Just not sure........

[jodil77]

I am a new school nurse and I run 3 schools. 1. K-5 2. K-2 and 3. 3-5. I rotate schools through out the week. I see some frequent fliers and then there are some that are new to me. This week I heard the "We need you to look at this student for us" as soon as I walked in the door. I turned around, saw this child and my heart dropped. She was an awful grey color. The teacher told her "Show her your mouth". She pulled her bottom lip down and her gums were bleeding. I then noticed her eye had a hemorrhage and she had petechiae on her face. So it was me, the student, the guidance counselor and the social worker talking to this student. After assessing her, her vitals were not off...though I did not have a pulse oximeter. I also discovered petechiae on her ears, neck, arms, legs. and she had some serious bruising too. It was not abuse (neglect maybe, but not the cause)...and I immediately feared the worst case scenarios in my head. Since I had no idea what her blood labs looked like (I just knew that she was low....WAY LOW), and that she needed to get to the doctor...THAT day. We took her home. She was taken to a hospital and then eventually life flighted to another. When I heard life flighted, I started second guessing myself. I knew she needed to be seen, but I did not think that EMS was warranted. Now I am not so sure. I didn't call EMS, because the student was already freaking out about going to the doctor, and I didn't think it was life or death emergent at the time. Her vitals were stable and she was not in distress. She was actually sitting in my office doing her math work while I was getting her paperwork together to take her home.

I also felt helpless, because I have done emergency nursing before and I felt helpless as to what I could do to help this student. I am used to seeing things in action (drawing labs, starting IVs, giving blood) and being able to follow things through. I felt like I could not REALLY help this student. Yes I recognized that she was in trouble, but hell anyone could have done that. How did I help her and did I even do enough, since I didn't call 911?

[Jolie, BSN]

You assessed her and recognized the need for prompt medical attention. Good for you!

I think you are allowing the terminology used by the transport team to intimidate you. Life Flight sounds dramatic. And it is. But the truth is that she was transferred because she had a condition that out-stripped the expertise of the admitting facility. That is not an indication of inadequate nursing care on your part, or anyone else's.

You recognized that your student had active bleeding and inadequate tissue oxygenation, as evidenced by bleeding gums, conjunctival hemorrhage, and ghastly color. Her vital signs were still WNL, which was good, but not an indication that she was stable, since children tend to compensate very well until their ability to do so simply is overwhelmed, at which time they tend to crash.

Given that assessment, I might hae called her parents and given them the option of picking her up immediately for a trip to the ER, calling the hospital to notify of her impending arrival, or callling 911 and accompanying her to the ER to be met by her parents.

Generally speaking, I am not a fan of ER treatment, and usually err on the side of the primary care provider's office, but few medical offices are equipped to treat rapidly decompensating children, and it was 100% likely that this child would need IV access for meds and/or blood products, so transfer to a hospital was going to be necessary.

That is NOT to say that your decisions harmed her care, but just perhaps delayed it a bit. Take it easyon yourself :)

What was the cause of her condition? ITP? Sepsis? Something else?

[jodil77]

Her parents did not have a phone, so we decided to take her home. Her house was like 5 miles or so from the school. I was more concerned with the Life Flight, because an ambulance ride between the two hospitals would have been an hour and a half...two tops, and they didn't want to wait that long. I haven't heard the definite diagnosis yet, but last I heard they were testing for Leukemia.

[pookyp, LPN]

Her parents did not have a phone so we decided to take her home. Her house was like 5 miles or so from the school. I was more concerned with the Life Flight, because an ambulance ride between the two hospitals would have been an hour and a half...two tops, and they didn't want to wait that long. I haven't heard the definite diagnosis yet, but last I heard they were testing for Leukemia.[/quote']

Oh my. I hope she's ok.

[Flare, ASN, BSN]

i think you acted appropriately given the recources that are on hand for a school nurse's office. Yes, I am sure that if you were given a set of fresh labs to look at you may have decided that a call to 9-1-1 was more in order than a call to the student's parent's and an eventual transport to home via school staff - but this wasn't an option. You work with what you have.

Now I'm with Jolie on the ER bit. I'm not a big one to ship kids right off to the ER. I will offer it in cases when i think it may be a possibility that a parent may take a child there and obviously in cases where there are no choices but to send a child out (or staff member ). Don't get hard on yourself because they ultimately ended up flying the child to a different facility. These types of decisions are often made due to a lot of reasons like distance between facilities, evidence of active bleed, poor oxygenation, available transport method, and in reality how good your insurance is (sadly)...

I am grateful that the little one had an experienced nurse that looked at this child as a whole picture. A lesser experienced nurse may have become more focused on the fact that the vitals were ok may have focused attention in a different direction.

[jodil77]

They are saying pancytopenia. Better then Leukemia I guess.

[NutmeggeRN, BSN]

Thx for the update.