Tips for bringing your child to the ER (rant)

[NYCRN16]

I was working in the pediatric ER the other night, and by the middle of the shift, I felt like jumping off the Verazzano Bridge. We had about 50 people waiting to be seen in the waiting room, with the average wait time about 6-8 hours. I am tempted to print this out and post it by the area where you sign in.

Feel free to add to this list!!

1) If your child has a fever, TREAT IT. Please dont let your baby have a 106 fever all day and not give them motrin or tylenol because "you want us to see that the child has a temp" or "my child doesnt like the taste of medicine". I doubt you or your child will like going into febrile seizures either. It wasnt the best idea for you to let your child have a fever for 3 WEEKS and then come in and expect to be seen RIGHT NOW.

2)If your child has a fever, dont keep them bundled up in a snow suit, 3 sweaters, wrapped in 2 blankets. I know the baby feels chilly, but they dont need to accumulate any more heat.

3) I know you know how much your baby weighs approximately, but we DO need to weigh the child again, and yes, we also need to weigh them without all the clothes/shoes on. Pediatric medications are based soley on weight, and we need an exact weight in kilograms order to not over/underdose them.

4) The order of being seen is based on patient acuity, not time of arrival. The child that checked in 2 minutes ago that can hardly breathe IS going to be seen before your child with the flu. Yes, we know your child is sick and that you have been waiting here for 6 hours, but the ER is not first come first serve. We need to see the sickest (and youngest in some cases first) The baby who is 6 weeks old who is sick cant wait, but the 2 year old probably can. We are trying our best to get you in and out as fast as we can.

5) Yes I know your pediatrician called ahead and they sent you here, but so did everyone elses. It seems that pediatricians these days are sending people to the ER for bloodwork/x-rays, ect that could wait to be done in SOME cases until you can get to the lab/radiology center the next day. If waiting to the next day is an option, do it. Chances are, you will be in the waiting room until the next day anyway before you are seen.

6) If your child has an earache or some other minor ailment, please bring them/call the pediatric office before you head to the ER. I promise you, if you bring your child to the ER for an ear infection or strep throat (unless instructed by your doctor or the child has an extensive medical history), you WILL be there all night waiting.

7) Yes, we do need to do a rectal temperature. I know your child doesnt like it, but we need the most accurate temp when the child has a fever in order to treat it.

8) If your pediatrician is sending you over, please ask for written instructions/orders. Parents tend to overdramatize the childs condition, and when I read the report/orders from the doctor they are usually much different from what the parent says. The parents will tell me that the child is in "severe respiratory distress" and the report says mild/moderate, and the child is sitting up, awake with an oxygen saturation of 100%. Besides, 9 times out of 10, the doctor will have given the child medication in the office and we need to know exactly what was given, how much and what time. Telling me that the child got "two breathing treatments and a steriod" doesnt help.

9) I know waiting in the waiting room is equal to a stay in hell, but I dont advise you to be going in and out. If they call you while you are out, they are going to think you left, and you probably wont be called again. If you really need to go outside to make a phone call ect, let the clerk know you will be right back.

10) I know you and your child dont like having an IV started or having blood drawn. Sometimes we need to do this. Dont start crying or freak out while we are doing this. Your reaction has a huge impact on how the child reacts. If you act like we are stabbing you in the neck, the child is not going to be calm either. Once the IV is in, please dont touch it. I know it sometimes hurts, but if you fiddle with it and it falls out of place than we need to do it all over again. If it looks "funny" or is causing pain, call the nurse/doctor and we will take a look at it and see if its OK.

11) If you gave your child any medications before you came in, please write down/remember what time you gave it, how much and what you gave them.

12) We know you have been waiting a long time, but we honestly cannot tell you when you will be seen. It could be 10 minutes, it could be 10 hours. Coming to the desk every 5 minutes asking, trying to choke the clerk, or trying to break the door down (this actually happened) is not going to get you seen any faster. In fact, it may buy you a visit from the police and/or child protective services.

