Treatment of the Newborn with Fever

I’m highlighting some blog posts this week that I did for Erin MacPherson’s Christian Mama’s Guide last year. Some of you may not know but I am a real live pediatric ER RN. As always, these posts are meant to be educational and do not replace a doctor’s visit if your child is ill.

Erin has a WICKED sense of humor and is releasing a series of books this spring so I hope you’ll keep an eye out for them.


Question:  Is it really a bad idea to take a newborn out in public? What will really happen if he/she gets sick?

Jordyn Says:
 
I can remember when my youngest was born and was just a few days old when my in-laws came by to visit. My father-in-law was horribly ill with bronchitis, coughing and hacking at the doorway. I held the baby up for them to see from a distance and kindly asked them to go on their way. They could come back around when he was well.
Here’s the issue: An infant less than two months (some doctors will say three months) that presents with a fever of 100.4 or greater generally gets a septic work-up. The concern is that an infant’s immune system hasn’t quite revved up yet and it can become easily overwhelmed by infection. Therefore, we approach this age infant very cautiously to prevent this from happening.
A septic work-up entails gathering specimens from the most likely places that would become infected. This includes placing an IV to get blood for a blood culture and blood counts, doing a urine cath (placing a small plastic tube into the bladder) for urine and doing a spinal tap (lumbar puncture) to collect cerebrospinal fluid (CSF) which is the fluid that bathes the brain.
Infants are generally admitted into the hospital for 24-48 hours at a minimum on IV antibiotics until their cultures are negative. If their cultures are positive, then they would stay longer to get a full course of antibiotics.
This is not always done but is your “worst case scenario” for ER management. There are some situations that may alter the physician’s medical approach. One may be that we can prove the infant has another source for the fever like an ear infection or RSV (in fall and winter). We generally look for these first. If another source cannot be found, then generally, these other tests are performed.
Unfortunately, a small percentage of infants do die from sepsis. This is why we are very cautious. 
As you can see, these are very invasive procedures and this is why I personally encourage minimal public contact when the infant is under two months.
If you choose to take your new baby in public, here are a few guidelines:
1. Use good hand washing. Before anyone touches the baby, they should wash their hands with soap and water. If water is unavailable, then use antiseptic hand gel.
2. If you develop a cold (runny nose, cough) wear a medical mask around the infant. These can be picked up at stores that have a pharmacy.
3. Keep sick siblings away from the newborn.
4. Encourage younger siblings to kiss the baby’s feet or the back of their head.
5. Immunize.
6. Well newborns need to stay out of the ER! A common scenario is for the whole family to show up with a sick older sibling and bring the new baby. This should only happen if that’s your only option. Otherwise, keep the newborn at home with a responsible adult. There isn’t a way to fully decontaminate the ER waiting room. It’s likely the baby will pick something up during the ER visit of the other sibling.

 

Author Question: Car Accident Injuries 2/2

We’re continuing with Amy’s question. Dianna gave her thoughts here. I’m going to give my thoughts from an ER perspective.

Amy asked:

I am putting one of my characters in a pretty major car accident — a rollover in which she lands on a broken window and ends up with a lacerated back full of broken glass, in addition to a broken leg, fractured ribs, etc. I need a scene to take place in the hospital where she is recovering. With those kinds of injuries, what treatments would she be under? More importantly, how exactly would she be laying in the bed? Obviously not on her back. But would she be on her side or stomach? Perhaps that depends on the other injuries she sustains… but the lacerated back is the biggest one I want her to have.

Jordyn says:

The biggest issue here is that she will likely have to lie on her back for a while. Considering her mechanism of injury (MOI)– the big rollover accident. The EMS crew is going to be very concerned that she may have injured her neck or back and she will be put onto a spine board and C-collar. To alleviate the pressure on her back, they may then tilt the whole board to one side but it’s going to cause some pain to lay on that flat board until her x-rays are complete.

