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Resuscitation of the child
Feb
24
I was called in emergently last week to see a 1 month
old found laying prone on the parents' bed
apneic/unresponsive. Apparently, the FOC brought the
baby back to bed with him early in the am and awoke to
find the baby face down. The infant was in v fib upon
ER arrival - shocked, given lidocaine, epi, intubated,
resuscitated and I arrived about 20 minutes into the
resuscitation. Long story short, this infant had PEA
off and on but intermittently had a palpable pulse. I
fought with myself about whether to just "let the baby
go" but with the palpable pulse and HR anywhere
between 30-80, felt compelled to continue following
the PALS protocol. 2 hours later, on a dopamine and
epi drip, we *finally* got an ABG (pH 6.8) and the
baby started getting *pink* and actually looked stable
enough to transfer. She died the next morning in the
PICU - presumably with a diagnosis of SIDS. There
were no indications of abuse. She was a completely
healthy infant prior to this event.
Fortunately, we don't see this sort of scenario very
often - last time I had to do this was almost 2 years
ago. My question (finally) is: are there
*guidelines* somewhere regarding when to "draw the
line" during a resuscitation like this? A point
beyond which it is so futile that despite a HR/pulse,
we should/can just *stop*? I ended up second-guessing
myself that whole day and finally heard that she had
died. :-(
Eve H. Switzer, MD, FAAP
rural peds
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Resuscitation of the child
Message from Julia hidden@email-address
On Monday, February 24, 2003, at 12:25 PM, Eve Switzer wrote:
> My question (finally) is: are there *guidelines* somewhere regarding
> when to "draw the line" during a resuscitation like this? A point
> beyond which it is so futile that despite a HR/pulse, we should/can
> just *stop*?
I had a similar situation a couple of weeks ago, but with a six month
old--shaken baby. It's a tough call. I ended up doing what you did
(everything) and transferred the baby to the University PICU, where she
was eventually taken off life support (after brain scans showed the
extent of damage).
One piece of advice I got after an earlier experience (3 mo old,
massive gut necrosis after volvulus) was to order a rectal temp as soon
as you get on the scene. I guess a very low temp gives you some info
about how long the baby has been down, but other than adding it to the
documentation, I'm not sure that would change my behavior any. . .
Once in residency I performed chest compressions for almost an hour on
a baby (complicated PMH) who had a pacemaker in place. We had to call
down one of the cardiology fellows to turn the thing off before we
could make up our minds to call the code. That baby was pulseless, she
just had electrical activity in response to the pacemaker.
I think it may be helpful for the family to see the local providers do
"everything" and then deal with the loss the next day with a decision
to remove life support. Of course, I've seen families who persist in
denial and want to continue the life support forever. That's a mess,
and I don't know what to say about that. I spent much of my residency
caring for devastated children (they populated my "well child clinic")
My local PICU docs seem to be quite reasonable and rational, so I'm
willing to leave those decisions up to them. I do remember a NICU
attending (more than just an attending--he ran the unit) who had such a
rabid "preserve all life" attitude that it left me with an uneasy
feeling about what I would do at a super-premie delivery. Luckily, it
never came up on my watch. . .
Julia in Waunakee
Resuscitation of the child
Thanks Hillary - thinking some more about what
happened and reading some of the responses to PedTalk
and yours, I think the real reason I *wanted* to keep
going was to be eventually absolved of being
*responsible* for making the final decision that would
result in the child's death. I think that's what I'm
really afraid of/wondering about. The one and only
time I have ever had to make that
decision/recommendation was with a child who had
trisomy 18 going into obvious respiratory failure.
That seemed a bit "easier" compared to this type of
scenario.
Eve H. Switzer, MD, FAAP
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Resuscitation of the child
Julia - what is the exact correlation between temp and
outcome? This child's temp (when we finally thought
to check it - about 1/2 hour after I got there) was 88
degrees F. What's the "cut-off"?
Eve H. Switzer, MD, FAAP
rural peds
--- Julia wrote:
> On Monday, February 24, 2003, at 12:25 PM, Eve
> Switzer wrote:
>
> > My question (finally) is: are there *guidelines*
> somewhere regarding
> > when to "draw the line" during a resuscitation
> like this? A point
> > beyond which it is so futile that despite a
> HR/pulse, we should/can
> > just *stop*?