[MrsWampthang, BSN, RN]

You're right, you don't learn about tylenol and motrin doses in medic school; I guess I just took for granted how well I know all the medics and I know most of them are parents that know how to take care of their kids.

Thanks for the response. I was dealing with the end of a twelve hour shift and a five day stretch so I was not in the best of moods (UNDERSTATEMENT!). It's funny, but I had two days off and came back feeling like a totally different person!

Happy Holidays!

Pam;)

[ShelleyERgirl, LPN]

Great list! Got another one to add to it:

If possible, please put some shoes on your child before coming in, and if you can't, please, for the love of God, DON'T let your child run around an ED with bare feet. Talk about germs, much less safety issues!

When I worked ED in the military in Puerto Rico, it amazed me the amount of parents that would bring their kids in with no shoes. Hello? I know this is the Carribean but you're not at the beach right now!

Obviously, if it was an true emergency, I would say hell with the clothes much less the shoesm but then I doubt the child would feel like running around and ED waiting room.:)

[ER Tigger Girl]

and what makes it an emegency now if this has been going on for 2 months??

oh!!! You want to check in all 3 of your children! They all had emergencies at the same time??? Oh! Yourself to- oh I understand, since your here that bump you have had for 4 years should be looked at now- I can understand it's convienient, and you all want to be in the same room???? I am sure the nurse would love a family of 4 in one room on top of her other patients- what is 4 more!!!

[atownsendrn]

Originally posted by ER-RN2

Also, let your child crawl all over the ER floor and eat things off the floor, and then tell the nurse "I just don't know why they are sick":idea:

AMEN!!!!!!

[teeituptom, BSN, RN]

I liked the lady who brought her husband in last week after he cut a varicose vein and it kept spraying blood all over, he walked into the ER and just sat down bleeding all over neither he nor his wife put a bandage or any pressure on it. Their comment was. " I wanted you to see how bad he was bleeding" That was so comsiderate of them. The poor housekeepers had a mess. But then I smiled. As I realized he had ble all over her Mercedes 560 D

that was brand new he he he he he he

[RainbowSkye]

Myths and Facts about Fever

Misconceptions about the dangers of fever are commonplace. Unwarranted fears about harmful side effects from fever cause lost sleep and unnecessary stress for many parents. Let the following facts help you put fever into perspective:

MYTH: All fevers are bad for children.

FACT: Fevers turn on the body's immune system. Fevers are one of the body's protective mechanisms.

Most fevers are good for children and help the body fight infection. Use the following definitions to help put your child's level of fever into perspective:

100°F to 102°F Low-grade fever: Beneficial. Try

(37.8°C to 39°C) to keep the fever in this range.

102°F to 104°F Moderate-grade fever: Beneficial.

(39°C to 40°C)

Over 104°F High fever: Causes discomfort, but

(40°C) is harmless.

Over 105°F High fever: Higher risk of

(40.6°C) bacterial infections.

Over 108°F Serious fever: The fever itself can

(42°C) be harmful.

MYTH: Fevers cause brain damage or fevers over 104°F (40°C) are dangerous.

FACT: Fevers with infections don't cause brain damage. Only body temperatures over 108°F (42°C) can cause brain damage. The body temperature goes this high only with high environmental temperatures (for example, if a child is confined in a closed car in hot weather).

MYTH: Anyone can have a febrile seizure (seizure triggered by fever).

FACT: Only 4% of children have a febrile seizures.

MYTH: Febrile seizures are harmful.

FACT: Febrile seizures are scary to watch, but they usually stop within 5 minutes. They cause no permanent harm. Children who have had febrile seizures do not have a greater risk for developmental delays, learning disabilities, or seizures without fever.

MYTH: All fevers need to be treated with fever medicine.

FACT: Fevers need to be treated only if they cause discomfort. Usually that means fevers over 102°F or 103°F (39°C or 39.4°C).

