What would Flea have done?

At about 3 AM a young couple brings in their 2 year old. She ‘s been vomiting repeatedly since about 8pm after dinner. Both mom & dad alternate giving the history. I ask if she’s tried to eat or drink anything. Mom says they’ve been giving her water. I ask if she’s taking little sips or gulps. Simultaneously, Mom says sips and Dad says gulps. Then mom says sips and gulps. Then dad shakes his head and says, “She’ll drink as much as you let her.” The problem is that she would vomit it back up within about 30 minutes. I continue with the history, it turns out dad stays at home with the kid and mom works during the day.

The girl looks very dry, her lips are cracked and wrinkled, her hands and toes are so cold that the pulse ox doesn’t even register, she’s got poor perfusion. But her capillary refill is great and she’s awake and cooperative.

I describe to mom & dad the difference between oral and IV hydration. I describe that there have been several studies done in ERs showing that the effectiveness of either is the same and that the time it takes to rehydrate a child is the same regardless of the method. I explain to them that the secret to oral rehydration is small sips…a teaspoon every few minutes and no more. Dad’s eyes light up in understanding. Mom scowls.

Dad agrees to try oral rehydration. I calculate a wieght based dose of oral pedialyte and the parents dutifully follow instructions and the girl is doing great. I recheck her and her lips look more full, her hands and feet are warming up. Mom tells teh nurse she wants teh IV to speed things up because she has to go to work in the morning. I explain that the oral rehydration is working, and the IV won’t be any faster. The nurse brings in the 2nd half of the pedialyte and minutes later dad comes out saying that she just threw everthing up.

The second half of the pedialyte that the nurse brought in is empty. It appeared that Mom had let her guzzle it because mom wanted to get home sooner…and the little girl vomited up everything she’d just drank.

The girl WAS looking better, and I could have sent her home right then, but with this mothers parenting style, I was not convicned that the girl would get appropriate hydration at home and she’d just be back later in the afternoon.

I ordered the 2nd half of the rehydration dose as an IV, explained to the parents that all we were trying to do was make sure that she was adequately hydrated, that she may continue to vomit at home, but if she did, to continue the frequent small sips they had done on arrival, pointing out that it had indeed worked. Dad was thankful and actually had a smile on his face. mom continued to scowl.

I was really irritated with this mother. Naturally they were both concerned or they would not have brought the child in to the ER at 3AM. But the mother seemed deceitful, lied about the history to give us the ‘right’ answer, then didn’t follow instructions ending up with the girl vomiting again, and pushed for the IV, which is painful and stressful for the child, parents and the staff.

Part of my job as an ER doc is to educate. If I can educate patients on proper care at home in order to avoid an ER visit, then I’ve done a good job. But all of that seemed lost on this mother. At least Dad learned something, and hopefully next time she’s sick, Dad will take charge and attempt proper oral hydration strategies and save the whole family a visit to the ER.

As I dictatedup the chart, I kept wondering, “What would Flea have done???”

ER/ICU

I hate my job.

We’re running a mini-ICU here tonight. With what nurses am I supposed to take care of the NEW sick patients that come in? The triage nurse helped me treat the 3 month old with respiratory distress, now he’s going to childrens.

I felt OK when I came to work, but it’s been a crappy night, and my sinuses are angry again, happens with every night shift, and I know I’ll be too exhaused to do any meaningful workouts tomorrow. I think I’ll just go sit in the steam room when I wake up.

Ugh.

The next battle to fight…

Have you ever received sedation in the ER for a procedure like fracture reduction, chest tube, cardioversion, being intubated?

Have you ever taken your child to the ER for a dog bite to the face or a broken arm or leg?

THese proposed legislations would be like stepping back a decade in teh field of conscious sedation in the emergency room. The three drugs proposed are about the only 3 drugs I use anymore. Taking away the ability for ER nurses to administer them would relegate us back to using a combo of narcotics & benzo’s…an effective combination, but one that I feel is much, much harder to titrate.

There is ample research in the field of both adult and pediatric emergency medicine supporting the use of ketamine, etomidate and propofol over the older agents. THis would just be a disaster if it passed.

The State Board of Nursing has promulgated regulations regarding the administration of agents for sedation by licensed professional nurses. The proposed regulations would require all nurses who administer agents for minimal or moderate sedation to complete an annual sedation course, and would restrict the use of agents for deep sedation (i.e., propofol, etomidate, ketamine) to intubate, mechanically ventilated patients. General anesthesia or medications by which manufacturer insert indicate administration only by persons trained in anesthesia would be limited to the scope of practice of a Certified Registered Nurse Anesthetist (CRNA). If passed, the regulations have the potential to negatively impact the provision of state-of-the-art care to patients in the emergency department.

A State Board of Nursing hearing regarding these regulations has been scheduled in Harrisburg on February 12. The chapter will submit written testimony and has requested the opportunity to provide comment at the hearing.

Did we ROAR loud enough?

This is an update on a recent plea from the American College of Emergency Physicians to voice concerns on a proposed requirement that would make the current situation in the nations Emergency Room even worse. It looks like we had an impact…

The Joint Commission said that it will consider revising a standard requiring pharmacists to prospectively review all medications administered in the emergency department.

The standard has provoked an uproar among emergency physicians, who said it was causing unnecessary delays in providing needed medications to patients in the ED.

While The Joint Commission develops revisions to the medication management standard–a process that likely won’t be complete until at least late 2007–hospitals will be deemed in compliance if a pharmacist conducts a retrospective review of medication orders within 48 hours, according to an announcement in the Joint Commission’s January newsletter.

“This modification will prevent treatment delays while retaining a pharmacist’s involvement,” according to the text of The Joint Commission’s interim provisions for the standard.

The interim provision was instituted after a large effort by ACEP and the emergency medicine community who persistently let The Joint Commission know the impact this standard had in emergency departments nationwide.

“It is a direct result of our concentrated efforts to make The Joint Commission aware of the difficulties and deleterious effect it was having on patient care,” said Marilyn Bromley, R.N., director of ACEP’s emergency medicine practice department.

In addition, ACEP, the Emergency Nurses Association and AAEM sent a strongly worded letter to The Joint Commission. Subsequently, ACEP kept in constant contact with the Joint Commission’s representatives as the problems caused by the standard got worse.

“ACEP would also like to thank the emergency physicians and nurses who completed The Joint Commission field survey requesting comments on the standard,” Ms. Bromley said. “The united front presented by emergency medicine sent a very powerful message to the Joint Commission.”

You’re Welcome. 😉