Calling 911

[moreoreo]

How many times have you called? Have you ever called and then questioned yourself? Particularly when you were new to school nursing?

I have been working for nearly four months. Just as I was starting to get comfortable, I had my first "emergency" (a broken arm. I have to admit it was my first time ever seeing a broken bone, it wasn't the worst break but the student was in a lot of pain). I have called EMS three times in six weeks due to recess injuries, the last time being today. Today's arm, I am not even convinced was broken, but the student was in such distress she was wailing the whole time she was in the office. Mom was driving in from another town and twenty minutes in, I called the paramedics because we were needing to remind her to take breaths and she was starting to look out of it. (I am very familiar with the student as she is a "frequent flier" and have seen her cry before.) I guess I am looking for validation because once she had left (medics waited for mom so she could decide whether to transport in her car or have ambulance take care of it--she opted for ambulance) I was reeling for a while because I felt like I had made the wrong decision.

We are so inundated with visitors (sometimes up to 24 in an hour) during recess that I worry that maybe feeling stressed overall pushed me to call. Students continued to stream in while I was trying to focus on her and even though her injury wasn't an emergency, I didn't feel comfortable with her overall presentation. I had help of my health aide and a secretary during most of this time but the situation was somehow more stressful for me than the other times when there was clearly a broken bone involved because I had doubts--I didn't want others to think I had overreacted considering her arm itself did not look horrible.

I remind myself that I would rather do too much than too little, but I had thoughts of quitting today not because of the amount of work or stress involved but simply because I wonder if I am really cut out for this.

I've felt overwhelmed because along with the students I called ambulances for, I have had a good handful of others during this short time who are now in casts and slings from recess injuries, and I am overall jumpy from constantly writing incident reports and following up with parents and am still struggling with the independence and liability associated with this role. I am going to discuss in detail with my superior tomorrow and that usually helps me feel better but I trust you guys too and could use some helpful criticism. Thank you!

[NurseBeans, BSN, RN, EMT-B]

Don't second guess yourself; mom chose ambulance when given the option so you did the right thing. You can't always tell a broken bone from the outside and sometimes all you have to go on is pain level (or drama level with the littles).

I guess my question is, WHERE THE HECK are the teachers at recess? Why are so many kids getting terribly injured? You might consider going out at recess to see if you can observe any particularly dangerous equipment or behavior, or just to let the recess monitors know what they are supposed to be doing.

I have been known to call a parent first when the situation is not really emergent and explained that if they can't get there within X number of minutes (I use my discretion) I will call an ambulance. But I know our ambulance station is about 2 minutes away so I have that comfort level.

[moreoreo]

I did mention to mom on my second call (when pain increased and I saw a change in her arm) that I might call 911 if she grew more distressed before Mom arrived and she was on board with it. So that helped the decision.

Thank you for your reassurance. It's hard because on the one hand I know she will survive, on the other hand I know sometimes 911 is called for chest pain that turns out to be acid reflux, on the other hand I am concerned about how her parent will manage transporting if she is in such distress, on the other hand I am a health care professional and should be able to control the situation, on the other hand others have been reprimanded for not calling when Tylenol is found in a student's possession (). All the staff I work with trust my judgment and I am just afraid to lose that trust.

As for recess, we have 800+ students and two grades out for recess at a time. The supervisors are amazing and I know some things cannot be prevented. Sometimes I am impressed that more emergencies don't happen. One student who broke his arm badly had just been told to stop doing the thing he was doing when he did it again, fell, and sustained the injury. Today's student fell on her way outside. The issue is a lot of students NOT currently at recess also come in during those hours. Many recess visits are for minor discomforts like "my arm started hurting while I was on the monkey bars" which is part of why I'm on my ice pack crusade, limiting ice pack use so students learn not to worry about such minor discomforts (or to go to the nurse for an ice pack reward) but those hours of the day feel like slaughter sometimes.

I really love my job. My health aide is awesome and believes in me and tells me it will get better with time. I am actually appreciated by the school and my supervisor as well as the students... I just need to prove to myself that I am enough to be responsible for all of them.

[GmaPearl BSN RN]

Hang in there! You are doing a hard job. Have confidence in your professional judgement and do not hesitate contacting your nursing supervisor for support.

[MrNurse(x2), ADN]

There will always be armchair quarterbacks, they even exist in hospitals where you have the luxury of other nurses to bounce things off of. Are you going to call an ambo when you shouldn't? Most likely at one point in your career if you do this long enough. Just make sure you don't NOT call one when you should. The former insures the latter doesn't happen.

