NN N N

O r i en ta t ion of nu r ses n e w to e m e r g e n c y nurs ing can b e overwhe lming , g iven the a m o u n t of ma-

ter ial to b e covered. H o w nur s ing educa to r s p r e sen t the informat ion m a y m a k e all the d i f ference in nurs- ing care. Mos t hosp i ta l s have pol ic ies r e g a r d i n g tele- p h o n e t r iage , bu t a s imple ca se s tudy m a y convey more effect ively s o m e key points .

Case r e p o r t It is 5 AM on the Four th of July. The p h o n e r ings and I a n s w e r with, " E m e r g e n c y d e p a r t m e n t , th is is Mary. May I help you?" A c o n c e r n e d w o m a n expla ins tha t she is b a b y s i t t i n g her g r a n d d a u g h t e r and has some ques t ions b e c a u s e her g r a n d d a u g h t e r has not b e e n feel ing well.

Te lephone t r iage is a very difficult, r isky task for e m e r g e n c y nurses . Nurses are at a d i s a d v a n t a g e be- cause t h e y are not ab le to s ee or touch the pa t ien t . They m u s t rely on l i s t en ing and ques t i on ing skills to ob ta in a c c u r a t e information. Our small c o m m u n i t y hosp i ta l ha s a pol icy tha t s t a t e s tha t w e do not give out informat ion b y te lephone . (I have r e i t e r a t ed this informat ion to n e o p h y t e e m e r g e n c y nurses for years.)

A w a r e of our policy, I c o n t i n u e d to l i s ten to th is d i s t r augh t g r a n d m o t h e r as she gave m e informat ion abou t her g r a n d d a u g h t e r ' s illness. It b e g a n 3 days ago wi th a fever. The 9-year-old girl had b e e n s e e n and t r ea t ed in ano the r e m e r g e n c y d e p a r t m e n t and w a s g iven ibuprofen and an ant ib io t ic . The fever p e r s i s t e d d e s p i t e the m e d i c a t i o n and the girl had jus t vomited . I t r ied to r ea s su re the g r a n d m o t h e r tha t t he i l lness m i g h t be viral and if t ha t was the case, an t ib io t i c s would be ineffect ive. The i l lness would have to run i ts course. After all, I ra t ional ized, a 9-year-old child wi th min ima l s y m p t o m s canno t be too sick.

Mary Alexander is director, Emergency Department, Gnaden Huetten Memorial Hospital, Lehighton, Pennsylvania. Reprints not available from author. J Emerg Nurs 1996;22:149-50 Copyright �9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/9/70248

With the focus on m a n a g i n g hea l th care dollars, I t hough t of ava i lab le and cos t -ef fec t ive opt ions at t ha t hour on the Four th of July. We d i s c u s s e d cal l ing her ped ia t r i c ian , bu t he would mos t likely s end the child to t he e m e r g e n c y d e p a r t m e n t . I s u g g e s t e d tha t be ~ c a u s e the girl had b e e n s e e n at the other e m e r g e n c y depa r tmen t , i t m i g h t b e b e s t to re turn there. They would have a copy of her cha r t and there would be less dup l ica t ion of effort. The g r a n d m o t h e r l i s tened care- fully and as w e talked, and I could hear in her voice tha t she really w a n t e d the child to be seen. I also a d d e d tha t w e would be h a p p y to see her in our emer- g e n c y d e p a r t m e n t if she w a n t e d . I h u n g up the p h o n e wi thou t really g iv ing any ou t r igh t advice , ye t I felt un- easy.

A t 6:15 AM, the p a t i e n t and her g r a n d m o t h e r wa lked into our e m e r g e n c y d e p a r t m e n t . On initial ex- aminat ion , t he child was extremely pale, a lmost as wh i t e as my lab coat. Her color ing was unlike any th ing I had seen in 25 yea r s of nursing. She was well h y d r a t e d and very coopera t ive . Her init ial vital s igns were as follows: t e m p e r a t u r e 101.2 ~ F, pu lse 128 bea t s /min , r e sp i ra t ions 16 per minute , and blood p re s su re 110/50 m m Hg. Her neck was supple, the lungs were clear, and her a b d o m e n was soft bu t ten- der in the r ight u p p e r quadran t . She d e n i e d any r ecen t t r a u m a bu t she was the pa le s t pe r son I had ever seen. Her g r a n d m o t h e r d id not re lay any s igni f icant medi - cal history.

