A Nurse’s Open Letter to Teachers Everywhere

I probably shouldn’t write this post. It will probably be considered controversial– even though it seems like it shouldn’t. However, I am writing from a place of lessons learned and I want to share those lessons with . . . teachers everywhere.

I was happily reading some on-line celebrity news (as a destressor) when I came across this article about Anthony D’Amico. The article explains that his 2 m/o daughter went in for her regular immunizations and he experienced ” . . . an overwhelming urge to punch out the nurse . . . ” as she was delivering the infant’s shots.

Now, I’m sure, he meant this as a unifying post among parents everywhere– that none of us like to see children experience pain. I get that. As a pediatric nurse, however, I was horrified. His first instinct is not to pick up and comfort his child or say reassuring words, but to injure the nurse providing lifesaving preventative care. I’m sorry . . . that just not cool.

Would it surprise you if I told you that nurses experience the most violence of any profession . . . including police officers? Here’s just one of many articles that eludes to that fact. I first started nursing in 1993. My first job was as an adult ICU nurse. During that first year, an elderly vented patient grabbed my stethoscope that was on my neck and began to choke me with it. I could not break their grip and only when a passing respiratory therapist saw my predicament was I freed from possibly a very serious injury and/or death. Sadly, that’s not been my only incident. Getting cursed or sworn at is common— not rare. I’ve been personally threatened with unwarranted law suits just so I would bend to a family’s demand. I’ve had men raise their fists at me more than once. I’ve seen so much worse happen to other healthcare workers.

When I first started nursing those twenty-six year ago, it was an unwritten expectation that these events were tolerated and nothing happened to the perpetrators. It was, “part of the job”. These “people are sick” and “they don’t know what they’re doing.”

Well, a police officer can still charge a drunk person if that person injures them physically. For decades, a nurse was not permitted to even think this was an option.

Not only do nurses experience violence from patients and their families, but from co-workers as well. In my own state, a hospital close to where I live (I am not employed there) a nurse was nearly strangled to death by a doctor.

Now, that is SLOWLY changing. Hospitals are beginning to see and understand that patients, families, and co-workers should not be allowed to commit violence against nurses (or any healthcare worker) for any excuse or reason. It’s inspired the hashtag #silentnomore.

People should be held accountable for their actions despite being sick, tired, and or frustrated. Change is not a speedy process. Hospitals are balancing employees need for safety and the image they project. It is a complicated issue. Should a nurse be able to involve law enforcement if a mental health patient injures them during a psychotic break? Not an easy answer. And I might add, nurses are reluctant to do so knowing the underlying medical states that drive many of these situations, but they are also so very tired of the violence. This violence contributes to reduced quality of life, PTSD, moral injury, and people leaving the profession.

This is why I write this post. Not for me and my fellow nurses who know this hell that we live in with violence . . . but for the legislators and school administrators who are loosening consequences for students who are defiant, disruptive, and dangerous. I speak specifically of this new law in California that passed the Senate and is moving forward to their assembly.

Interestingly, I couldn’t find much commentary about the CA law except from conservative commentators. Here is one such example. Perhaps it’s because California lawmakers believe that there is bias in how school based punishments are merited out.

I don’t know the veracity of those claims. That’s not the point of this piece because this trend of backing off of student punishments for outrageous classroom behavior is not isolated to one state. Here’s one example from 2002 where a teacher resigned because a Kansas school board wanted her to reverse failing grades for students who had plagiarized. 

I am writing this because when disruptive classroom behavior and even violence is tolerated in schools from children or teens— they eventually become adults and then it becomes a problem for all of us. Ask any pediatric nurse when limits should be set and it starts from the beginning.

At some point we have to set firm and clear boundaries for bad behavior. When did it become reasonably sane to allow anyone to exhibit unruly and/or violent tendencies without consequences? Nurses have known all along that this was insanity and we are suffering from this, but felt powerless to do something about it because it was an expected part of our jobs. Nurses are now collectively saying we can’t live like this anymore.

Teachers . . . unruly and violent behavior should not be tolerated parts of your job. If we say to students that there is “zero tolerance” for violence and bullying then how can we allow it to happen to another one of our most trusted professions? The issue is, the behaviors before violence need to first be curbed. Kids know what boundaries are– their job is to test crossing them. Now the boundary is moving to allow more egregious behavior from students toward their teachers.