Care for lacerations: One, she’ll need x-rays of her chest to look for the glass. She’d likely have this anyway for her MOI which could then reveal the rib fractures. If the lacerations are severe and extensive– she may end up going to the OR so they can be cleaned and stitched up under general but they’d have to be REALLY bad. Otherwise, we irrigate them out with sterile saline. Stitch them up. Antibiotic ointment over top. Make sure she’s up to date on tetanus. She would get a shot if she hadn’t had any in five years. It’s 10 years without injury.

Rib fractures are generally problematic because you don’t want to take a deep breath because of the pain which can lead to pulmonary problems. Lung contusions can actually put you on a ventilator if they are extensive enough. If several ribs are broken in succession– this is actually referred to as a flailed chest which can inhibit the patient’s ability to breathe. So, I’d keep it simple with one or two rib fractures so the character mostly has to deal with the pain issue and not the lung issues.

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Amy Drown has a History degree from the Universityof Arizona, and has completed graduate studies in History and Archaeology at the University of Glasgow. An executive assistant by day, she also moonlights as an award-winning piper and photographer. But her true addiction is writing edgy, inspirational fiction that shares her vision of a world in desperate need of roots—the deep roots of family, friendship and faith. Her roots are in Scotland, England and California, but she currently makes her home in Colorado. Find her on Facebook at www.facebook.com/GlasgowPiper.

Author Question: Car Accident Injuries 1/2

Author questions are some of my most favorite posts to do. How do you really write an accurate medical scene? Which injuries are plausible and which are not?

Amy is visiting and Dianna Benson (EMS expert) and myself (ER nurse extraordinaire) are going to tackle her question. Dianna will be today and I’ll be Friday.

 

Amy asks: I am putting one of my characters in a pretty major car accident — a rollover in which she lands on a broken window and ends up with a lacerated back full of broken glass, in addition to a broken leg, fractured ribs, etc. I need a scene to take place in the hospital where she is recovering. With those kinds of injuries, what treatments would she be under? More importantly, how exactly would she be laying in the bed? Obviously not on her back. But would she be on her side or stomach? Perhaps that depends on the other injuries she sustains… but the lacerated back is the biggest one I want her to have.

Dianna Says: The story and the characters are first priority, so I’ll make the medical aspects fit into what you’ve explained. Since it sounds like you don’t have an EMS scene at all (no scene where rescue crews—EMS and fire—are present), it keeps it simple from my end, but I’ll give you pertinent background on what I’d do if I were the EMS crew on your scene. Also, based on the MOI (mechanism of injury) you described, I’ll explain what type of injures are possible. Every patient is different, every MVC (motor vehicle collision) is different, and every rollover is different, so that definitely gives you leeway.

First of all: I like the scenario: Your character runs a red light causing another car to slam into hers, which causes it to spin then roll over while her back is dragged on the asphalt over the broken window. I also like the adding of a boyfriend; yes, he’d definitely worsen her injures by landing on her, so have him either land elsewhere inside the car or just have him belted in (unless you want her seriously injured to the point she’s in-hospital for a long while and possibly suffering with lasting effects). Just so you know: The reason for the seatbelt law is not just to protect the person wearing the seatbelt; it’s to protect others from being struck by that person propelling in the air (inside and outside of vehicles) like a weapon. Just a thought — if she landed on the driver window and it’s a rollover, then the car is on its side (driver side) upside down, right? Make sure you’re clear about that.  

Any rollover is a high index of suspicion of injury; meaning, severe injuries and death likely. You have two separate impacts in this story: 1) Smash from the other car 2) Rollover. Therefore, you have two separate MOI’s and both cause different injuries.

Since fiction is about the story and the characters, make the speed of the car fit; meaning, if you want your character(s) to be seriously and extremely injured, keep the speed high. For a character who is injured and needing in-hospital care (not just on-scene EMS treatment and ED treatment) yet doesn’t sustain any life lasting effects or long term damage, then keep the speed down low.  

Possible injuries for both the side impact and the rollover: Again, every patient and incident is different, and I’ve seen it all—some accidents where based on the MOI patients surprisingly die and some where patients surprisingly live.   

