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.

[SHERCAT]

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. [/b]

I work in a telephone triage dept. and several yrs. ago another nurse I worked with at the time turned me on to Dr. Schmitt's great protocols and I use them to educate parents alot, especially now with the flu season. I always knew that fevers are our friend and not foe- I actually tell parents that when I am educating them. I have photocopied alot of his stuff and have it handy in my notebook here at work. I highly recommend his book.

[CarVsTree]

I'll add my rant about a bad Ped.

I'm a first time Mom and my little one (6mo) was sick (104) tylenol ineffective.

I called the ped (hated this practice, could no longer use our good ped due to ins) and told on call doc that baby had fever not responding to tylenol. She told me to take baby to ER. (could here her blaring TV in background). It was around 9:30p and she told me to take her to a bigger hospital than the local one (hour drive vs. 20 minutes).

I had NO IDEA that you could switch off btw tylenol/motrin every 3 hours. Security guard in ER told me. I felt so stupid. The ER doc and nurse were great and her fever came down to 101 after they gave Motrin. They also told me to switch btw. tyl/motrin q3h.

Had on call ped told me this, we never would have had to subject our baby or the ER staff to the ER visit. This woman is such a jerk and that was my last day with this practice.

[RainbowSkye]

I agree, that's why I think telephone triage is so great. Moms (and dads) have the opportunity to ask questions, and they'll always get a consistent answer. I like the idea of giving Dr. Schmidt's book as a baby present as well.

When I first did telephone triage I learned that many pediatricians have one of two answers to patient calls:

1. Take your child to the ER

2. Call the office in the morning.

I don't blame the docs, many of these physicians were getting over 50 - 100 calls from worried parents from midnight to 7am.

[Medic946RN]

Originally posted by RainbowSkye

When I first did telephone triage I learned that many pediatricians have one of two answers to patient calls:

1. Take your child to the ER

2. Call the office in the morning.

I don't blame the docs, many of these physicians were getting over 50 - 100 calls from worried parents from midnight to 7am.

That's their job to answer phone calls from parents at all hours of the night. No one made them go into pediatrics. It's part of the deal. If it's too tough for them to handle maybe they should consider a career in dermatology.

I took my son to the pediatrician for a sore throat that hadn't resolved in 4 days. Just wanted to do a rapid strep test. (Note I did not take him to the ED for same) While waiting to be called I listened to his secretary tell just about everyone who called to take their child to the ER. In fifteen or so calls you'd have thought there was at least one complaint that the doc could have seen today or tomorrow. Sometimes parents only need reassurance that they're doing the correct thing for their child.

[hogan4736, BSN, RN]

medic,

you make some good points, but the fact remains, many parents will do what they want (usually take the kid to the ER). i did phone triage for a large HMO, and 75% of the parents had their minds set on going to the ER, but called for whatever reason (they think they have to, so as to get permission, or they don't know the answer, or just to yell at you if you don't say "Go to the ER")

I agree, docs chose to be on call (by virtue of a private practice). If they don't like it then:

1) hire a nurse triage phone group to weed out the BS at 0200

2) hire a hospitalist group

3) go to culinary school

4) quit complaining

BUT, many parents are unbelieveably uneducated (about what to do medically, yes i know, not everyone can be a nurse, but my mom is a teacher, and I NEVER went to the ED, AND I have asthma)

I have worked w/ several pediatricians who moonlight in our ER on Friday/Sat nights (they have their own practice.) When a doc gets repeated calls from the same (overanxious) parent in a 3 hour span, and he has no more advice to give, the ONLY advice left is to "go to the ER"

You should hear some of the inane questions at 0200...

it's a no win

common sense isn't that common

sean

[teeituptom, BSN, RN]

I was at triage last night, I hate triage. I had a mother bring all 6 of her kids in with colds, for the last few days. I got yelled at by the fast track doctor... I got yelled at the delay in being seen by other pts due to the family. I got yelled at by the fast track nurse

Smile and the world smiles with you because they cant see that middle finger raised in salute.

[SnowymtnRN]

Originally posted by teeituptom

So all I could do was smile and in my mind salute everyone with my middle finger.

Smile and the world smiles with you because they cant see that middle finger raised in salute.

:chuckle :roll :chuckle :roll

That just made my day! Sounds like you did good work to me tho. I mean would they rather you have had the 6 kids one at a time in each room? lol I don't think you would have made them happy no matter what.

