LIN Session - Pediatric Code Grey


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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Carlos J. -

Excellent talk! As an EM PA who works both fast track and main ED, we see a large amount of adult and pediatric psych. I couldn't help but laugh when the first step in the management algorithm was "sign out", it's also closely followed by "is there a resident/PA that can see this patient?" The most challenging aspect of managing these cases is making sure you don't ignore the subtle signs despite having already been "screened/triaged" based on their obvious injury or basic complaint without a history: "just a lac, mechanical fall, head injury, extremity injury, panic attack, ect"

I have had more than a few close calls with those cases, and those are the cases that matter most in my opinion. Many patients experiencing a new psychiatric emergency, non accidental trauma or abuse are prone to minimize and obfuscate, you have to pay attention to changes in posture and demeanor when friends or family enter the room, when questions make a patient look away or tear up, or when a story doesn't make sense. I also ask my nurses "was that weird?" after the history or exam if there is something i cant put my finger on, EM nurses live and breathe weird, its their baseline. I've been hit back with "OMG yes! I wanted to say something to you but didn't know what" more times than i can count. It's a clear indication for me when both myself and my nurse are picking up on something, to make sure I do my due diligence in history exam and documentation even if it means asking them the same questions a second time.

Most if not all of what I learned about managing these cases was over 10 years of trial and error, and wanted to offer a few more "sneaky" ways to get a chance to talk alone with your adult or pediatric patient.

Ambulatory Trials: Let the family know were going to take the patient for a short walk to assess for dizziness, nausea, instability, weakness. Works in most cases if you hit a brick wall with not being able to escort the patient to the bathroom. Just have them ambulate out of direct line of sight or past your workstation. If you find new information have someone let the family/friend/spouse know the patient failed and isn't going home yet, and they can wait in the waiting room for a few minutes while we bring the patient back to the room.

Imaging: In the setting of concerns for non accidental trauma where diagnostic imaging is warranted, I give my tech or nurse a heads up before they escort the patient to radiology so I can either meet them there or walk along with them and ask them questions directly

Contact information: A great way of getting parents/spouses out of the room is to have registration "update" their contact information, billing information, whatever information you want, just review and update it. I find that every time i ask my registrars are excited about the chance to play a role in sniffing out the truth, I have never once had them view it as an inconvenience.

Dina W., MD -

Great tips, Carlos! I especially love your technique of involving oft-neglected, yet vital, members of the care team, such as radiology techs and registration workers. We are all working together in the department with the goal of helping our patients be healthy and happy, and 360 degree input is vital to help us reach this goal.

You're also completely correct that it's super important to perform a detailed H&P, including asking certain questions multiple times, in all of these patients-- this can help us pick up on subtle clues that the situation is more serious than we thought.

Thanks again for your engagement and commentary!

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