1)      Whiplash: back and neck
2)      Air bag deployment: facial injures (soft tissue), labral tear (shoulder), etc.
3)    Seat belt injures (chest injuries, labral tear, etc.)
4)      Head injures
5)      Anything flying around inside the vehicle and hitting her and boyfriend
6)      Other possibles: knee ramming into door and shattering patella, elbow ramming into steering wheel, shoulder striking window., etc. etc. 
7)      Fractured femur or fractured tib/fib or just one of them (tibia or fibula) from twisting or hitting, etc. 
8)    Fractured hips
9)      Fractured ribs
10)      Etc. Etc. Etc.

A fracture is the medical term for broken bone.

Assuming the patent is unconscious when I arrive on scene, I’d verify she has a pulse and is breathing efficiently. If so, then I’d control all bleeding via wound care—sterilization and bandaging. I’d strap a C-collar (cervical collar) around her neck then extricate her from the vehicle onto a back board with padded blocks holding her head in place and strapped to the board. I’d splint any dislocations or suspected fractured (I don’t have x-ray vision) if not properly splinted via backboard. We do a ton of medical treatments and monitoring, but I won’t blah, blah, blah it all, especially since you don’t have an EMS crew on your scene.

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Dianna Torscher Benson is a 2011 Genesis Winner, a 2011 Genesis double Semi-Finalist, a 2010 Daphne Finalist, and a 2007 Golden Palm Finalist. In 2012, she signed a nine-book contract with Ellechor Publishing House. Her first book releases March 2013.

After majoring in communications and a ten-year career as a travel agent, Dianna left the travel industry to earn her EMSdegree. An EMT and a Haz-Mat and FEMA Operative since 2005, she loves the adrenaline rush of responding to medical emergencies and helping people in need. Her suspense novels about adventurous characters thrown into tremendous circumstances provide readers with a similar kind of rush. You can connect with Dianna via her website at www.diannatbenson.com.  

Author Question: The ER Doc and the EarthQuake

Patrick Asks:

In my novel, I have an ER doc on vacation with his family. An earthquake strikes. His 14 y/o son suffers grievous injuries (I’m thinking a concrete pillar falls across his midsection.) The doc knows that in the best of situations, in an equipped trauma center, he’d only have a slim chance of saving his son’s life. As it is all he can do is try to comfort his son and be with him as he dies.

So my questions are threefold:

1.  What would be the signs that would convince him that his son is doomed and there’s nothing he can do?

2.  How long would it take for the poor kid to die?
3.  How would the doctor identify himself, or think of himself, in a casual situation?

Jordyn Says:

Hi Patrick! I am happy to help with your question.

#1: What would be the signs that the son is going to die?

Essentially the scenario you’ve set up would be death from hypovolemic shock (the son is bleeding out). Or, organ dysfunction from crush injury. But, let’s stick with hypovolemic shock as it will work well in this scenario.

What would be more concerning to the father and trained ER doctor would be his signs of shock— this would lead to his death. I’m going to use the medical words because this is how your ER doctor would think and then I’ll put what they mean in parenthesis.

I think one thing that helps is to understand the symptoms in light of the injury. When you’re bleeding out, you’re losing blood. Blood carries oxygen. So the body compensates by trying to circulate those remaining red blood cells faster.

Shock is your body’s inability to meet its oxygen demands (hypovolemic shock is one type of shock.) So, initial signs of hypovolemic shock are: tachycardia (increased heart rate to circulate the blood faster), tachypnea (increased breathing rate to load more oxygen on the cells that remain), complaints of thirst, pallor (pale skin– circulating red blood cells gives you your color) and diaphoresis (sweating). Also, diminished, weak, rapid peripheral pulses. Peripheral pulses are those at your wrist (radial) and feet (pedal). This would progress to central pulses–those in your neck (carotid) and groin (femoral)— being weak and thready.

In kids (this is my area of specialty)– the blood pressure will be normal initially because kids can do really well at compensating for shock up to a point.

So– hypotension (or low blood pressure) is then an ominous sign. One way a trained ER doctor can estimate what his son’s blood pressure is is by palpating his pulses.

eMedicine

For instance:

If you have carotid, femoral and radial pulses: Your BP is at least 70mmHG systolic.

