Not it (I wish)

I did hearing and vision screenings all morning, which are never my favorite days. While kids are my favorite part of the job, they're not as fun when I have to keep masses of them in line. From there, I thought I'd get a step ahead and swing by my middle school to fill out some paperwork that was waiting on my John Hancock. I left my phone at a friend's house and hadn't yet retrieved it, and I'd been thinking how nice it was to be sans cell phone: my schools hardly call me anyway, and when they do, it always seems to be about lice. 

I was in for a surprise when I walked into my middle school. The staff looked at me with relief and ushered me into my office, where one of the diabetics there was in distress. I'd never seen anything like it: she was not coherent, couldn't speak, but at the same time, crying and making noise. Conscious, but barely. Apparently they found the girl in the cafeteria, half-carried her to the nurse's office, where they'd called my cell phone and her mom. It was purely coincidence that I walked in at the right moment, and I got busy getting a blood sugar on her, because she was way too far gone to get it herself: 36. By then mom had arrived, and I announced to the growing crowd that I was calling 9-1-1. The principal nodded in agreement with me while the mom suggested that she'll get better in half an hour; she was dribbling in some orange juice, after all. I repeated I was calling for help, while the mom just stared at me blankly with clearly a "why" on her face. What seemed like hours later, though really only four minutes by my watch, the paramedics and fire department arrived. They also took a blood sugar (40) and whisked her away after a quick assessment. There wasn't time to mess around, and it's unsettling to see even the paramedics debate just what the best way is to get a line in her the fastest. 

It wasn't until this event had passed that I was able to process it. I'd come in to do some paperwork, and happened to have timing so impeccable that I'm pretty sure I just earned the one week vacation I'm taking starting Wednesday. What concerned me most though, was the overall attitude, both the mother and the staff. I honestly can't say for sure whether the student was able to swallow; had I had glucagon on hand for her, I would have used it. That alone is a very scary fact: I can't count the number of times I have taken glucagon from a parent and told myself I never wanted to use it and was sure I'd never see the day; I don't know a single other nurse in our district that has even considered using it. I don't know what would have happened had I not shown up, and it didn't appear that most people understood the gravity the situation, including the principal and the mother that were in the room. I've been through more than my fair number of emergencies, and none has fazed me the way the one today did. Having the parent in the room, disputing my phone call to the paramedics (even if I was sure I was doing the right thing), was so disconcerting that my hands started shaking, maybe to compensate for her own lackadaisical attitude. “She'll be fine,” she said. I honestly wonder what would have happened if I hadn't shown up. Would the staff had thought to call 9-1-1 at some point? Would the student have maintained the semi-conscious state she was in? She was so far past the normal point of consciousness, I'd have called 9-1-1 even if I couldn't get a quick read on her. Bleh: I am having trouble even putting the severity of the situation into words, and it's these kinds of days that make me really sure that having me split my time between schools isn't safe for students...but sitting at one site all day doesn't make sense financially, either, for the district.
<Sigh.> I have some friends who are teachers, and jealous of my so-called flexible schedule, and that schools don't always have tabs on me. What I always say, and especially after today, is this: You don't want to be the one everyone is looking at during an emergency. 


  1. PICU nurse here. Have you thought about having a debriefing meeting with the school staff involved? While it sounds like the child will be okay, the most important thing to do is to learn form these events to make sure the situation is handled better next time. It sounds like there are things that both you and the school could have done better.

    A few things to note:
    1) If the child is not responsive or not able to swallow properly, do not allow anyone to give anything PO- even orange juice. This places the child at risk for aspiration pneumonia.
    2) Don't hesitate to give the glucagon- especially since it wasn't safe to give anything PO in this case, so glucagon was going to be the only way the kid got more sugar to bring those sugars back up
    3) It is EXTREMELY difficult to get a line in on a kid once they have altered mental status from either DKA or hypoglycemia. It is not uncommon for us to have to try 10-15 times to get one successful IV. This is because the altered mental status is a sign of poor perfusion to the brain, and thus likely poor perfusion to the rest of the body as well. So when you have small veins in the first place (because this is a child not an adult), and then those small veins shrivel up to look like spider veins because of the poor perfusion, then it becomes nearly impossible to get a line on the kid. So do the paramedics a favor and give the glucagon immediately after calling 911 if the kid has altered mental status with sugars this low- that way hopefully the glucose can start to get into their system a bit by that time, and the perfusion will start to improve by the time paramedics arrive, making it easier for them to get a line in.
    4) It seems like you already have plans to instruct the school staff to call 911 whether you are there or not whenever there is a case of altered mental status or loss of consciousness- it sounds like this re-education of staff is entirely appropriate.
    5) A call to the hospital asking they re-educate the parents about safe diabetic emergency response plans may be appropriate as well.

    Again, it sounds like the kid will be fine. And you did a good job calling 911 and getting the kid the emergency care she needed. But there are still things to learn here.

    1. As for a meeting to re-educate the staff: that is *definitely* happening. I'm trying not to dwell on the amount of time that had passed between her starting to droop, so to speak, and when I happened to arrive. A care plan was distributed at the beginning of the year, but it didn't appear anyone had read it, or the paramedics would have been on scene before anyone dragged her to the office from the cafeteria. As for trying to get something in her, this incident was an unpleasant reminder in how alone a school nurse is in a medical emergency. I have only so many hands and mouths with which to do things and give directions - and when I asked a person who shall not be mentioned to call 9-1-1, she froze, so I had to call myself instead of get the dribbling orange juice person away from her. Someone thought to try to give her a glucose tab, but I did manage to stop her from that at least. Not ideal, but a learning lesson for sure. Glucagon would have been nice to have, but we had nothing for this student. Ugh. The whole thing was one unpleasant learning experience, but hopefully if this ever happens again, I'll be better prepared.

  2. These usually are unpleasant. I rarely hear someone say "gee I had a fun little code the other day" :) My worst day/biggest learning experience was a child abduction- yes someone was able to make it through all of our security systems in place to abduct my patient. They were caught while still in the hospital, so all's well that ends well. These are our "war stories"