This is healthy?

So from this nurse to teachers everywhere– please fight to uphold the standards of behavior you expect in the classroom. Don’t give an inch. It could be your life that is at stake.

If anything, please learn from this nurse’s storyOr this nurse’s story. Need another one? Or this? Maybe her story will change your mind.

Hold the line in the classroom . . . hold the line for all of us.

Child Abuse Injuries: Part 2/2

April is Child Abuse Awareness Month. Last post, I covered how a given history for an injury may be a signal that an injury was intentionally inflicted. Today, I’m going to cover how the injury itself may give off clues for an abusive injury.

1. The injury is beyond the child’s developmental level. You’ll notice this is the first clue I gave concerning the history, but it also plays into the injury itself and I’m going to talk specifically about infants. Any bruising in an infant to the face, head and neck when they are not yet pulling themselves up to a standing position is concerning for abuse. To create an injury, you have to fall off of or run into something and you need to have some velocity behind it. Now, of course, injuries in this age group can have lots of accidental causes, but the story needs to match the injury.

2. The injury has a pattern. Consider typical childhood bruises. They are roundish in shape, of varying circumferences, and received from a low-velocity type injury . . . say the child running into a counter with their forehead. Anything that makes a visible pattern generally requires high-velocity force to imprint the pattern onto the skin. If I loop a belt and tap you with it, there likely won’t be any injury at all. However, if I take it and swing it at you like a pitcher throwing a baseball, it has the potential to create a loop like bruise.

3. The injury is not over a bony prominence. Again, if you have children, think back to their younger days when injuries were common. When they fell, where did they bruise? Head (scalp, forehead, nose, chin), elbows, shins, and knees. Most often, kids fall or run into something in a forward motion. Bruising to the buttocks in a diapered child is particularly concerning. Often, they will fall onto their bottoms, but they also have extra padding.

4. There are a lot of bruises. This is not definitive but can be a signal for abusive injury, particularly if the pattern is not a normal bruising pattern as in #3.

None of these items is taken in isolation as a single indictment against the caregiver. Let’s say you accidentally drop a toy onto your two-month-old’s face while cleaning up. It causes a bruise and you want it checked by the pediatrician. The pediatrician is not going to report you. Why? You have a plausible story (dropping something onto the baby’s face), it is a low velocity injury (the bruise is probably small and round) and there is only one.

Medical professionals look at the totality of the child’s case: the history, the social environment, and the injury is considered before a report to child services is made. Reports are not made lightly.

The above offers some beginning guidelines. In the comments section, give a specific injury that might be concerning for abuse.

Child Abuse Injuries: Part 1/2

Nothing is more heartbreaking than to take care of a child that has been abused. April is Child Abuse Awareness Month so I thought I’d do a few posts about child abuse injuries and how medical providers pick up on the fact an injury may be intentional or inflicted.

As a pediatric nurse, I’ve been witness to child homicide at the hands of abuse. Yes, it is murder. It’s a necessary part of my job in dealing with these families, perhaps even the confessed abuser, as I care for the child abuse victim. And yes, there is a lot of conflict in these situations.

How do we as pediatric medical providers begin to suspect that an injury is abusive? During the initial evaluation of an injury, confession among abusers is rare (perhaps, they will confess later.) Often, there is a history given to account for the injury. Both parts: the history of the injury and the injury itself can give red flags for abuse. Today, let’s examine the story and how it may signal an abusive injury.

1. The story not realistic considering the child’s developmental level. This is more common than you might think. Most people cannot rattle off when a child should meet certain developmental milestones so they’ll say the child injured themselves in a manner that is beyond their developmental age. For instance, “my daughter broke her arm by rolling off the couch”. The baby is two-weeks old. Infants typically roll over starting at 3 months. Here’s a great resource for any writer/parent for developmental milestones.

2. The story changes. Just like other criminals, abusers can have a hard time keeping their story straight. Often times, the more abusers are questioned about the plausibility of the story, it will begin to change. Medical staff interviewing a potential abuser can be like a detective getting a criminal to confess. The doctor will often approach the caregiver several times to ask questions about the injury to see if the story changes. In later interviews, the doctor may say, “This injury is suggestive of abuse.”