MYTH: Without treatment, fevers will keep going higher.

FACT: Wrong. Because of the brain's thermostat, fevers from infection top out at 105°F or 106°F (40.6°C or 41.1°C) or lower.

MYTH: With treatment, fevers should come down to normal.

FACT: With treatment, fevers usually come down 2° or 3°F (1.1° or 1.7°C).

MYTH: If the fever doesn't come down (if you can't "break the fever"), the cause is serious.

FACT: Fevers that don't respond to fever medicine can be caused by viruses or bacteria. Whether the medicine works or not doesn't relate to the seriousness of the infection.

MYTH: If the fever is high, the cause is serious.

FACT: If the fever is high, the cause may or may not be serious. If your child looks very sick, the cause is more likely to be serious.

MYTH: The exact number of the temperature is very important.

FACT: How your child looks is what's important, not the exact temperature.

MYTH: Temperatures between 98.7°F and 100°F (37.1°C to 37.8°C) are low-grade fevers.

FACT: The normal temperature changes throughout the day. It peaks in the late afternoon and evening. A low-grade fever is 100°F to 102°F (37.8°C to 39°C).

Reading Temperatures

A reading of 99.4°F (37.4°C) is the average rectal temperature. It normally can change from 98.4°F (36.9°C) in the morning to a high of 100.3°F (37.9°C) in the late afternoon.

A reading of 98.6°F (37°C) is just the average oral temperature. It normally can change from a low of 97.6°F (36.4°C) in the morning to a high of 99.5°F (37.5°C) in the late afternoon.

Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.

I ran a telephone triage department for several years where we utilized protocols developed by Dr. Schmitt. We were actually able to effectively teach parents who called about fever. I think the above is great evidence based info. There's more at http://www.med.umich.edu/1libr/pa/pa_feverpho_hhg.htm if you're interested.

[RainbowSkye]

Here's some information from Barton Schmidtt about severe allergies:

Anaphylactic Reaction

What is a severe allergic reaction?

A severe allergic reaction is called an anaphylactic reaction. It is an immediate, severe reaction to a bee sting, drug, food, or other item. The symptoms are:

wheezing, croupy cough, or difficulty breathing

tightness in the chest or throat

dizziness or passing out

widespread hives, swelling, or itching (If these symptoms occur without the symptoms listed above, your child is probably not having an anaphylactic reaction. However, hives, swelling, or itching often occur with other serious symptoms when a child has a severe allergic reaction.)

a previous severe allergic reaction to the same item.

What should I do if my child has a severe allergic reaction?

Call 911 IMMEDIATELY.

Call the rescue squad (911) if your child is having difficulty breathing or passes out. Have your child lie down with the feet elevated to prevent shock.

Epinephrine

If you have an anaphylactic kit (Epi-Pen or Ana-Kit), give an injection of epinephrine (adrenaline) immediately. Epinephrine can save the life of your child. If in doubt, give it. Inject it into the subcutaneous (fat) layer of the outer part of the upper thigh.

Antihistamine

If you have Benadryl at home, give it. If not, see whether you have another antihistamine or cold medication containing antihistamine. If you do, give one dose immediately in addition to epinephrine.

Bee sting treatment

If a stinger is left in the skin, remove it. Do this by scraping the stinger off with a knife blade or credit card rather than by squeezing it. Then apply an ice cube to the site or a cotton ball soaked in a solution of meat tenderizer and water.

What can I do to prevent an allergic reaction?

Children with anaphylactic reactions need to be evaluated by an allergist. Since the reactions can be fatal, you should keep emergency kits containing epinephrine at home and in the glove compartment of your car (epinephrine is available by prescription only).

Also, your child should have a medical identification necklace or bracelet that states the insect, drug, or food allergy. Some ID necklaces and bracelets can be found in pharmacies.

Written by B.D. Schmitt, M.D., author of "Your Child's Health," Bantam Books.

