Nurse In Australia » Emergency and Triage

Distracting a screaming toddler

Ross — Thu, 02 Jul 2009 13:15:49 +0000

When I first started nursing in an emergency department I was amazed at how we treated injured toddlers.

I’m being a bit liberal with my use of the word ‘toddlers’ here, basically I mean any child between the ages of around 1 to 5 years of age.

I was amazed for a few different reasons – firstly, at just how frequently toddlers injure themselves! Fortunately most of the ‘injury presentations’ (as opposed to fevers etc) are for fairly minor things such as head lacs from running into tables, finger lacs from sharp objects, lip and facial lacs from trampolines/sports/running etc, or splinters/foreign bodies in fingers and nostrils. Of course there are much more serious things like burns or getting stuck into the parents tablets too, but management of these presentations are quite different from other injuries.

I’ve had kids myself so I know how hard it is to reason or negotiate with a 2 year old child. Basically it’s impossible! A normal conversation would go something like this “just hold out your hand, and….” at which moment the child would thrust his hand as high as possible into his jumper and cling to his parents, making sure you can’t get anywhere near the injured body part.

Sometimes the parent desperately tries a futile attempt at bargaining for the child’s obedience by promising treats: “lollies! Want lollies? Mummy’s gonna buy you McDonalds! Want a new toy? A new toy?!!!” which really isn’t enough insentive for a two year-old to lie still and hold out their hand for an injection of anaesthetic and a round of suturing!

And so it makes sense that you have to treat injured toddlers a little different than adults.

credit: Floodlighting

Traditionally, as I soon discovered, this often involves either sedating the child chemically (using medications like midazolam or ketamine, carrying out the procedure, and monitoring them closely in a resuscitation bay), or the tried and true ‘wrap em up’ method.

I was quite amazed the first time I came across this method, which basically involves wrapping a child up tightly and holding them down, while the child bucks and screams and the procedure is carried out. Sounds traumatizing, right? Well it can be… One advantage of this method is that if the procedure is minor, like gluing a lac to a forehead, the child can be unwrapped and out the door in only a few minutes. One major disadvantage (particularly for more complicated injuries), is that it’s distressing to the child, it’s distressing to the parents, it’s distressing to the other patients who can hear what’s going on, and it’s distressing to the staff!

But I digress…

Distraction Therapy

The method I see most commonly these days (particularly where I work) is distraction therapy. Normally this involves one person being a dedicated ‘distractor’, armed with several distraction inducing implements such as books, noise makers, glowing rods, videos or anything that’s particularly interesting for kids to look at and touch.

If you time things well, you can distract the child quite well with these things while the procedure is simultaneously carried out. There’s no negotiating involved, and a whole lot less screaming! Sometimes (particularly for painful procedures) you can couple this with a small dose of intra-nasal fentanyl to help with pain relief or mild sedation.

Of course it’s largely dependent on the type of injury, nature of the child and a whole host of other factors, but it’s good to at least have an option that’s not quite as archaic and traumatising as holding down a thrashing child.

What has worked well for you when dealing with injured toddlers?

Help! I’ve been ramped!

Ross — Wed, 24 Jun 2009 14:57:37 +0000

credit: martinhoward

I had something rather interesting happen to me this week – I was ramped!

While ramping is not an uncommon process every day in Australia, it is one that usually annoys / frustrates and infuriates ambulance staff more than anyone else.

What is ramping?

From the health and community services union:

“Ramping occurs when patients are forced to wait on an Ambulance stretcher in a hospital corridor before being admitted into the Emergency Department.

During ramping, Ambulance Officers are unable to leave the hospital and respond to ambulance cases, and in some cases Ambulances have been “Ramped” for up to six hours at a time.”

My ramping experience occurred when I escorted a patient with a Subarachnoid Haemorrhage to another hospital, where the patient had been accepted by neurosurg. On arrival, guess what? Oh yes they had been accepted, however there was no bed – so there we stood, ramped with a heap of other ambulances in the emergency dept.

“How much fun is ramping?” I hear you ask…. Well, let me describe it to you. First, you stand there in the hallway… and then you stand there a bit more. Time goes by, and you keep on standing there. Later, your patient runs out of portable oxygen so you get another canister. Then the monitor’s batteries run low, so you go grab some more from the ambulance. Then they get CHEST PAIN… and still you wait, while administering morph/GTN etc & monitor for ECG variances… Oh yes, these things all happened to me! Occasionally you move a little up the line… You stand around and stand around – eventually the patient needs to pee, and so on and so forth….

Fortunately my ramping experience was only an hour and a half, sometimes these guys wait waaaaaay longer than that.

Here’s an interesting letter to the editor on ramping from the journal of emergencies, trauma and shock.

Ramping for sometimes short periods and other times many hours happens pretty much every day at my hospital lately. Needless to say I have a greater appreciation of what the ambulance crews have to put up with on a daily basis. Hopefully it’s something that can be dealt in the near future, & a situation I won’t have to go through again too soon!

10 surreal minutes – did that just happen?