The doctor e x a m i n e d her and blood s amp le s were t aken for a comple t e blood cell count , chemis t ry panel , and cultures. The labora tory cal led and gave s tar t l ing results: the gir l ' s hemog lob in level was 4.9 gm/d l and hema toc r i t w a s 13.7%. They w o n d e r e d if there could be any e v i d e n c e to suppor t the i r f indings. On the ba- sis of t he ch i ld ' s a p p e a r a n c e , I told t h e m they mos t cer ta in ly could b e right. A l though she was not obvi- ously b leed ing , s o m e t h i n g w a s not right. I gave the resul ts to the p h y s i c i a n and w e d i s c u s s e d the poss i - bi l i ty of occul t b leeding , pos s ib ly from the sp leen af ~ ter a b e n i g n fall. The g r a n d m o t h e r overheard our con ~

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ve r sa t ion and c a m e to t he desk. She told us tha t the ch i ld ' s fa ther ' s s ide of the family had a d i s e a s e and t hey all h a d thei r sp leens removed . She w a s not sure of t he n a m e of the d i sease , bu t the doc tors had b e e n w a t c h i n g her g r a n d d a u g h t e r . The e m e r g e n c y phys i - c ian i m m e d i a t e l y cal led the ch i ld ' s ped i a t r i c i an and w a s in formed tha t the child had he red i t a ry spherocy- tos is and her c a se w a s b e i n g followed by a ped ia t r i - c ian at a ped ia t r i c t e r t i a ry care facility. The emer- g e n c y p h y s i c i a n not i f ied the ped i a t r i c i an at t ha t facil- i ty and a r r a n g e m e n t s we re m a d e to i m m e d i a t e l y t ransfer the child.

This g r a n d m o t h e r did no t k n o w s p e c i f i c a l l y w h a t w a s w r o n g w i t h her g r a n d d a u g h t e r , b u t k n e w s h e w a s sick. E m e r g e n c y n u r s e s n e e d to r e m e m b e r t h a t t h e c a r e g i v e r k n o w s t h e p a t i e n t m u c h b e t t e r t h a n t h e n u r s e .

Sphe rocy tos i s is a he red i t a ry form of hemoly t i c a n e m i a wi th the p r e s e n c e of s p h e r o c y t e s in the blood. Af fec ted cells have an i n c r e a s e d pe rmeab i l i t y to sod ium, thus acqu i r i ng the spher ica l shape . Al though the sphe r i ca l cell r e ta ins i ts abi l i ty to t r anspor t oxygen, i ts r igid s h a p e r ender s it s u s c e p t i b l e to des t ruc t ion as it p a s s e s th rough the venous s inuses of the s p l e e n ) A l i f e - th rea ten ing ap las t i c cr is is m a y occur w h e n the re is a r ap id d e c r e a s e in hema toc r i t and hemog lob in lev- els. 1 This compl ica t ion is usual ly a s s o c i a t e d wi th an a c u t e (viral) infec t ious process . Charac te r i s t i c find- ings inc lude anemia ; inc reased , dec rea sed , or a b s e n t re t i cu locy te count; sp lenomega ly ; and jaundice . 2 Our p a t i e n t had a n e m i a bu t no jaundice . The recom-

m e n d e d t r e a t m e n t is b lood t ransfusion, sp lenec tomy, or bo th to correc t the anemia . T r e a t m e n t does not re- pair t he m e m b r a n e abnorma l i t y bu t p reven t s the cells from t r ave r s ing the spleen; thus cells are not de s t royed as readily. 3

The child w a s s een at the te r t i a ry care facili ty and r ece ived two un i t s of p a c k e d red blood cells. She re- tu rned to the hosp i ta l 6 days la ter for a r epea t comple t e blood cell count . Her hemog lob in level was 11.2 gm/d l and he ma toc r i t was 31.3%. A n e lec t ive s p l e n e c t o m y was s c h e d u l e d a t the end of the summer .

Lessons learned Giving me d ic a l adv ice b y p h o n e is tricky. This 9-year- old, wi th min ima l s y m p t o m s , who had been s een wi th in the p a s t 3 days and t r e a t e d wi th ant ib iot ics , had a l i f e - th rea ten ing condi t ion. The impl ica t ions for re laying adv i ce over the phone are qu i te clear. Wha t s e e m e d to b e a minor condi t ion on the bas i s of the p h o n e conversa t ion in real i ty w a s just the opposi te . The s e c o n d lesson is to t rus t in w h a t the ca reg iver tells you. This g r a n d m o t h e r d id not know specif ical ly w h a t was w r o n g wi th her g r anddaugh te r , bu t k n e w she was sick. E m e r g e n c y nurses need to r e m e m b e r tha t the ca reg iver knows the pa t i e n t m u c h be t t e r than the nurse. B e c a u s e nurses a re not ab le to control incom- ing t e l ephone calls, t hey should e m p h a s i z e tha t the e m e r g e n c y d e p a r t m e n t is avai lable should the caller feel the n e e d to be seen.

References

1. Porth CM. Pathophysiology: concepts of altered health states. 4th ed. Philadelphia: JB Lippincott, 1994:328. 2. Cohen A. Hemolytic disorders. In: Fleisher G, Ludwig S, eds. Textbook of pediatric emergency medicine. Baltimore: Williams & Wilkins, 1993:720. 3. Behran R, Vaughn V, eds. Nelson textbook of pediatrics. Philadelphia: WB Saunders, 1987:1045.

Cont r ibu t ions to this co lumn should be sen t to Gall P isarc ik Lenehan , RN, EdD(c), CS, c/o M a n a g i n g Editor, ENA, 216 Higg ins Rd., Park Ridge, IL 60068-5736; p h o n e (847) 698-9400.

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