3. The story has too much detail. This one may seem odd, but it can be a red flag for abusive injuries. If you have children, think back to their toddler/elementary school years when they seem to come home with lots of bumps, bruises, cuts and scrapes. If asked, could you come up with an explanation for each and every injury? Likely, no. Abusers will try and explain away every injury. A non-abusive parent will be truthful and likely say, “I have no idea how that happened.” and then probably feel guilty about not knowing.

What other parts of a medical history/story might give a signal for abusive injury?

Author Question: Prioritizing Medical Care

Ethan Asks:

My main character was in a fight. He has a skull fracture with epidural bleed, a dislocated shoulder, and a twisted ankle. He arrives at the hospital unconscious. Would the ER try relocating the shoulder right away or wait for him to regain consciousness first? Just a common anterior shoulder dislocation. Also how? I’ve seen too many videos to know the ‘tried and true’ from a best guess. How would you do it?

Jordyn Says:

For this patient, the neurological injury would take precedence. It doesn’t matter much about his shoulder if he never wakes up. So, if he does have an epidural bleed, that would be the surgical priority. When he’s under anesthesia for the surgery and his epidural bleed has been stabilized, they could relocate the shoulder intra-operatively.

The videos you’ve seen are probably accurate— yanking and pulling a certain way to get the shoulder back in. Sometimes, if the patient is just sedated enough, the shoulder will relocate on its own, but it is more common to have to pull it back in to place.

The only thing that might make them rush with the shoulder is if they felt that the patient wasn’t getting blood flow into his hand on that side. Since he’s unconscious, he really couldn’t say if there were any numbness to that hand that would also be an indicator he might be having trouble with blood flow into the hand.

That being said, I’ve not personally seen neurovascular compromise with a “simple” shoulder dislocation (though I’m sure it does happen on occasion) so precedence would be his head injury.

Author Question: Rehabilitation after Gunshot Wound Injuries

Sean Asks:

Hi Jordyn!

Looking for a little bit of help with some 9mm gunshot wounds. I was going for non-lethal aside from possible bleeding out and injuries that would have long recovery time.

I have a character get shot at point blank range in the lower right abdomen from the front. Then in the right shoulder/clavicle, also from the front, about five to ten feet away, breaking the clavicle. Finally, in the left calf from behind from ten to fifteen feet away, breaking the tibia which is made worse when the shooter grinds his foot into it.

I’m guessing the shoulder/clavicle and calf/tibia would require a sling or cast and a serious amount of PT. The abdomen wound I’m guessing would require some reconstructive surgery depending on if and how much the bullet bounced around?
I figured it would take her almost a year to walk without assistance from those.  Am I close in that assessment? Thanks in advance for ANY help!
_______________________________________________________________________________________________

Jordyn Says:

 

Since this is largely a rehab question I reached out to Tim Bernacki, a great physical therapist, who I highly recommend from personal experience. If you live near Castle Rock, CO look up his clinic, Front Range Therapies.

Tim Says:

Generally, time frame of healing is 6-8 weeks for most things, especially soft tissue. All these injuries would require surgery. The clavicle fracture would require an open reduction/internal fixation (ORIF)—this means that there is an incision made and hardware placed to stabilize the fracture.

I wouldn’t know what is done if the clavicle is “shattered” and is in a multitude of pieces. The wound would have to be a glancing hit that results in a fracture. Anything more severe in the area could result in ruptured arteries, as well, and the person cannot die from this wound.

The tibia fracture also would require an ORIF—either plate, screws, or rod with locking screws. The difficult thing in all this would be that due to the leg recovery, the person will be using an assistive device, but probably cannot use crutches due to the clavicle pain. Perhaps a walker could be used. Depends on how conditioned the person is, how young, etc . . .

The leg injury would require limited weight bearing for 6 weeks I would guess. If all heals as expected according to x-rays, then they would transition into weight bearing as tolerated (WBAT). Probably would have a limp for several weeks after that. Likely wouldn’t run until four months following surgery if all goes well. The clavicle would probably have a sling for maybe 2-4 weeks (if no repairs to muscle or rotator cuff were done). After that, overhead reach would be most affected and for several months.