>
> I had a similar situation a couple of weeks ago, but
> with a six month
> old--shaken baby. It's a tough call. I ended up
> doing what you did
> (everything) and transferred the baby to the
> University PICU, where she
> was eventually taken off life support (after brain
> scans showed the
> extent of damage).
>
> One piece of advice I got after an earlier
> experience (3 mo old,
> massive gut necrosis after volvulus) was to order a
> rectal temp as soon
> as you get on the scene. I guess a very low temp
> gives you some info
> about how long the baby has been down, but other
> than adding it to the
> documentation, I'm not sure that would change my
> behavior any. . .
>
> Once in residency I performed chest compressions for
> almost an hour on
> a baby (complicated PMH) who had a pacemaker in
> place. We had to call
> down one of the cardiology fellows to turn the thing
> off before we
> could make up our minds to call the code. That baby
> was pulseless, she
> just had electrical activity in response to the
> pacemaker.
>
> I think it may be helpful for the family to see the
> local providers do
> "everything" and then deal with the loss the next
> day with a decision
> to remove life support. Of course, I've seen
> families who persist in
> denial and want to continue the life support
> forever. That's a mess,
> and I don't know what to say about that. I spent
> much of my residency
> caring for devastated children (they populated my
> "well child clinic")
>
> My local PICU docs seem to be quite reasonable and
> rational, so I'm
> willing to leave those decisions up to them. I do
> remember a NICU
> attending (more than just an attending--he ran the
> unit) who had such a
> rabid "preserve all life" attitude that it left me
> with an uneasy
> feeling about what I would do at a super-premie
> delivery. Luckily, it
> never came up on my watch. . .
>
> Julia in Waunakee
>
>
> This message is from PEDTALK - a Pediatric Focused
> email discussion group.
> Admin questions: "hidden@email-address" or
> "http://www.pcc.com/lists/"
> To unsubscribe: mail "hidden@email-address" with
> "unsubscribe"
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Resuscitation of the child
Message from Julia hidden@email-address
On Monday, February 24, 2003, at 07:49 PM, Eve Switzer wrote:
> Julia - what is the exact correlation between temp and
> outcome? This child's temp (when we finally thought
> to check it - about 1/2 hour after I got there) was 88
> degrees F. What's the "cut-off"?
I can't really say, Eve. I got that advice, and I followed it the next
chance I had, but I can't say that anyone has told me about a
"cut-off." It's just another data point. I wouldn't base any decision
upon it. . .
Julia in Waunakee
Resuscitation of the child
For what does PMH stand?
Dan Nussbaum
Resuscitation of the child
--- hidden@email-address wrote:
> For what does PMH stand?
>
> Dan Nussbaum
I believe she was referring to a complicated Past
Medical History...
Eve H. Switzer, MD, FAAP
rural peds
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Resuscitation of the child
> The father of the child?
Of course. I was expecting a complex medical acronym ;o)
--
Cheers,
Rich Churcher, RN
PICU, Children's Hospital at Westmead, Australia
Phone Nurse Services
I'm curious to know how many practices have a "phone nurse" staffed to
answer calls M-F (40 hours)?
Thanks
Brenda
Traverse City
Phone Nurse Services
We have full time phone nurses, but they rotate so they don't go nuts.
We also use a "nurse triage"call in service at night and weekends. Costs us
about $25,000 per year. We charge the patient for phone calls made at night.
Not too popular a policy but many of the practices here (Raleigh) doing it.
Has increased usage of our website advice though... www.tripeds.com. They also
have the option of messaging us on the web through MDHub.
Phone Nurse Services
That is a bunch of $$ for phone call answering. Maybe you need to forward
those calls my way...
Don't you still get 20% of the calls through from the service?
We have an 8 provider practice but I doubt we average 10 calls a night. $68
/ night seems like a lot.
Does billing the patients pay for it? I am afraid that I would end up
spending a lot more money on billing costs than it is worth.
Any other practices out there doing this?
-graham
----- Original Message -----
From: "Bill"
To:
Sent: Tuesday, February 25, 2003 11:27 AM
Subject: Re: Phone Nurse Services
> We have full time phone nurses, but they rotate so they don't go nuts.
>
> We also use a "nurse triage"call in service at night and weekends. Costs
us
> about $25,000 per year. We charge the patient for phone calls made at
night.
