School Nurse: Managing a scene/coworkers

[guest464345]

Looking for advice. I had a HS student who was assaulted by another another kid - punched hard several times in the face. Face is a mess, blood all over, kid is crying and freaked out. Airway OK, no broken teeth and wasn't choked or anything. Breathing fast but good color, crying and talking in complete sentences, sats good. A&o, recalls events before & after, no loss of consciousness, didn't fall or hit head against anything, steady drip of blood and a big visible clot hanging out but not gushing, nares patent after the bleeding stopped, nose already very swollen, eyes reddened and already starting to bruise but PEARRL and vision OK. No palpable or visible injury to the rest of head, mouth, jaw, ears; no pain in back or cspine, no changes in sensation; no obvious asymmetry or fractures in face, wasn't struck anywhere else. Not nauseated, vomiting, dizzy or confused. Not on anticoagulants, no worrisome medical history.

So, a terrible situation requiring monitoring until he went to a provider (it took his group home over an hour to arrive, despite saying they were coming immediately. Vitals OK and he remained a&o managing OK with Tylenol and ice. But I gave them a stern talk about going straight to the hospital, and wished I would've just called 911 to get him going). But not appearing to be immediately life threatening.

I never worked pre-hospital or in community settings like this before; I'm used to being around other nurses. So running through my ABCDE checklist seems logical and obvious, but I'm thrown off by my coworkers who say and do completely unexpected things (three of them hassling me about the blood while I'm trying to assess the kid - insisting floor should be cleaned up and his clothes changed immediately - while I of course am not concerned with the floor. I want to make sure there's not some c-spine problem or other injury before anyone moves anything). One of them actually yelled out from behind me mid-assessment that the kid should tip his head way back so the blood would stop dripping (um, no).

I'm not used to managing onlookers on a scene. Also not used to a setting where freaked out teenagers can crawl underneath a shelf, making assessment a challenge. I probably should have just kicked all the staff out.

How do you handle your coworkers in these situations? And what else could I have done for this kid? We don't do debriefings at work (we should) so I'm going over and over in my mind about it.

[JenTheSchoolRN, BSN, RN]

As was stated above, jobs for staff helps gets them out of your way and make them useful (for you and the student) at the same time. For me tasks include getting me parent/guardian contact info, calling 911 (with instructions to give them my exact location in the building), get senior admin who will help me clear the area and direct halls (of staff and students - they are awesome at this thankfully), and get anything from my office I need (student emergency card, supplies, etc).

We have made an announcement over the speaker if class transition is happening/about to the happen to stay clear of xyz place due to medical emergency. An admin or two guards the door, so to speak, for me. Maybe as part of debrief, see if admin on your end can help you manage any rubberneckers?

[ruby_jane, BSN, RN]

You did a great assessment.

For the bystander who wants to clean the floor - "Can you call the custodian please?" or "There are some chlorox wipes on my desk, please feel free to get them and some gloves if you'd like to help."

I have never actually had to say "back off, I'm assessing." I just assessed and anyone around me knew I had my game face on and backed off.

A side note- apparently my game face looks really mean.

I love the debriefing idea. Especially if you can indicate that the well-meaning bystanders got in the way of actual nursing care.....

[NurseInTheHall, ADN, RN]

Great job handling this situation and great advice from all.

Mostly I just wanted to say that your assessment note is great! I wish I was better at that.

[guest464345]

13 hours ago, Flare said:

It never fails! Your co-workers can be the biggest rubber neckers full of suggestions, but these are NEVER the people that are willing to sign up for epipen delegate training or stay late for CPR or ALICE training. In time you'll learn to filter them out, you'll learn who you can lean on, and you'll learn who to send right away to get the backpack and find the custodian. Another favorite trick of mine is to clear my office / the area during the initial assessment and have the biggest PITA be my bouncer. Tell them to stand at the door and keep everyone else (including themself) out. Ahh peace and quiet.

This is great! I just ignored them and got the job done, but it created unnecessary difficulty.

I love the idea of giving the staff jobs, and the bouncer thing is BRILLIANT. I already know who gets that assignment next time. And you're right, the problematic people are the same people who arrived 30 minutes late for the mandatory 45 minute training on rescue meds and emergencies just last week.

We unfortunately have fights and violent incidents a couple times a week, even with less than a hundred students - a security staff was injured trying to restrain a student today. Last year both students and staff suffered fractures diring incidents, and one staff person required multiple surgeries and was out on disability for an entire year.

I have repeatedly pushed for debriefings, even giving examples of how they helped me in hospital jobs, but have been told in no uncertain terms that administrators are not interested. I think that they don't want to admit how out of control our environment is.

I'll be looking for a new school next year. I think this one is about as bad as it gets, honestly. I like the kids, even the ones who I strongly suspect will be in prison soon, but it's out of control. For instance a student called me a "f*cking ***-@ss whore" last week when I politely said he couldn't use my phone. I debated about whether it was even worth writing up...because where do I draw the line? I'll be writing referrals all day. At this point I'm just trying to reach May 22 with myself and everyone else in one piece.

You all have great advice and I so appreciate it. I really enjoy the autonomy of this job, but sometimes it's just hard to figure out how to get things done when you're new in what amounts to a foreign culture.

Incidentally, according to the vague message from the group home staff - who did not pick up their phone all day today - "he is fine, nothing is broken"

[guest464345]

14 hours ago, Flare said:

Also: This corner of AN is the best! Peace, love, and practical solutions ?

[amoLucia]

To OP - I echo others saying you did a terrific job in your situation.

And, WOW. I'm impressed by your assessment. ?

To all PPs - I salute you all for your amazing handling of similar situations.