If you have carotid and femoral Pulses: Your BP is at least >50mmHG systolic.

If you have only a carotid pulse: Your BP is about 40mmHG systolic.

You cannot discern diastolic pressure using this method.

As his shock progresses, his level of consciousness will begin to wan. He’d have periods of being coherent– then unresponsive (depending on how fast you’d want this death to occur). The brain is oxygen hungry so when it doesn’t have enough– you become unconscious.

His ultimate sign of impending death will actually be bradycardia (low heart rate– less than 60 beats/minute) progressing to asystole (no heart beat). This is how kids generally die. The child would become unconscious. His breathing would slow/stop. His heart rate would slow then stop. Pupils will dilate and become unresponsive to light.

#2. How fast would this happen?

This is really your choice. If your character has a major aortic rupture (this is a major blood vessel–your descending aorta– that is in your abdomen) death could take place in 1-2 minutes. Also the spleen and liver are highly vascular (meaning they have a lot of blood vessels) and crush injuries to these organs would lead to rapid exsanguination (bleeding out) as well. Or, you could have slow leaking type bleeding that could take longer to die from. All bleeding– if not stemmed– can lead to death.

#3. How would he refer to himself? “Hey, I’m Dan, I’m an ER doctor.”
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Patrick J. Worden is the author of several books, including the just released novel, VoraciousHe blogs on culture and current events at http://pworden.com/.

Decompression Illness: Dianna T. Benson, EMT

If you ever write a scuba diver character, a deep sea diver, a search/rescue/recovery diver, a Navy submariner, etc., you’ll need to understand Decompression Illness (DCI), a serious illness caused by trapped nitrogen.

There are two mechanisms of DCI:

1)      Decompression Sickness

2)      Arterial Gas Embolism

SCUBA (Self-Contained-Underwater-Breathing-Apparatus) divers breathe a purified air mixture of 79% nitrogen and 21% oxygen. The longer a diver is breathing this mixture and the deeper he/she descends, the more nitrogen will be absorbed by the body. A slow ascent and a safety stop at about thirty feet for three minutes, allows the diver to efficiently exhale the nitrogen. Dive tables set limits for dive times and depths. Decompression Illness is caused by tiny nitrogen bubbles forming (instead of being exhaled) and becoming trapped in the blood and tissues.

There are two types of Decompression Illness:

1)      Type I

2)      Type II

Type I:

1)      Skin capillaries fill with the nitrogen bubbles, resulting in a red rash.

2)      Musculosketal: Joint and limb pain

Type II:

1)      Neurological decompression sickness: Tingling, numbness, respiratory problems and unconsciousness.

2)      Pulmonary: Bubbles interrupt blood flow to the lungs, causing respiratory distress or arrest.

3)      Cerebral: Bubbles travel to arterial blood stream and enter the brain, causing arterial gas embolism and symptoms of blurred vision, headache, confusion, unconsciousness.

General Decompression sickness symptoms:

Extreme fatigue, joint and limb pain, tingling, numbness, red rash, respiratory and cardiac issues, dizziness, blurred vision, headache, pain with swallowing, confusion, loss of consciousness, ringing in ears, vertigo, nausea, AMS (altered mental status), pain squeeze, SOB (shortness of breath), chest pain, hoarseness, neck fullness, cough. 

Factors that increase the risk of getting decompression illness: Dehydration prior to dive, stressful dive or rapid movements during dive, alcohol intake prior to diving, flying too soon prior or post diving, not following dive tables.

As every patient is different, every diver will have their unique combination of symptoms and reaction to both the illness itself and the treatment.

Decompression illness is treated by hyperbaric recompression chamber therapy. Only certain hospitals in the word have a hyperbaric chamber. The severity of the patient’s condition and his/her symptoms will decide the length of time the patient is treated inside the chamber. 

Nitrogen narcosis is also caused by trapped nitrogen, but this is a simple fix and isn’t serious if resolved. The diver simply ascends to a shallower depth until his/her symptoms clear. Symptoms include: An altered state of awareness and gives the diver an intoxicated state of feeling, incoherent reasoning and confusion.