[TinyNurse, RN]

GREAT POST!!!!!

gotta tell ya that about 6 mo ago my babysitter took my son to the ER because his "ear hurt". I work in a completely seperate city in the ER and my son't pediatrician was OPEN at the time she took him to the ER., so here I am., left with ER bills............. She did not give tyl or motrin., didn't even check a temp...uggggggg needless to say., i changed sitters.

please forgive the ".," my keyboard is broke"

[moia]

when I worked er we didn't have triage..it was a 30 bed hospital..that includes the 2 bed ICU and the 6 bed er...it was cute as a button..strangely we had a terrible time convincing moms to bring their kids in...in fact nobody came unless they were bleeding or holding their chest.

It was a really good hospital but it was the south in a an agriculture area. Farmers have a really weird mindset and are really stubborn..we also had a big Amish comminity..going to hospital just wasn't the thing to do.

We did get to see some truly gruesome farm injuries and we were right off a major highway..lots of vacationing heart attacks..in fact that was the reason for the 2 bed ICU..we got so many heart attacks in summer we needed to have a place to hold them until the helicopter could transfer them to a big center.

We did get a lot back pain in the middle of the night and that was fairly gruesome too because these people would treat at home until they were literally beside themselves wth agony..they would be pretzels in the car and on one occassion the family couldn't get the guy out of the car...we had to go outside and whack him with morphine tll he was limp and then pull him out.

Most of them didn't want to cause any trouble and refused MRI or CT...I suspect they had the same crappy insurance I did and couldn't afford the inevitable insurance comment not within standard..meaning you had to pay the difference usually a couple hundred dollars.

I always wondered what their MRI would have looked like...

Now that I work in a big teaching hospital... the girls say everybody uses it like a family practice...and you can tell them a hundred times give the tylenol at home..they won't listen...they want a DOCTOR to tell them ...most just stopped trying.

[prmenrs, RN]

When my son was ~ 7, I took him to the ER @ 0200 for croup. I know that's too old for croup, but he had been a premie, several intubations, yada, yada.... The resident, whom I knew, said, but he's too old for croup, I said, well, you'd better talk to him, because I'm hearing croup! She agreed, he got cool mist and 24 hrs of steroids. (The triage nurse had taken him right back, too. Helps to know everyone in your own ER.)

I probably could've managed him, but watching him lean over the toilet, not able to swallow his own saliva, retracting unnerved me emough that I dropped part of the humidifier and broke it. Eventually, I learned that I couldn't always handle being a nurse and a mom simultaneously. Since I was the only one there, "mom" role usually won. Kind of a wuss, I guess.

[bluesky, BSN, RN]

OK. Let's say that about 0.5% of all fevers are actually something serious ... bacterial meningitis, pneumonia, you get the picture. And let's say, of that 0.5%, roughly 10% don't have insurance (they could be illegal or the mothers haven't had the time to apply for medicaid) or don't have the sense to call a triage nurse. That's .05% of the total U.S. children's population which is still a substancial number of children,really- especially the underserved. It is my feeling that since the rest are eventually payed for by either insurance or the government, that it is worth all the extra trouble, just to reach those that might die otherwise. Sorry, just my .02

[PA-C in Texas]

I feel everyone's pain. The hospital where I did my 3rd year clinical rotations was a large urban facility that was frequently inundated with patients that were of zero acuity.

I work in a small town that is largely dominated by farming and ranching. We simply don't get people coming in for ear aches and the like. All three physicians in town (LOL) are really well-known in the community and it has led to a relationship between physician and patient that avoids the attitude of sending everyone to the ER. These docs still make the occassional house call and really don't mind going to the office at 11 in the evening to suture your kid's thumb, but that is probably because people don't abuse them.

The people around here are know how to take care of their kids. It might involve a whiskey-lemon-honey toddy at night, but they just make an appointment with the doctor and deal with it that way unless the kids are really sick.

I do occassionally see kids, but I can't remember the last time that I saw one for a sore throat or a bout of nausea. I see a lot of lacerations and orthopedic injuries. Kids around here (and people in general) still tend to be very active and like to play outside instead of playing video games, so you do tend to see musculoskeletal injuries perhaps more often than you would elsewhere.

I don't know what the answer to this problem is. Perhaps an expansion of fast-track capabilities in these larger pediatric hospitals. Not really sure.