> Not too popular a policy but many of the practices here (Raleigh) doing
it.
> Has increased usage of our website advice though... www.tripeds.com. They
also
> have the option of messaging us on the web through MDHub.
>
> This message is from PEDTALK - a Pediatric Focused email discussion
group.
RE: Phone Nurse Services
Message from Michael L. Webster hidden@email-address
We have two nurses doing phone triage and advice most of the time.
Sometimes 3 on Monday mornings. Sometimes one at the end of the day.
Unfortunately, we still get complaints about phone access. To reduce time
on the phones, we tell the phone nurses that if the patient needs advice
that would take 5 minutes or more then they need an office visit. Of course
the problem with that during this time of year is that we don't have time
for that many office visits. We have 3 pediatricians and one nurse
practionner.
Michael
________________________
Michael L. Webster, MD, FAAP
Hamot Medical Center
Shriner's Hospital for Children
Erie, PA
-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
Brenda Roderick
Sent: Tuesday, February 25, 2003 9:45 AM
To: hidden@email-address
Subject: Phone Nurse Services
I'm curious to know how many practices have a "phone nurse" staffed to
answer calls M-F (40 hours)?
Thanks
Brenda
Traverse City
Phone Nurse Services
Sounds like you need more phone lines! By the time you hear about one or two
complaints, there are at least 20 others out there grumbling to themselves
about lack of service.
We have our receptionists field the calls, pull the charts, and put the
questions with the charts back for the nurses. We try hard never to put a
patient straight to a nurse for anything other than an urgent call. If you
make it too easy for someone to call for a tylenol dose, they won't bother
to get their glasses and read the label - they call. And I think it is
always better for the nurse to have the chart and record a note documenting
the call.
-gb
----- Original Message -----
From: "Michael L. Webster"
To:
Sent: Tuesday, February 25, 2003 7:27 PM
Subject: RE: Phone Nurse Services
> We have two nurses doing phone triage and advice most of the time.
> Sometimes 3 on Monday mornings. Sometimes one at the end of the day.
> Unfortunately, we still get complaints about phone access. To reduce time
> on the phones, we tell the phone nurses that if the patient needs advice
> that would take 5 minutes or more then they need an office visit. Of
course
> the problem with that during this time of year is that we don't have time
> for that many office visits. We have 3 pediatricians and one nurse
> practionner.
>
> Michael
> ________________________
>
> Michael L. Webster, MD, FAAP
> Hamot Medical Center
> Shriner's Hospital for Children
> Erie, PA
>
> -----Original Message-----
> From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
> Brenda Roderick
> Sent: Tuesday, February 25, 2003 9:45 AM
> To: hidden@email-address
> Subject: Phone Nurse Services
>
>
> I'm curious to know how many practices have a "phone nurse" staffed to
> answer calls M-F (40 hours)?
>
> Thanks
> Brenda
> Traverse City
RE: Phone Nurse Services
Message from Michael L. Webster hidden@email-address
You hit the nail on the head with us. Our patients are used to getting
through to a nurse for ANYthing. Therefore they expect to. . . and they get
made if they have to wait because everyone else is expecting to also. I
can't get more phone lines because I can't afford to pay more people to
answer them. With your system, I would expect that your call volume is
lower and people get trained to utilize the phone nurse calls more
appropriately. I am the youngest member of a an old practice whose senior
members have no interest in change and little interest in improving the
practice for the future.
Michael
________________________
Michael L. Webster, MD, FAAP
Erie, PA
-----Original Message-----
From: Graham Barden
Sounds like you need more phone lines! By the time you hear about one or two
complaints, there are at least 20 others out there grumbling to themselves
about lack of service.
We have our receptionists field the calls, pull the charts, and put the
questions with the charts back for the nurses. We try hard never to put a
patient straight to a nurse for anything other than an urgent call. If you
make it too easy for someone to call for a tylenol dose, they won't bother
to get their glasses and read the label - they call. And I think it is
always better for the nurse to have the chart and record a note documenting
the call.
-gb
----- Original Message -----
From: "Michael L. Webster"
> We have two nurses doing phone triage and advice most of the time.
> Sometimes 3 on Monday mornings. Sometimes one at the end of the day.