Like who would think that a school nurse could get so enmeshed in such environments.

[Flare, ASN, BSN]

8 hours ago, laflaca said:

This is great! I just ignored them and got the job done, but it created unnecessary difficulty.

I love the idea of giving the staff jobs, and the bouncer thing is BRILLIANT. I already know who gets that assignment next time. And you're right, the problematic people are the same people who arrived 30 minutes late for the mandatory 45 minute training on rescue meds and emergencies just last week.

We unfortunately have fights and violent incidents a couple times a week, even with less than a hundred students - a security staff was injured trying to restrain a student today. Last year both students and staff suffered fractures diring incidents, and one staff person required multiple surgeries and was out on disability for an entire year.

I have repeatedly pushed for debriefings, even giving examples of how they helped me in hospital jobs, but have been told in no uncertain terms that administrators are not interested. I think that they don't want to admit how out of control our environment is.

I'll be looking for a new school next year. I think this one is about as bad as it gets, honestly. I like the kids, even the ones who I strongly suspect will be in prison soon, but it's out of control. For instance a student called me a "f*cking ***-@ss whore" last week when I politely said he couldn't use my phone. I debated about whether it was even worth writing up...because where do I draw the line? I'll be writing referrals all day. At this point I'm just trying to reach May 22 with myself and everyone else in one piece.

You all have great advice and I so appreciate it. I really enjoy the autonomy of this job, but sometimes it's just hard to figure out how to get things done when you're new in what amounts to a foreign culture.

Incidentally, according to the vague message from the group home staff - who did not pick up their phone all day today - "he is fine, nothing is broken"

you say group home, i hear "ward of the state". this is why, even though nothing is broken and "he is fine" I think you need to push the issue with sending a child like that to the ER. If not for the CYA factor alone, you have children who tend to get less reaction from their primary home caretakers and will have to wait typically longer lengths of time for care. These children are subject to more scrutiny when something goes wrong. But given the constraints and often undertraining and overwhelming nature of being a group home staff member, if often not the case.

[guest464345]

59 minutes ago, Flare said:

you say group home, i hear "ward of the state". this is why, even though nothing is broken and "he is fine" I think you need to push the issue with sending a child like that to the ER. If not for the CYA factor alone, you have children who tend to get less reaction from their primary home caretakers and will have to wait typically longer lengths of time for care. These children are subject to more scrutiny when something goes wrong. But given the constraints and often undertraining and overwhelming nature of being a group home staff member, if often not the case.

Right again... Maybe half the kids in our school are in group homes, or less commonly with a foster parent.

Some of those group homes.... Man, don't get me started. I'm lucky if I can browbeat them into catching kids up on required vaccines. Of course a few are better, and I have a lot of respect for their hardworking and underpaid staff .

This particular facility has consistently been hard to work with though; they simply don't pick up the phone or call back in some cases. Had I realized that's where he is placed, it would have tipped the balance toward calling EMS. He's relatively new to us, so I didn't know, and it was an administrator who called while I was tending to the student.

[tining, BSN, RN]

Amazing job OP. Sound advice from our virtual nurses station. Everyone here is amazing. ❤️

[Flare, ASN, BSN]

23 minutes ago, laflaca said:

Right again... Maybe half the kids in our school are in group homes, or less commonly with a foster parent.

Some of those group homes.... Man, don't get me started. I'm lucky if I can browbeat them into catching kids up on required vaccines. Of course a few are better, and I have a lot of respect for their hardworking and underpaid staff .

This particular facility has consistently been hard to work with though; they simply don't pick up the phone or call back in some cases. Had I realized that's where he is placed, it would have tipped the balance toward calling EMS. He's relatively new to us, so I didn't know, and it was an administrator who called while I was tending to the student.

i totes get it. It sounds like a rough scenario for those kids. I'm glad they have a cool headed - diligent school nurse looking out for them ?

[ILoveHorsesRN, ADN]

I am not a school nurse. I just wanted to say you sound like an excellent nurse, you did everything right. The onlookers were obviously clueless to what was most important, the child. Um ya, we don't tilt the head back....clueless onlookers!

[evarunnr1]

you did the right thing to do your ABCDE's. As trauma can happen in your situation, calmness is key. Delegating tasks for the co-workers that sounded as if they were freaking out could help you focus. (they sounded psychologically traumatized) a couple of tasks to delegate: someone to get his chart/info sheet and contact information, one to document your assessment/actions on a piece of paper-(speaking deliberately and calmly to this person) one to keep the room clear of anyone who does not need to be there. one to communicate to the custodian the need to clean up the blood afterward-not to be in room with the child-this person can then help to be your hall monitor for gawkers. so now your child is still on the shelf freaking but can see that you have calmed the room. i am sure you have dealt with the situation of traumatized people: calm voice, don't approach too fast, don't touch until you get their trust, sometimes just starting to hold their hand is essential to trust. all the while you are looking at his airway, speech, teeth missing, bloody ears, any eye trauma, breathing, pinkness, warmth of skin, dryness of skin. with kids in these situations 80% of your assessment can be done in the first 30 seconds across the room. 911 is not a bad number. medical attention is a must when head trauma occurs. there is the possibility of subdural hematomas, sinus fractures, facial and ocular fractures that can be found with a CT of the head. the group home does not have the facility of a scanner. Not knowing if they also have a nurse and advanced training, calling 911 would have been appropriate. you sound knowledgeable in the pre-hospital setting of trauma.

big thing, debriefing. what happened, how could we have done it better, what can we take away from the situation, NO pointing fingers. Finally, establishing an algorithm on when to call 911 and what to do with the situation when it occurs. role playing and table top situational discussions for preparation of the next challenge. You did good. keep up the strength.