As for the abdominal injury, other than not bearing down with pressure for a short time, I wouldn’t think there are other issues to consider.

I’ve seen some gunshot wounds (GSW) where the bullet enters, hits a long bone, changes course and travels along the bone. This assumes the round is a practice round (full metal jacket) and not a hollow point. Hollow point bullets or defensive rounds open up when they hit something, resulting in a much-enlarged object/wound. I’ve seen rounds left in place because taking them out was unnecessary and I’ve seen rounds removed because of the location. Sometimes there are exit wounds and sometimes there aren’t depending on what stops the round. Sounds like there wouldn’t be an exit wound with the clavicle and leg but could be with the abdominal (perhaps in the low back).

Hope this helps and good luck with your story!

Author Question: The Perfect Skull Fracture

Ethan Asks:

I’m looking for the Goldilocks of skull fractures. My main character is a college age male that got into a fight. I’ve tried doing my own research but I’m second-guessing myself on which part of the skull to hit. I’m looking for a crack (not a shatter), minimal blood loss, he stays conscious for ten minutes or so, and a hospital stay of about five to seven days. I’m guessing there’s no way to avoid a concussion, as long as there’s no permanent brain damage I can work with it. Is such a skull fracture possible? If so, where on the skull?

Jordyn Says:

Yes, there is such a skull fracture that I think would fit your scenario perfectly.

In a small amount of cases, patients who receive an injury to the side of their head causing a fracture of the temporal bone can tear their middle meningeal artery causing an epidural bleed.

An epidural bleed/hematoma is considered a neurological emergency. Most of these patients will require surgery to save their lives. With epidural hematomas, the patient can have an initial loss of consciousness followed by a distinctive lucid period, and then worsening neurological status after that.

This article gives a nice overview of the condition and treatment for epidural hematomas. Also, this is a good article as well.

Hope this helps and best of luck with your story!

Author Question: Details for Chest Tube Placement

Rachael Asks:

I’m sure you get questions on this all the time, but I was wondering what insight you can provide on traumatic wounds. My project is science fiction and the characters in question have enhanced healing and a sped up metabolism which I’ve just been using as my cure-all, smooth-over for any inaccuracies thus far. But then I found your blog- which has been incredibly fascinating and entertaining.

The first question I had which led me here was in general for a gunshot wound to the chest though not involving the heart. Namely, the various potential complications, the meds, supplies, or procedures that may be employed, and the sorts of phrases and terminology and reactions that may be overheard from the staff working on the patient. I’ve read on the risks of things like a sucking chest wound and consequential lung collapse, punctured lung, of course blood loss, but I still am at a loss for particularly the things the medical staff on hand would be saying or doing. (Bonus points if you have any tips for the internal monologue for the victim besides “ow.”)

Jordyn Says:

Hi Racheal! Thanks for sending me our question.

Your question is hard to answer. You don’t give specifics of the injury though it looks like you’re leaning toward a collapsed lung. There are a couple of ways you can research the feel of an emergency and that is by watching reality based (non scripted) shows that center on emergency medicine or look for teaching videos (or live videos where they capture the procedure on a real patient on You Tube).

For instance, a patient with a collapsed lung will likely need a chest tube placement. You can search You Tube for “placement of a chest tube” and see what comes up. The below video is pretty good as it gives lots of technical detail on what the physician is doing, seeing, feeling, and even what medicines might be prescribed for the patient. However, it does lack a lot of language of what would be said to the patient during the procedure.

The next video shows more patient interaction and what might be said. Between these two videos you could probably extrapolate together a scene. I will say that typically patients are connected to a larger suction device, but what the below physician is connecting to looks to be a more portable device so the patient can be up and walking. Also, a patient with a tension pneumothorax who is crashing may not receive local anesthesia and may even be unconscious.

Your best option, once the scene is written, is have a medical person who actively is practicing in the field review it. If your scene is written from the POV of the doctor placing the tube, it would need to be more technical versus if you’re writing it from the POV of the patient. You can also search Google for patient experiences of having a chest tube placed to get a feel for the inner dialogue you’re looking for.

Hope this helps and good luck with your story!