> Unfortunately, we still get complaints about phone access. To reduce time
> on the phones, we tell the phone nurses that if the patient needs advice
> that would take 5 minutes or more then they need an office visit. Of
course
> the problem with that during this time of year is that we don't have time
> for that many office visits. We have 3 pediatricians and one nurse
> practionner.
>
> Michael
> ________________________
>
> Michael L. Webster, MD, FAAP
> Hamot Medical Center
> Shriner's Hospital for Children
> Erie, PA
>
> -----Original Message-----
> From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
> Brenda Roderick
> Sent: Tuesday, February 25, 2003 9:45 AM
> To: hidden@email-address
> Subject: Phone Nurse Services
>
>
> I'm curious to know how many practices have a "phone nurse" staffed to
> answer calls M-F (40 hours)?
>
> Thanks
> Brenda
> Traverse City
Phone Nurse Services
WOW! Everyone's postings were very interesting to read. We have 5 docs, 3
NP's, are open from 8-5 M-F and 9-12 on Sat. We pay on average $13,000 per
year for phone calls. We average 3 calls per night. Our phone service was
severely abused prior to us making the call a long distance number (not alot
of after hours services in our community, so we have to use one downstate).
We have one full time phone nurse however are looking at that because of the
decreased reimbursement from payers for other things. I'll keep you all
posted if we make any changes--and let you know the response from the
patients.
Everyone's input was valuable. Thank you!
Brenda
Office Manager
Kids Creek Children's Clinic
Traverse City, MI
----- Original Message -----
From: "Michael L. Webster"
To: "Graham Barden" ;
Sent: Wednesday, February 26, 2003 6:44 AM
Subject: RE: Phone Nurse Services
> You hit the nail on the head with us. Our patients are used to getting
> through to a nurse for ANYthing. Therefore they expect to. . . and they
get
> made if they have to wait because everyone else is expecting to also. I
> can't get more phone lines because I can't afford to pay more people to
> answer them. With your system, I would expect that your call volume is
> lower and people get trained to utilize the phone nurse calls more
> appropriately. I am the youngest member of a an old practice whose senior
> members have no interest in change and little interest in improving the
> practice for the future.
>
> Michael
> ________________________
>
> Michael L. Webster, MD, FAAP
> Erie, PA
>
> -----Original Message-----
> From: Graham Barden
>
> Sounds like you need more phone lines! By the time you hear about one or
two
> complaints, there are at least 20 others out there grumbling to themselves
> about lack of service.
> We have our receptionists field the calls, pull the charts, and put the
> questions with the charts back for the nurses. We try hard never to put a
> patient straight to a nurse for anything other than an urgent call. If you
> make it too easy for someone to call for a tylenol dose, they won't bother
> to get their glasses and read the label - they call. And I think it is
> always better for the nurse to have the chart and record a note
documenting
> the call.
> -gb
>
> ----- Original Message -----
> From: "Michael L. Webster"
>
> > We have two nurses doing phone triage and advice most of the time.
> > Sometimes 3 on Monday mornings. Sometimes one at the end of the day.
> > Unfortunately, we still get complaints about phone access. To reduce
time
> > on the phones, we tell the phone nurses that if the patient needs advice
> > that would take 5 minutes or more then they need an office visit. Of
> course
> > the problem with that during this time of year is that we don't have
time
> > for that many office visits. We have 3 pediatricians and one nurse
> > practionner.
> >
> > Michael
> > ________________________
> >
> > Michael L. Webster, MD, FAAP
> > Hamot Medical Center
> > Shriner's Hospital for Children
> > Erie, PA
> >
> > -----Original Message-----
> > From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
> > Brenda Roderick
> > Sent: Tuesday, February 25, 2003 9:45 AM
> > To: hidden@email-address
> > Subject: Phone Nurse Services
> >
> >
> > I'm curious to know how many practices have a "phone nurse" staffed to
> > answer calls M-F (40 hours)?
> >
> > Thanks
> > Brenda
> > Traverse City
>
> This message is from PEDTALK - a Pediatric Focused email discussion
group.
>
> This message is from PEDTALK - a Pediatric Focused email discussion
group.
Phone Nurse Services
I am surprised how much people are willing to pay to have someone else
answer the phone. To me it is just part of the job. Plus I am too cheap to
pay someone $11/ call to have them answer it!
