right or wrong or in between?

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I am second guessing myself again! Would like opinions, pro or con. This is the scenario........ middle school student ingests a known allergen. I work 2 schools, middle and prek-5. They are approx. one minute from each other by car......

12:40- student brought to my office at m/s, c/o throat tightness, hard to breathe, etc. I did not know this student had allergies, and I KNEW FOR A FACT that I did not have any meds for him there. call dad to verify.... So I pop him in my car and fly to E/S. (where I have an abundance of meds)

12:50- administer 10 mls of Benadryl (which btw I do not have an order for)........ wait a few minutes to see if relieves symptoms, no it does not....... the student is not starving for air, however his throat is swollen. i make the decision to give epipen (which I never had before) and call dad to let know and tell him I am calling 911.... which hospital does he prefer?

1:09- epipen given (again no order) and 911 called... they arrive within 5 minutes and access the child, he is doing well and they praise me up and down :) they cart him of to the ED.......... later I found out he is doing well.

Here is my issue........ later I found out that school staff were ???? why I waited so long to call 911. I suppose to the untrained eye it does appear that way...... My ??? to you is......... would you have done anything differently? If so, please state rationale so I can learn from this....... thank you so much!

For backgrounds sake, I went straight from nsg school to school nsg, now yr 3. For reasons I will not go into, I AM THE ONLY MEDICAL PERSON at this school/district. There is NO ONE to call for advice. rdsxfn

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Specializes in Maternal - Child Health.

As I understand your post: Child ingested a common allergen (but not one he was known to be allergic to). You transported him by car to another school to have access to and administer meds for which you had no order. Child improved with Epi-pen injection and was transported to ER. Staff questions why you waited to call 911.

I mean no disrespect and I appreciate that I am Monday-morning quarterbacking from the comfort of my kitchen, but I have a number of concerns regarding your actions.

#1 If I assessed a child with airway difficulties, and no immediate orders or access to approved medications, I would have immediately called 911.

#2 I would never get into a car alone with anyone having breathing difficulties, especially not a child whom I had no authorization to transport.

#3 It matters not how close the other school is. Car troubles, an accident on the way, a downed power line, bad road conditions, etc. could all prevent you from getting there and leave you with a child in severe respiratory distress and no assistance of any kind.

#4 Take this one with a grain of salt...I have had reliable patients report an allergy to Benadryl. I would probably not administer this without an order, especially to a child who is having throat/airway issues. Aspirating this solution may lead to a nasty pneumonia.

#5 I am fortunate to live in a state with standing orders for Epi in school in the event of presumed severe asthma/anaphylaxis. I will not have to make this judgement. I may have done this as well, hopefully with at least verbal permission from the parent you had on the phone.

Ultimately, this worked out well. You made decisions I don't have to make in my practice setting. Please use this opportunity to refine your district's policies and procedures to avoid ever being in this situation again.

Thank you for posting.

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Specializes in Maternal - Child Health.

Information on Nebraska Rule 59

http://onwebmanager.net/asthma/view/view.php?read_id=103

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Thank you for your response. You have given me much to think about......

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btw, my thoughts at the m/s were to get this kid help asap. i understand the thinking regarding taking him in my car... ( i had permission) and the same rationale regarding my transporting him could be applied to EMS, yes? What if God forbid, they had been delayed and this kid went into full anaphylactic shock???? I would have had to stand there and watch him die....... just thinking outloud.........

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Specializes in School Nursing, Public Health, Home Care.

If EMS arrived in 5 mins, then the student could have started rx at 12:45. To me, that says it all. I know it's hindsight to analyze, but with limited resources as we have, I often think

"get this kid out of here" when in distress. I 'm glad it all worked out ok, but I think there would be a sh**storm if things had gone poorly.

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Specializes in Maternal - Child Health.

A couple of questions:

What are the requirements for meds in your district? Must you have a specific order from the child's own healthcare provider? Who provides the meds? Are there any standing orders or stock meds in your school? I'm assuming you used meds that belong to another student. How was that explained to the parents of that student, and who will be responsible for replacing the Epi-pen?

If your only source of Benadryl and Epi was the other school, could you have had someone grab those meds and come to you? I realize that bad travel conditions can effect EMS as well, but you are not on the legal hook for that. You would be if there had been an untoward event on your way to the other school?

I appreciate this discussion. We often ponder these "hypothetical" situations. It's interesting to dissect a real one :)

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When I did first-aid training at my school, I told the teachers that they could never go wrong calling 911 and administering epipen to child w. breathing difficulties. The thing is, you just have no idea where these rxs are going and how fast they're going there. I know you couldn't aminister epi-pen b/c you didn't have one, but, honestly, I would have activated EMS earlier in the process. And no student ever goes in my car....

I'm so glad to hear the child is okay. Don't beat yourself up. Live and learn and move ahead.

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Thanks for the feedback. The meds were stock meds...... and when I said I did not have an order I meant a SPECIFIC order for that child. We do have standing orders for this specific situation. Dad was very hesitant for me to give the epi......... I also never put students in my car but in this case I did. It is done fairly often around here. In retrospect, perhaps Ems should have been called immediately. During our training I always tell the staff to give epi and call 911 immediately. I just did not want him to die. Anyways lots to think about and learn from...........

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Specializes in Med-Surg; Telemetry; School Nurse pk-8.

Phew... It's good that you want to analyze what happened. Jolie has raised some excellent points. Regarding what happened, remember Benedryl is great for a localized rxn ( I hate it that some Docs STILL insist this as an order for 1st line of defense -- research has shown it to be ineffective for a systemic rxn) , if you are seeing any symptoms that its systemic in that airway is at all compromised go to the Epi right away, as Sudsy mentioned. Regarding EMS -- their transport is better than yours. There are 2 plus providers, they have O2, and they can do quite a bit if they are ACLS.

So moving forward -- Can you get standing orders written for the future? I would also have an "oh crap" bag that you keep with you for emergencies when you are out of your office. In mine, I have emergency meds, emergency supplies, and my binder that contains copies of my standing orders, and the MD orders for my kids with known allergies.

I know that must have been a scary situation, so (((HUGS))) to you. Use it as a learning experience for how to prepare for the next time.

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Specializes in School Nurse; ICU.

we have been very lucky to have good support from our allergy specialists over the last few years-the guidelines say epi and only epi (no benadryl) is to be given for any suspected case of anaphylaxis and to call 911. not beating up on you as i know how you feel. i have had to give it a few times and i swear there is more adrenaline in me then the kid after all is said and done but it felt good to be able to say this is why i did it. check your policy and procedures but here is the link..

http://www.niaid.nih.gov/topics/foodallergy/clinical/pages/patients.aspx

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Specializes in Peds, School Nurse, clinical instructor.

I would not have under any circumstance put a child in my private vehicle. As for orders, if you have stock meds and standing orders to use them, you did not administer meds without an order. I truly do understand your not wanting "watch the child die" However, I would have called 911 immediately. Just my 2 cents.....

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