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"Hypothetical" Situation

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BrisketRN has 4 years experience as a BSN, RN.

2,768 Profile Views; 686 Posts

If you had a student with an apparent dislocated elbow/broken arm with mild swelling, full movement in fingers, good cap refill, low pain would you agree with the following treatment?

  • Finger movement and cap refill checks q 5 min
  • Immobilize arm by placing in lap 
  • Waiting 30 min for parent to arrive as long as vitals stable/normal cap refill/no swelling of lower arm/arm remains in immobilized position

Should the arm be immobilized in a sling or should it be kept straight if that causes the least pain for the child?

Would you have done anything differently?

At what point would you call 9-1-1 for this type of injury?

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MrNurse(x2) has 28 years experience as a ADN and specializes in IMC, school nursing.

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My wife drove my son 3 hours home after a snowboard fall that broke his wrist, no harm sustained. Not an emergency and not necessary to call 911.

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jorilo has 28 years experience and specializes in School Nursing.

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That's only a 911 call if they suddenly lose conciouosness. Sounds like you did exactly what I would have done. I would have the child in position of comfort and then decide how to keep the arm in that position for transport. They can still walk to the car and be assisted with seatbelts, so no ambulance needed for any reason that I can find. 

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BrisketRN has 4 years experience as a BSN, RN.

686 Posts; 2,768 Profile Views

Thank you.  Doubted my actions.  Felt pretty yuck about being questioned.  

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Cas1in72 has 26 years experience and specializes in school nursing/ maternal/child hospital based.

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I would not have called 911 on that.  VSS, child was not in terrible pain. Arm was essentially immobilized while sitting and parents were in agreement. 

The only way I would call on something like that would be if there was a circulation issue, and a big one at that.  

When I was in the 8th grade, I broke my clavicle during Gym class.  They called the ambulance, I was terrified by that and so embarrassed. 

That was a "hypothetical" good call. 

2 minutes ago, BiscuitRN said:

Thank you.  Doubted my actions.  Felt pretty yuck about being questioned.  

Who questioned you?  Nothing like arm chair quarterbacking to make you feel like crap.  DONT, you made the right call!!!! 

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BrisketRN has 4 years experience as a BSN, RN.

686 Posts; 2,768 Profile Views

3 minutes ago, Cas1in72 said:

Who questioned you?  Nothing like arm chair quarterbacking to make you feel like crap.  DONT, you made the right call!!!! 

Non-medical professional guardian claiming to quote ER staff.  

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Cas1in72 has 26 years experience and specializes in school nursing/ maternal/child hospital based.

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No way that needed a 911 call.  Who knows, the "ER staff" might have been housekeeping ( not a slap to housekeeping staff) but I would let that roll off my back. 

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jorilo has 28 years experience and specializes in School Nursing.

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Oof, you certainly sound like you have a different set of parents/guardians than I have. My students' parents would be much more likely to thank me for not calling an ambulance so they wouldn't have to pay for it.

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CanIcallmymom has 4 years experience.

381 Posts; 1,109 Profile Views

Depends on student's condition. If they're stable, limb has good circulation, it would depend on my pain assessment, I think.  I've called 911 for dislocated knee, even with palpable pulses, good cap refill, etc. but due to student displaying great amounts of pain and unable to ambulate/needing to be transferred and lifted. They can't safely ride in a car in that case. With an arm, they CAN.

Based on what you describe, I wouldn't call 911 if parent could be there in <30 mins to take to ER. If they would take any longer, I *might.* 

With ER triage, it would receive a decently high acuity rating due to needing conscious sedation, IV, xray, etc. Lots of resources. So I can see the ER nurse making a remark, but really they have no clue on the pre-hospital setting unless they've worked it.

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10 Followers; 3,584 Posts; 26,142 Profile Views

Reasons to call 911 in this situation:

1. Dislocation/distraction with absent pulses.

2. Legit screaming in pain.

3. Significant pain with unreasonably long wait for transport to hospital.

4. Obvious dislocation with unreasonably long wait for transport to hospital.

Your situation met none of these parameters. Your decision making was just fine. Ignore the grumblers. They have no idea what your situation is.

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nursej22 has 30 years experience as a MSN, RN and specializes in med/surg,CV.

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This same er probably let the patient sit in the waiting room for an hour, like they did for my son with a dislocated shoulder and another son with 3 rib fractures and a small pneumo.

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ruby_jane has 10 years experience as a BSN, RN and specializes in ICU/community health/school nursing.

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1 hour ago, BiscuitRN said:

Thank you.  Doubted my actions.  Felt pretty yuck about being questioned.  

Were you being questioned by:

Parent? Pff. Took them 30 minutes to arrive? Splinting is good IF you are trained at it. Position of comfort is best and the kid likely kept the arm in the "sling" position of comfort anyway. EMS for this?? I don't believe they would have transported a stable student as described.

Staff? Pff. You have a nursing license. See my comment about transport.

ER staff? Pfff. You provided an assessment, triage, and handed off care. You do not have any doctors' orders or equipment you could have used. Like...you were NOT about to realign that sucker!

(An aside:  a cool ER nurse once showed me how to make a split from a magazine and some curlex but I don't routinely have those things now).  Is the parent complaining? Refer them to administration so you can get the supplies that the parent thinks you need????

I probably would not have been as attentive as you were. Q5 min checks...that's a lot.  It is always good to debrief oneself. You may do things differently next time.  Unless there was bone visible or palpable, I would say you did as well or better than most of us.

These are my thoughts. Hope it helps.

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