-gb
----- Original Message -----
From: "Brenda Roderick"
To: "Michael L. Webster" ; "Graham Barden"
;
Sent: Wednesday, February 26, 2003 8:14 AM
Subject: Re: Phone Nurse Services
> WOW! Everyone's postings were very interesting to read. We have 5 docs, 3
> NP's, are open from 8-5 M-F and 9-12 on Sat. We pay on average $13,000
per
> year for phone calls. We average 3 calls per night. Our phone service was
> severely abused prior to us making the call a long distance number (not
alot
> of after hours services in our community, so we have to use one
downstate).
> We have one full time phone nurse however are looking at that because of
the
> decreased reimbursement from payers for other things. I'll keep you all
> posted if we make any changes--and let you know the response from the
> patients.
>
> Everyone's input was valuable. Thank you!
>
> Brenda
> Office Manager
> Kids Creek Children's Clinic
> Traverse City, MI
> ----- Original Message -----
> From: "Michael L. Webster"
> To: "Graham Barden" ;
> Sent: Wednesday, February 26, 2003 6:44 AM
> Subject: RE: Phone Nurse Services
>
>
> > You hit the nail on the head with us. Our patients are used to getting
> > through to a nurse for ANYthing. Therefore they expect to. . . and they
> get
> > made if they have to wait because everyone else is expecting to also. I
> > can't get more phone lines because I can't afford to pay more people to
> > answer them. With your system, I would expect that your call volume is
> > lower and people get trained to utilize the phone nurse calls more
> > appropriately. I am the youngest member of a an old practice whose
senior
> > members have no interest in change and little interest in improving the
> > practice for the future.
> >
> > Michael
> > ________________________
> >
> > Michael L. Webster, MD, FAAP
> > Erie, PA
> >
> > -----Original Message-----
> > From: Graham Barden
> >
> > Sounds like you need more phone lines! By the time you hear about one or
> two
> > complaints, there are at least 20 others out there grumbling to
themselves
> > about lack of service.
> > We have our receptionists field the calls, pull the charts, and put the
> > questions with the charts back for the nurses. We try hard never to put
a
> > patient straight to a nurse for anything other than an urgent call. If
you
> > make it too easy for someone to call for a tylenol dose, they won't
bother
> > to get their glasses and read the label - they call. And I think it is
> > always better for the nurse to have the chart and record a note
> documenting
> > the call.
> > -gb
> >
> > ----- Original Message -----
> > From: "Michael L. Webster"
> >
> > > We have two nurses doing phone triage and advice most of the time.
> > > Sometimes 3 on Monday mornings. Sometimes one at the end of the day.
> > > Unfortunately, we still get complaints about phone access. To reduce
> time
> > > on the phones, we tell the phone nurses that if the patient needs
advice
> > > that would take 5 minutes or more then they need an office visit. Of
> > course
> > > the problem with that during this time of year is that we don't have
> time
> > > for that many office visits. We have 3 pediatricians and one nurse
> > > practionner.
> > >
> > > Michael
> > > ________________________
> > >
> > > Michael L. Webster, MD, FAAP
> > > Hamot Medical Center
> > > Shriner's Hospital for Children
> > > Erie, PA
> > >
> > > -----Original Message-----
> > > From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
> > > Brenda Roderick
> > > Sent: Tuesday, February 25, 2003 9:45 AM
> > > To: hidden@email-address
> > > Subject: Phone Nurse Services
> > >
> > >
> > > I'm curious to know how many practices have a "phone nurse" staffed to
> > > answer calls M-F (40 hours)?
> > >
> > > Thanks
> > > Brenda
> > > Traverse City
> >
> > -----------------------------------------------------------------------
> > This message is from PEDTALK - a Pediatric Focused email discussion
> group.
> > List address: "hidden@email-address"
> > Admin questions: "hidden@email-address" or "http://www.pcc.com/lists/"
> > To unsubscribe: mail "hidden@email-address" with "unsubscribe"
> > in the body of the message.
> >
> > -----------------------------------------------------------------------
> > This message is from PEDTALK - a Pediatric Focused email discussion
> group.
> > List address: "hidden@email-address"
> > Admin questions: "hidden@email-address" or "http://www.pcc.com/lists/"
> > To unsubscribe: mail "hidden@email-address" with "unsubscribe"
> > in the body of the message.
>
> This message is from PEDTALK - a Pediatric Focused email discussion
group.