Published by McKesson Health Solutions LLC.

[santhony44, MSN, RN, NP]

Your Child's Health by Barton Schmitt is my favorite new-baby gift to give. I too have worked telephone triage from his protocols. Great advice! Fever phobia is rampant. It doesn't help at all to combine fever phobia with a tympanic thermometer, which in my experience is highly unreliable.

If your child wakes up screaming with an earache, don't give Tylenol or Motrin; rush him or her to the ED. (I've told lots of people lots of times that there is nothing the ED can do for your kid at 2 AM that the pediatrician can't do tomorrow. Except give Tylenol or Motrin, which of course you can do right now, at home.)

Don't give more than one dose of Tylenol or Motrin because "the fever went down but then it went back up." Obviously the medication didn't cure the kid!

If your kid is vomiting, you *must* give him or her food and/or fluids just as soon as possible; after all, you don't want him/her to starve to death. Giving a dose of Tylenol or Motrin is a good idea too, especially if he or she has *no* fever. You like all that nice pink throw-up all over everything!

If you've been told by the doctor or nurse to rest your child's stomach, but the child is wanting to eat, then of course don't pay any attention to their advice.

Never never never force your child to do anything he or she doesn't want to do; you don't want to harm the kid psychologically. So what if he or she refuses medications? How important is that? (Especially if he or she is a two-year-old.) Besides, you want to establish his or her place as the boss in your home and the center of the universe, right?

Don't bother to invest in a thermometer. After all, you can give me an exact temperature just from touching the child's forehead, can't you??

If your kid breaks out in a rash that is possibly contagious, then take him or her to the ED at the busiest possible time. Make sure the whole community is exposed! And of course, that rash is probably measles; those are still so common!

I realize, as someone else pointed out, that sometimes ER visits are a necessity. However, I have two teenaged boys and have taken them to the ER for: RSV pneumonia (hospitalized one week); croup (hospitalized for 3 days); pneumonia combined with a severe allergic reaction (hospitalized for one week); a fractured collarbone; a fractured arm; a foot laceration requiring sutures; and an accidental gunshot wound to the foot. One actually had two ER visits for croup, but the second wasn't my fault; my SIL was babysitting and panicked. All this with one kid who had M&T done twice for chronic ear infections, and one who is accident-prone.

I also have worked in family practice and pediatrics. The vast majority of pedi ER visits are for non-emergent illnesses. Many of these visits are made by parents who have insurance/Medicaid and regular primary care providers for their children.

[santhony44, MSN, RN, NP]

By the way, a traveling medicine cabinet is an excellent idea. I did that myself for years. Tylenol, Motrin, Benadryl, Dimetapp, cough medication, a thermometer, first aid stuff, etc. Better safe than sorry!

[RainbowSkye]

One of my favorite telephone triage stories was when a dad called me about his four year old daughter who had been "vomiting all day". I did the usual assessment, and advised him to have her rest her stomach for four hours then gradually reintroduce clear liquids and of course, to please call me back for any problems. He called me back about an hour later, really angry with me, telling me his daughter was still vomiting and that he was going to take her to the emergency room. I said, okay, tell me what happened. Well, turns out his daughter took a 30 minute nap, woke up hungry so he gave her a tuna fish sandwich. Geez.

[Rapheal]

I enjoyed the common sense of this thread but have a confession to make. As a very young mother- I did not know it was "okay" to give your child medicine for a fever before they were to be treated by the doctor. I was very very young, and naive. Once I was told by the nurse that I could do this before I brought my child in, I knew better. Sometimes people are just young and stupid and you can teach them. In my experience however, rude and obnoxious people usually are resistant to education.

[hogan4736, BSN, RN]

A 10 year old vomited once in the waiting room. the father comes to the triage area, yelling, "Do something"

I handed him a trash can and continued working.

Please, people. I am a new parent, and understand some fears. BUT a little common sense goes a long way, and many parents in the ED are just wasting our time.

sean