I work in the Emergency Department and am a fairly new grad, 6 months out of school. I had a patient come in this past weekend and I just can't stop thinking about what I could have done differently as I am usually very, very hard on myself.
Here's the scenario:
Parents bring their 4 year old child in to the ED with chief complaint of fever and abdominal pain for the past three days. They deny any other symptoms except three episodes of emesis over the course of the three days he has been sick.
I medicate him for his 102.1 fever with Tylenol, draw some blood, give him some fluids and anti-nausea medication. Pt is vitally stable, crying but consolable, and sleeping on bed with mom as it is 3 am. Send urine to lab, it is dark in color.
Once all the results come back, he is diagnosed with "fever in children, vomiting in children, UTI, and renal insufficiency". His BUN was 39 and Cr. 1.6. Pt is discharged and parents are given instructions to follow up with PCP and urologist.
Fast forward to the next night, pt is brought back to ED by parents stating that his abdominal pain has not decreased, but parents now state that en route to ED, child began having difficulty breathing. Pt ends up satting at 84% on RA, and gets admitted to hospital with a diagnosis of pneumonia as well as the diagnoses that were given the night before.
Long story short, pt ends up getting intubated as soon as he arrives to PICU. The pt was mine the first night, but I saw him come into triage the second night.
I guess my question is was the doc wrong in discharging a 4 year old with renal insufficiency? Are the two diagnoses related? What causes a 4 year old to even have renal insufficiency? I guess I'm mostly just looking for reassurance, when the pt was mine, he was totally stable and there wasn't even an indication for a chest x-ray or any respiratory related exams. I just feel bad that we maybe could have prevented all this from happening. I'm not as familiar with pediatric patients as I should be, but am hoping I can get some advice/words of wisdom from you more experienced nurses out there
I'm wondering why he wasn't following up with PCP? Only ER? Sick for 3 days and comes to ER? Then again to ER, not his PCP? I'm just thinking that his PCP might have caught things b/c he knows his history, know what I mean?
Kids are resilient but when they go down, they go fast and hard. My theory would be sepsis or aspiration of emesis. Next time, maybe get the charge nurse/house supervisor involved if you feel the pt shouldn't be going home and the doctor can't give you a clear cut clinical explanation for the d/c. Hugs
This is why i'm glad that any pt under 18 who comes into my er with a medical complaint gets a pediatric hospitalist consult. Definetely should have been an obs at the least.
xoemmylouox, ASN, RN
3,150 Posts
Some do not understand just how quickly kids can spiral out of control. That kid should have been admitted for at least observation if nothing else.