RE: Phone Nurse Services
At $11 per call, the docs and the NP in our office would be fighting to be
the "phone nurse"! For our office that would be a salary of close to
a thousand dollars a day lately. -Diane, CNP
-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address] On Behalf Of
Graham Barden
Sent: Wednesday, February 26, 2003 11:47 PM
To: pedtalk@pcc. com
Subject: Re: Phone Nurse Services
I am surprised how much people are willing to pay to have someone else
answer the phone. To me it is just part of the job. Plus I am too cheap to
pay someone $11/ call to have them answer it!
-gb
Phone Nurse Services
You may have misunderstood. That's our AFTER HOURS triage service...
----- Original Message -----
From: "Diane and Al"
To: "PedTalk"
Sent: Thursday, February 27, 2003 8:28 AM
Subject: RE: Phone Nurse Services
> At $11 per call, the docs and the NP in our office would be fighting to be
> the "phone nurse"! For our office that would be a salary of close
to
> a thousand dollars a day lately. -Diane, CNP
>
> -----Original Message-----
> From: hidden@email-address [mailto:hidden@email-address] On Behalf Of
> Graham Barden
> Sent: Wednesday, February 26, 2003 11:47 PM
> To: pedtalk@pcc. com
> Subject: Re: Phone Nurse Services
>
> I am surprised how much people are willing to pay to have someone else
> answer the phone. To me it is just part of the job. Plus I am too cheap to
> pay someone $11/ call to have them answer it!
> -gb
>
> This message is from PEDTALK - a Pediatric Focused email discussion
group.
Phone Nurse Services
Brenda Roderick wrote:
> Our phone service was
> severely abused prior to us making the call a long distance number (not alot
> of after hours services in our community, so we have to use one downstate).
Has anyone contemplated using a "900" type number for after hours calls? I
think we "give away" too much of our cerebral services and with the razor
thin margins we now have with managed care, we have to come up with some
way to pay the bills.
--
Shalom,
Gary M. on LI
Volunteer Your PC for Cancer Research @
http://members.ud.com/services/teams/team.htm?id=6065F531-AD68-47F5-938D...
RE: Phone Nurse Services
A few years ago, some doctors in New Brunswick set up a 900 service for
their calls. It seemed to be a great business since they got calls for
advice from people who weren't their patients. It folded when the insurance
carrier got wind of it.
Jon Slater
Comox, BC
-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
Gary Mirkin
Sent: February 27, 2003 3:33 PM
To: Peds Talk List
Subject: Re: Phone Nurse Services
Brenda Roderick wrote:
> Our phone service was
> severely abused prior to us making the call a long distance number (not
alot
> of after hours services in our community, so we have to use one
downstate).
Has anyone contemplated using a "900" type number for after hours calls? I
think we "give away" too much of our cerebral services and with the razor
thin margins we now have with managed care, we have to come up with some
way to pay the bills.
--
Shalom,
Gary M. on LI
Volunteer Your PC for Cancer Research @
http://members.ud.com/services/teams/team.htm?id=6065F531-AD68-47F5-938D...
F5CDFC284
RE: Phone Nurse Services
I operate a solo consulting practice in a small rural community on Vancouver
Island. I have a medical office assistant who answers phones, schedules
appointments and types letters. She's the front office and decides who gets
to talk with me or the practice nurse. The registered nurse is available for
case management, telephone advice and crisis counseling. The two of them
keep me honest.
Jon Slater
Comox, BC
-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
Brenda Roderick
Sent: February 25, 2003 6:45 AM
To: hidden@email-address
Subject: Phone Nurse Services
I'm curious to know how many practices have a "phone nurse" staffed to
answer calls M-F (40 hours)?
Thanks
Brenda
Traverse City
Phone Nurse Services
Our practice of 5 physicians and 5 PNP's (total patient population approx
10,000) has a triage phone station that usually has 3-4 nurses and MA's that
rotate through it. All clinical staff have at least a day on the phone,
rotating to work with the providers on other days. They follow Barton
Schmidt protocols, giving home advice or scheduling in the patient if the
protocol dictates or parent insists. We also have the Pediatric Advisor on
the computer in front of each nurse for reference. All scheduling is done
by computer. All notes are written and disposition is placed in the chart
(special phone note with double sided tape...about eight calls can be
layered on a page at a specified site in the chart for future reference).
