figure out where one obtains this "whif of benzo??"

Great Job! You absolutely did the right thing.

You did the right thing. A person with a history of asthma with no inhaler warrants a call to EMS.

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?