As always, thank you for reading and for your interest. Please do not hesitate to ask if you have any questions.

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After majoring in communications and enjoying a successful career as a travel agent, Dianna Torscher Benson left the travel industry to write novels and earn her EMS degree. An EMT and Haz-Mat Operative in Wake County, NC, Dianna loves the adrenaline rush of responding to medical emergencies and helping people in need, often in their darkest time in life. Her suspense novels about characters who are ordinary people thrown into tremendous circumstances, provide readers with a similar kind of rush. Married to her best friend, Leo, she met her husband when they walked down the aisle as a bridesmaid and groomsmen at a wedding when she was eleven and he was thirteen. They live in North Carolina with their three children. Visit her website at http://www.diannatbenson.com

 

Author Question: Refusing Medical Treatment

Carrie Asks:

My novel is set in the US and my MC, who’s eighteen, is injured. He’s suffering from concussion, blood loss, and hypothermia, and is very weak and quite disorientated. He is, however, conscious and responding, and adamant that he does not want to be treated or taken to a hospital (and the plot requires him not to be). I understand that he’d be able to refuse treatment if he signed a form saying so. My question is, is there a standard procedure that an EMT would follow before letting him sign?

Jordyn Says: Thanks for e-mailing me your question. You have an interesting scenario here.

I’m going to come from the standpoint of this person presenting to the ER. Put simply, we are not going to let this patient sign out AMA. A couple of things in your statement about his condition will prevent this. Almost everything you’ve listed as far as his medical condition makes it impossible for him to make a reasonable decision regarding his care–concussion, disorientation, hypothermia. Even though he can talk, it doesn’t mean he has enough medical capacity to make an appropriate decision regarding his care until these issues are straightened out.

We would do everything in our power to keep him in the ED. Considering that– you have a couple of options. Make him a lot less sick. Maybe just a few bumps and scrapes. Or, he could elope from the ED somehow, but if we were really concerned about his medical condition we might send the police to fetch him back. Of course, this could add conflict into your story.

I did verify this through an EMS friend of mine as well. The issue is not whether or not they can talk, it’s whether or not they are medically competent to make a decision about refusing care. This character’s condition precludes that.

Treatment of Minors in the ED

It may surprise you to learn that there are circumstances where an underage minor can sign themselves into the ER for medical treatment without parental consent. In most states, if the patient is 13 y/o and up and requesting treatment over concern for a sexually transmitted disease or concern for pregnancy, they can seek treatment and we cannot call their parents.

This is one area that can be a huge source of conflict in the ED and most doctors and nurses I work with are very uncomfortable with the situation. More sticky would not be the patient who presents alone, but one that does present with a parent. Let’s take a situation where a teen girl presents with her parents over complaints of abdominal pain. We do a pregnancy test and guess what… she’s got a little bun in the oven. How do we disclose those results?

First off, we ask to speak to the teen alone. We will tell her the results. We tell her that legally we cannot tell her parents though we would like her to tell them and we will help her tell them if she would like.

Let’s assume the teen says “no”. She doesn’t want her parents to know. Then we can’t disclose it to them.

Now, parents are very smart and they will likely know what tests were performed. They may ask specifically, “What about the pregnancy test?” What we’ll say is, “Mom, I can’t legally tell you the results of that test. You need to speak to your daughter about that.” A mother’s intuition will kick in. After all, what would be the big deal if the test were negative?

Same goes for STD testing. I’ve had parents call back in a few days for these test results. Again, positive or negative, I can’t disclose if the parent knows the test was performed. If the parent doesn’t know the test was performed, I can’t even disclose they had the test.

Can they get the results through medical records? This is iffy. An astute medical records department will be savvy enough not to disclose but I can see this being a potential gap in the system.

Also, when the insurance bill arrives, the test may be disclosed on that. Or, the parent may call the hospital billing department and ask specifically what test was run. This may be a potential way for them to learn about the test. But again, billing personnel don’t have access to lab results.

I want to make clear that all ER professionals I know will make every effort to get the teen to disclose the results to their parent. Other potential areas of conflict. What if the parent is a drug user? An abuser? What should the ER team do then?