If home advice is given or the patient scheduled in, the note does not go
back to the provider for any signature. If further direction/advice is
needed from the provider, a note goes back for his/her response and then put
into the chart after it is completed by the nurse.
We have a phone operator who answers the call and directs it to the
appropriate site (sick of day goes to nurse at triage, future appt. goes up
front to clerical scheduler, billing calls to our billing dept, etc.) She
has many other duties...doesn't just sit and wait for the phone to
ring...sorts and delivers mail, types/readies charts for new patients,
assembles VIS sheets so nurses can have a packet ready as a handout at the
appropriate visit, etc.
One of the triage nurses is designated "call back nurse". She also triages
(including meeting with parents who walk-in for advice!) etc., but keeps the
work flowing as the answers come back from the providers so that there are
not those "piles of notes" to answer at lunch or at the end of the day. As
notes are answered by the providers, they come back to her and she calls
pharmacies, parents, etc. If she finds that notes are piling up back with
providers, she "gently" gets them to answer even a couple at a time :) so
that efficiency is maintained up at the triage station. All triage staff
ultimately assist with the call back process as time permits. There is a
small picture of the triage workstation on our website
www.hollandhospital.org/hollandpediatrics
Karen Kohlruss BSN RN
Holland Pediatric Associates, PC
Phone Nurse Services
Just to clarify my first sentence of previous post....there are 3-4 staff
members on the phone at the same time.
Karen Kohlruss BSN RN
Holland Pediatrics
Resuscitation of the child
What is FOC and PEA?
Len
Resuscitation of the child
Len asked:
> What is FOC and PEA?
PEA is pulseless electrical activity - in other words, a rhythm
without a pulse. You sometimes hear the term 'electromechanical
dissociation' (EMD) bounced around, which I understand means much the
same thing.
I have no idea what FOC is, and remain curious!
--
Cheers,
Rich Churcher, RN
PICU, Children's Hospital at Westmead, Australia
Resuscitation of the child
Message from Michelle Ratau hidden@email-address
FOC is Father of Child.
FOB is Father of Baby.
Michelle
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RE: Resuscitation of the child
Hi Eve,
I don't think there are any guidelines. For me, the knowledge that the
outcome for a pulseless apneic child in any situation other than cold water
immersion is so dismal makes the decision easier. Sounds to me as though you
made a heroic effort to save this child's life, and I doubt any of us could
have done any better.
Jon
-----Original Message-----
From: hidden@email-address [mailto:hidden@email-address]On Behalf Of
Eve Switzer
Sent: February 24, 2003 10:25 AM
To: hidden@email-address
Subject: Resuscitation of the child
I was called in emergently last week to see a 1 month
old found laying prone on the parents' bed
apneic/unresponsive. Apparently, the FOC brought the
baby back to bed with him early in the am and awoke to
find the baby face down. The infant was in v fib upon
ER arrival - shocked, given lidocaine, epi, intubated,
resuscitated and I arrived about 20 minutes into the
resuscitation. Long story short, this infant had PEA
off and on but intermittently had a palpable pulse. I
fought with myself about whether to just "let the baby
go" but with the palpable pulse and HR anywhere
between 30-80, felt compelled to continue following
the PALS protocol. 2 hours later, on a dopamine and
epi drip, we *finally* got an ABG (pH 6.8) and the
baby started getting *pink* and actually looked stable
enough to transfer. She died the next morning in the
PICU - presumably with a diagnosis of SIDS. There
were no indications of abuse. She was a completely
healthy infant prior to this event.
Fortunately, we don't see this sort of scenario very
often - last time I had to do this was almost 2 years
ago. My question (finally) is: are there
*guidelines* somewhere regarding when to "draw the
line" during a resuscitation like this? A point
beyond which it is so futile that despite a HR/pulse,
we should/can just *stop*? I ended up second-guessing
myself that whole day and finally heard that she had
died. :-(
Eve H. Switzer, MD, FAAP
rural peds
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Resuscitation of the child
Eve Switzer wrote:
> She died the next morning in the
> PICU - presumably with a diagnosis of SIDS.
Just curious - but was a death scene investigation done? SIDS protocol
requires a death scene investigation. I know this is one of those 'ify'
situations because technically the child died in the hospital. However, in
some locales the ultimate dx may have been "positional asphyxia," given the
circumstances that led to her death and her very young age.