[Flare, ASN, BSN]

it's a tough decision to make sometimes. If the parent is far / unreachable, that sometimes sways the vote. We know that a kid can sit for quite some time with a fracture, especially if it's not severe, but I will often tell the parent that if someone can't get there in 20-30 min, that they can meet their rugrat at xyz ER. Of course there are the fractures that are the no brainers where you look at the kid and think that there is NO way this kid is even getting in a car.

I have often wanted a "code blue" or something to be called so that the staff knows that I am dealing with an emergency and to PLEASE stop sending kids to me office right now for week old bruises, dry skin and headaches they've had since last night. I promise i'll clear the code once EMS leaves.

[ruby_jane, BSN, RN]

Take a deep breath. It's easy to break down everything you might have done differently after it's all over. In the moment, you have to rely on your assessment skills - and since we have tongue depressors, ice packs, a blood pressure cuff, some band aids and saltines, if someone has a condition that requires their departure to another level of care, this is the only way.

Our EMS is usually very good at helping a parent make a decision. We have one crew where I've actively disagreed with the captain about the severity of the medical condition. But the other crew takes no chances and usually transports. If the kid was unable to calm him/herself down....it's not likely the parent's going to be successful getting the kid into the car, right?

You learned a lot from this experience. One of the things you learned is that you need to have a plan in place for the next time this happens. When EMS is needed, our policy is to have our resource officer call them so I can treat the kid. I do an "Any available administrator to the clinic" and that gets someone (or three) there to help crowd control. I generally task one of them with calling the parent. Once my aide has printed up the current health form with medication allergies, etc. she stands at the door and tells kids if it's not an emergency they need to come back. If it's something urgent, they can take a seat outside and wait.

Hang in there. Next year this will be just another story you tell. And find out what's going on at the playground...surely the principal cares that EMS has been called multiple times for playground injuries, no?

[Finally2008]

Don't be discouraged! I would probably say, 4 months into my job here at school, I had called 911 twice. Now, 4 years later, I have only called 911 about twice in the whole year. As you become more comfortable in this role, you will feel a bit more confident in your decision to call or not call. I do agree, though, it is better to overreact than under react. Every time I have called 911, I question myself and go over the whole scenario for hours afterwards in my head--when a student is admitted to the hospital, I then feel better about my decision. My staff is great and we have gotten the 911 calls down to a fine art. My clerk immediately grabs the icepacks and bandaids and takes over while I try to keep the student in distress calm. Good luck!!

And, yes, now that the weather is nice, they are coming into the clinic in droves!! More times than not, it is due to not following the playground rules...

[WineRN]

I almost had to call on a student with acute respiratory distress who wasn't responding well to our emergency neb treatment, because her guardian was trying to argue with me about coming to get her. Finally I pulled the, if you can't be here in 15 more minutes OR if she gets worse I'll be calling 911. Mom works from home and showed up in literally 5 mins. But I was shaking on the inside with just the idea of calling for the first time.

And do you have a risk management person in your district? The previous nurse didn't document incidents that "just required a band aid" (one of the many reasons she was replaced), so when I started there was a HUGE increase in recess injury documentation and our risk management person came out for a week to whip the recess monitors into shape and its made a big difference.

[scuba nurse, BSN, MSN, RN]

I have called 911 twice this school year, once was for a seizure, and we couldn't get the parents, and the other was for mobile crisis, for suicide thoughts and self-harm. I had a girl with a broken arm (i have seen several, so I knew what it was) from gym and I called the parents first, but if there was bone sticking out or I couldn't get them, I would call 911.

You are the medical expert on site, it is your judgement what needs to be, don't second guess, you did the right thing. Also, just document well, for example "c/o hurt arm in gym, no bruising noted, +ROM....etc...ice pack given, told to come back if pain worsening, or no movement."

[ohiobobcat]

Deep breath!! You did fine. While a 911 call is not always necessary for a suspected fracture, it's also not unheard of or unreasonable to call for a suspected fracture either. I absolutely feel it is always better to err on the side of caution in situations like these. It sounds like you were more concerned with how the student was presenting with the fracture vs. calling for the fracture itself.

Mom was on board with your decision as well. Even if mom had refused EMS transport, you still made the right decision in my mind.

I echo what others have said about the what seems to be an excessive amount of recent recess injuries. That might deserve a closer look at the duties and process of how kids are monitored at recess.

[OldDude]

Don't worry about it.