Ross — Thu, 11 Jun 2009 11:16:16 +0000

credit: la_cola_de_mi_perro

So today using my powers of amazing dodge-ability, I managed (by mere milliseconds) to get out of the path of a power-vomit. Not just any power vomit, this was the kind experienced only by those who have joined the ranks of the bowel-obstruction team.

As any emergency nurse would know, this normally entails such copious amounts of vomit that you begin to feel quite amazed and surprised that someone could actually fit that much in. It also smells and looks fecally, and has amazing projectile properties (all adding to the ‘excitement’, of course).

Anyway, using my amazing powers I dodged that sucker in a move that would make matrix fans proud! However, the next ten minutes happened so quickly that it left us looking around at each other saying “did that actually just happen?”.

Basically a guy came in with vomit all over the place and a big distended abdomen. Rolling over to one side caused more vomiting, and rolling to the other to change the sheets / do a PR exam caused even more. And more. Followed by… more.

Bear in mind this all happened within a very small space of time. While we were suctioning etc he suddenly went rigid, and looked like he was fitting. His eyes deviated to the left briefly, and he started going a greyish colour. Which soon turned to blue.

Hold up, he’s not breathing – yet fecal fluid continued streaming from his mouth and nose.

Tough situation – is he coughing up muck with the intention to gasp at the air again anytime soon? Do we keep suctioning till the cows come home?

Airway comes first, and it turns out he didn’t try breathing again – suctioning as much as we could, we then started manually bagging him with an air-viva, until he started some shallow respirations of his own after a minute or two. Pretty soon he was sedated, anaesthetised, intubated, IDC’d, art-lined and very unwell. More lines, more drugs, more consults. Medical, surgical, intensive care.. Antibiotics, fluid I/O, suctioning. The blood pressure juggling act….

It’s funny how things can turn so quickly – one minute it was a regular bowel obstruction patient with that special kind of vomit, the next – well it was kind of surreal…

Anyway – my colleague was not so fortunate and managed to wear some of the blood/vomit on her clothes, which is always slightly sickening to the person it happens to, and slightly amusing to the rest of the staff!

I guess you’d chalk this up to a fairly typical day in the world of emergency nursing…..

Taking some responsibility for our health issues

Ross — Mon, 01 Jun 2009 23:40:37 +0000

credit: D Sharon Pruitt

As any emergency nurse will tell you, sometimes it’s really difficult not to be judgmental of emergency presentations, particularly if they are self inflicted.

For example, some of the more infuriating presentations include:

The long term smoker with chronic smoking related problems who continues to smoke heavily, and once again ends up on bipap in the middle of the night
The pancreatitis patient who drinks heavily then presents screaming in pain
The insanely obese patient with any number of obesity related issues who presents looking for a magic cure (note – once this patient is on a bed, they typically become completely dependent on nurses for everything, and can’t possibly exert the energy required to get off the bed for anything, especially for such mundane tasks as using the toilet)
Drunks, alcohol related injuries or any presentation that begins with “I was completely off my face when…”
People with chronic pain issues who have either gone through their fortnightly allocation of analgesics in one week and are looking for more, or have some shady story about not being able to get a script filled so need some opioid-based pain-killers in the middle of the night (happens more frequently than you would think!)

These sentiments are shared in a recent post I read at ER Nursey titled This is why we are failing, but it got me thinking about why these presentations are so annoying. I think its more than just the fact that in many circumstances the presentations could have been avoided with a bit of foresight, self-control and good health practices.

One of the things I recognise is that we live in a very self-centered world. People who present with such complaints are not only hogging precious hospital resources (staff, time, expenses, A BED), but often they seem to be completely oblivious to the fact that THEY are causing their own problems.

To make things worse, many of these people frequently present not only with self inflicted injuries or complaints, but have some attitude to go with it:
“what are you gonna do to help me?” Almost a “fix this up, it’s your job” mentality. “Get me better”.

I wouldn’t make such a harsh claim if I had not seen it with my own eyes over and over and over again.

And so nurses try and maintain some degree of compassion, empathy – certainly there are a huge percentage of patients who deserve it. This other group of patients however sure make it difficult sometimes.

Surely sooner or later, for the good of ourselves, our resources and our fellow man, we as a society have to take some responsibility for our own health issues.

Watching a patient die

Ross — Fri, 24 Oct 2008 07:44:09 +0000

credit: roujo

Today I watched a man die. A few of us stood around as his heart stopped beating, and did nothing about it. It was kind of surreal, but the mood in the room was quite calm – there was no frenzy of activity with buzzers going off and people running: instead there were three professionals standing up at the top of his bed, discussing the ins and outs of his situation. In his final minute or two our talk was mostly academic, about the physiological responses to hypoxia and such other exciting things. But I’m getting ahead of myself a little, let me explain:

A man who looked to be around his mid to late seventies presented to emergency after collapsing at a care facility. He had a GCS of 3, and the only known history was that of recent renal problems which landed him a stint in ICU.