Tammy
Resuscitation of the child
I think the real reason I *wanted* to keep
going was to be eventually absolved of being
*responsible* for making the final decision that would
result in the child's death. I think that's what I'm
really afraid of/wondering about.
I missed this conversation. Rest assured that you made the right decision,
the only decision that could be made really. It is always a very painful
decision but the family will understand eventually if they don't understand
now. I remember once when we had twins in the Unit. We lost one. The other
Twin coded and we resus'ed for 20 minutes. The Neonatologist leading the team
said "let's stop now: Is everyone comfortable with that?". I remember feeling
like begging him to continue just for 5 more minutes and I was sure the Lord
wouldn't take the 2nd child from these parents who tried so hard to get
pregnant. Tears were running down my face when I said "yes" I'm ready to stop
and discontinued ventilations. My co-worker couldn't stop compressions, and
the Doc who was a very large man just gently lifted her away from where she
stood at the bedside. She was in shock. None of us ever likes to feel
responsible for declaring death. It hurts too badly. Ultimately the decision
is taken out of our hands. I hope you will find closure and believe in your
self. There was not a choice here!
Bonnie Lovette PNP
Resuscitation of the child
One advantage of letting the patient live an extra 24 or 48 hours is that
it gives a chance for the family members to say goodbye.
One of the things I learned is that there is no right answer. All we can
do is our best and hope we don't make the big mistakes, like putting in a
heart and lungs from someone with type B blood into the chest of someone
with type A blood. It better to call a code a little late rather than a
little too early.
All the best,
Jeff
On Tue, 25 Feb 2003 21:57:23 EST hidden@email-address writes:
> I think the real reason I *wanted* to keep
> going was to be eventually absolved of being
> *responsible* for making the final decision that would
> result in the child's death. I think that's what I'm
> really afraid of/wondering about.
>
> I missed this conversation. Rest assured that you made the right
> decision,
> the only decision that could be made really. It is always a very
> painful
> decision but the family will understand eventually if they don't
> understand
> now. I remember once when we had twins in the Unit. We lost one. The
> other
> Twin coded and we resus'ed for 20 minutes. The Neonatologist leading
> the team
> said "let's stop now: Is everyone comfortable with that?". I
> remember feeling
> like begging him to continue just for 5 more minutes and I was sure
> the Lord
> wouldn't take the 2nd child from these parents who tried so hard to
> get
> pregnant. Tears were running down my face when I said "yes" I'm
> ready to stop
> and discontinued ventilations. My co-worker couldn't stop
> compressions, and
> the Doc who was a very large man just gently lifted her away from
> where she
> stood at the bedside. She was in shock. None of us ever likes to
> feel
> responsible for declaring death. It hurts too badly. Ultimately the
> decision
> is taken out of our hands. I hope you will find closure and believe
> in your
> self. There was not a choice here!
> Bonnie Lovette PNP
>
> This message is from PEDTALK - a Pediatric Focused email discussion
> group.
> Admin questions: "hidden@email-address" or
> "http://www.pcc.com/lists/"
>
>
>
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Resuscitation of the child
That's a good question. I don't honestly know what
the final diagnosis was. I'm sure they did do an
investigation - there were so many police officers
there at the resuscitation waiting to see the outcome.
I wonder what the subtle difference would be between
a final diagnosis of SIDS and positional asphyxia. I
thought that SIDS was not felt to be just positional
asphyxia so a distinction would need to be made I
suppose. It seems that positional asphyxia rather
than SIDS might imply a bit more "blame", no?
Eve H. Switzer, MD, FAAP
rural peds
--- hidden@email-address wrote:
> Eve Switzer wrote:
>
> > She died the next morning in the
> > PICU - presumably with a diagnosis of SIDS.
>
> Just curious - but was a death scene investigation
> done? SIDS protocol
> requires a death scene investigation. I know this
> is one of those 'ify'
> situations because technically the child died in the
> hospital. However, in
> some locales the ultimate dx may have been
> "positional asphyxia," given the
> circumstances that led to her death and her very
> young age.
>
> Tammy
>
>
> This message is from PEDTALK - a Pediatric Focused
> email discussion group.
> Admin questions: "hidden@email-address" or
> "http://www.pcc.com/lists/"
> To unsubscribe: mail "hidden@email-address" with
> "unsubscribe"
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