On arrival: his pupils were non-reactive to light, and he was making no spontaneous respiratory effort. He was being manually bagged with an LMA mask, and was quickly intubated after arrival. He was hypertensive, and had an erratic heart rate with frequent arrhythmias (ventricular runs with rate 90-100, runs of bradycardia at 30-40/min with ectopics, then runs of tachycardia ~110-130).

The usual lines, bloods, fluid, ECG, and neurological checks preceded the obvious CT scan, which subsequently revealed a large intracerebral haemorrhage . Consultation with neurosurgery based on his scans and myriad of other co-morbidities resulted in a prognosis of basically zero, which left him intubated with pupils now completely fixed and dilated, an erratic heart rate, and no spontaneous breaths at all.

We reversed some of his prior drugs such as vecuronium with neostigmine and atropine, to ensure he was not under the effects of earlier drugs, then used the old watch and wait treatment.

credit: littlenelly

Which brings us to watching him die. Gradually he was weaned down off the ventilator, with frequency of breaths lowered from 16 to 14…. 10…. 8…. 4…. and percentage of delivered oxygen lowered from 100% to around the 50% mark. There was no neurological response at all, and no spontaneous breathing: even hypoxic encouragement failed to induce any kind of respiratory effort.

And so we stood around, waiting to see if he would take a breath, all other avenues exhausted at this stage.

Everyone was in agreement with the treatment of this man, yet it remains a kind of surreal moment: our aim is to fix, to heal, to help, to treat…. and also at times to watch the inevitable. And so we made him as comfortable as possible, this disheveled 66 year old man, and contacted the only member of his family we knew of, who did not want to come in.

Part of being able to work well in emergency departments largely depends on the aftermath of this kind of situation: how you deal with bodies, putting them in a bag, removing all the tubes… writing up your notes, making sure your times are accurate, double checking the drugs you gave… liasing with other staff, making sure you were spot on legally. Finalising the paperwork, making sure correct forms are done, talking to the mortuary, arranging to remove the body…. And coming to terms with death yourself.

I’ve been in the game long enough to cope very well with such situations, but everyone handles things differently. Personally I find the only way is to completely remove myself from the situation emotionally, and if anything we tend to keep the mood as upbeat and productive as possible, despite the dire situation. And the reason? There’s a new trauma arriving in 3 minutes – the bay needs to be ready by then……

Is it really an emergency?

Ross — Mon, 20 Oct 2008 09:25:01 +0000

photo credit: viva la vibs

There has been a lot written on emergency departments and the frequency of patients who attend for frivolous and stupid complaints. Certainly this has become a part of my day to day life, and there have been many times when I have wished that the Australasian Triage Score system had a category 6, 7 or 8….

Here’s a few presentations that actually rocked up to the triage desk this week:

“I’ve had a sore throat for 2 days…”
“My daughter fell onto her hand, it’s not sore but I’d like it checked out…”
“He’s vomited twice in the last couple hours…” (20y/o male)
“This tooth has been bugging me for a few months, now it’s REAL bad!…”
“I’m on holiday and my script has run out…”

Suburban Emergency has a great post called Never mind that’s worth checking out. It’s a bit of a rebuttal aimed at someone who suggested the ED is the best place to go instead of a GP, and outlines why this is not a particularly good idea.

credit: gemsling

It seems universal that emergency departments are used inappropriately, regardless of the health care system / payment structure and regulations that apply to each particular country. The NSW Health Deparment has a blurb on their web site which describes the purpose of emergency departments in Australia as follows:

The main function of an emergency department, or ED, is to treat patients who are suffering from an acute serious illness or injury that would lead to severe complications if not treated quickly. The ED is not designed to provide ongoing care. Patients requiring urgent attention will always be seen first. Treatment in the ED is based on clinical need and not your financial situation or whether you have health insurance.
Non-emergency conditions are best treated by your local doctor or after hours medical centre because:
- You are more likely to see the same doctor each time
- You usually won’t have to wait as long to be seen
- It frees up emergency departments to treat emergency cases

I guess that unfortunately a massive portion of the general public have been so busy visiting the emergency department, they haven’t had the time to visit the web site & find out if it’s appropriate for them to go or not….

Parents and newborns at triage

Ross — Sat, 11 Oct 2008 12:46:50 +0000

I’m a parent, I’ve been one a couple times over now! And, I can appreciate it’s not always easy being a parent.

credit: ElvisHuang

Some parents bring their kids into emergency for such minor reasons though, its hard not to raise your eyebrows and think “errr…. and why are you here!?”

Some classic examples are:

- “he has a rash!” (cannot find with magnifying glass)

- “he threw up!” (once, thirty minutes ago…)

- “she’s so upset, see?” (baby smiles)

Today I saw a baby in a similar situation (and I understand, babies are really tough to assess sometimes, so don’t take my flippant attitude the wrong way!) and grandma was doing everything short of throwing the baby to show me it was unwell! She exclaims to me as I enter the room (gripping baby for dear life) “he’s just not himself, this is so out of character… and I MEAN IT!” (baby alert, interactive, smiling…..)

Anyway… I shouldn’t complain – newborns are tough…. good luck parents!