By Laura Nathanson, M.D., FAAP, Author of What You Don't Know Can Kill You
When a child is admitted to the hospital, pediatricians have the same concerns that families have: make sure the child stays safe, comfortable, and as emotionally secure as possible.
In my childcare book The Portable Pediatrician, I talk about the emotional meaning of hospitalization for children of each age group from Birth to Five. (It’s in the “What If” section of each age-based chapter, along with such challenges as parental divorce, death of a pet, arrival of a new sibling, and so on.) While I still stand by that advice, there have been three big changes since then when it comes to keeping children as safe and as comfortable as possible:
1. A national shortage of nurses, including pediatric nurses, may require parents to step up their own role as caretaker to a greater degree one would ever have expected.
2. Physician care in the hospital is more likely to be directed by a “Hospitalist,” a doctor employed specifically to care for hospitalized children. Primary care physicians are fading from the picture, and sometimes parents need to be the link among three physician groups: primary care doctor, hospitalists, and specialists (in such fields as infectious disease, neurology, cardiology.) This is especially crucial if physicians disagree, and also at the time of discharge, when follow-up instructions can be crucial.
3. Over the last few years, the study called MRI has become much more available and more casually used. At the same time, there are no governmental regulations or oversight to make sure that safety is maintained. An ordinary thoughtless action, such as bringing an IV pole into the MRI suite, can cause disaster, even death; parents need to be present and watchful to help prevent such accidents.
My book What You Don’t Know Can Kill You, discusses in detail the implications of all of these changes, but primarily for adults. Parents of hospitalized children need a different take on these matters. I hope that reading these, even casually, before a planned or unplanned hospitalization, will tell you what to prepare for.
So here is my advice for parents on each of these topics, starting with the Nursing Shortage.
Nurses: Missing in Action
We are in the midst of a critical nursing shortage. Nurses are “aging out” -- half are 45 and older. So there are fewer and fewer of them, which means that they have to work longer and harder, making it tough to recruit new nurses. And even if there were lots of candidates, there is a corresponding shortage of nurses qualified to teach them.
This shortage, with its avalanche of increased demands, is particularly hard on Pediatric Nurses, who went into the profession in the first place because they really like children, and who now rarely may get a chance to interact with anything that isn’t sounding an alarm.
The bottom line here is that when you assume a nurse is going to be there, for whatever situation, there just may not be a nurse available. You, the parent/grandparent/other loving adult, must step in. To do so, you need to be familiar with the contents of the child’s room, the ward the room is in, and solutions to common and to crisis situations.
Most especially, you need to bond with the nursing and helping staff, making yourself useful without being intrusive. If something needs to be cleaned up, or fetched, or changed, see if it is possible to do it yourself -- ask a staff member if you’re not sure. If you think there is a problem, present it as your concern, not as a foregone conclusion that the staff person has erred. Once you have a reputation for being positive, helpful, and reliable, the staff will be even more responsive to your requests.
The Constant Grown Up
Someone competent, loving, and familiar should be with the child 24/7, both at the bedside and accompanying the child on any within-hospital trips.
When you stay overnight in the hospital, you need to be both self-sufficient and vigilant.
Self-Sufficient: Try not to ask the staff for help with your own needs. You must be responsible for your own food, drink, and hygiene products. A hospital overnight kit for the adult should include all your personal needs, a flashlight, and a sleep mask and ear plugs. I also recommend a shrill loud whistle to wear round your neck tucked into your shirt, to use ONLY if there is a true emergency and nobody comes to help.
Protect against hospital-acquired infections: Hospital-acquired germs can be very dangerous. Hand-washing is crucial, and nurses tend to be more fastidious than doctors about this. Nonetheless, keep a rub-in hand cleanser at bedside: use it yourself, and offer it to any professional or staff member before they touch your child.
Since both children and hospitals tend to be sticky, bring along a container of disposable antibacterial/antiviral wipes, and frequently clean off the surfaces that need it most -- TV remotes, telephones (including your own cell), door knobs, bed control buttons, toys and dolls.
- Get to know your surroundings. Early on, get used to where these are: the Nurses’ station, the emergency exit, the source of drinkable water, and the public or visitors’ bathroom (unless you can use a private bathroom.) At the bedside, locate the “call” button for the nurse, and vow to use it ONLY in an emergency. Figure out how the bed buttons and side rails work. - Remember that wards become darker at night. Make sure you can make your way around with your flashlight. Figure out what you are going to sleep on well before night falls, and get acquainted with that piece of furniture -- and make sure it doesn’t obstruct the path to the child’s bed.
- Ask the nurse to give you a basic explanation of each of the “Lines” placed for your child. Lines are tubes: to deliver oxygen, fluids, medication, blood, liquid feedings; to collect for the lab or to evacuate stomach contents, urine, drainage, pus, air pockets. Each line should be clearly identified, so that the fluid or medication doesn’t go into the wrong tube -- food into a vein, for instance. Ask how the lines are labeled or identified to be “foolproof” in this way.
And then, of course, keep a watchful eye when any substance is injected into a “Line.” If you think someone is about to make an error, speak up at once, but try to be vigilant, not offensive. “I’m sorry to interrupt, but I thought that that is the arterial line, and they said nothing should be put into it.”
If a change is made in lines -- if one is going to be removed or added -- make sure you understand why, and what it is for. If the person doing the procedure is one you don’t know, or is clearly a subordinate to the main doctor involved, make sure that the supervising physician has ordered the change.
Monitor your child:
Make friends with the Monitors.
Monitors are computers that receive and interpret the signals your child’s body is sending out. These signals are delivered as numbers via a “lead” placed on or in the body, transmitted by a wire to the machine. Most commonly, monitors measure heart and breathing rate, blood pressure (how hard the heart needs to work), and the blood’s supply of oxygen. Other monitors measure more special signals: the pressure of the spinal fluid, for instance.
The Settings on a monitor determine at what point the number value of each particular “vital sign” gets too high or too low, at which point the monitor should alarm. A heart rate over 150, say, or oxygen saturation under 90. These settings vary from individual to individual, depending on age and condition.
Well that’s all fine and good, but it doesn’t take childhood behavior into account. You may notice, and be alarmed, that when a monitor alarm goes off like a cat with its tail stepped on, it very often doesn’t get an instant full team response. Almost always, that’s because nurses, no matter how busy, know which children are in a precarious situation and which are not.
What if Timmy starts tantruming about the tapioca pudding and his heart rate goes up to 180? Or Nancy, also inflamed by the mere concept of tapioca, holds her breath until she turns blue and her oxygen drops, for thirty seconds, to 78? Or angelic little Franklin doesn’t like the itchy monitor leads on his chest and finger and in the space of fourteen seconds takes them all off and tries to eat them? Or chubby little Poppy sweats so much all her leads come unstuck?
But it can work the other way, too. Monitors can’t monitor everything -- how a child is feeling, or talking, or behaving, or whether he looks as if he is going to throw up. They also can’t announce that even though the numbers are within the range of the settings, there is a sinister trend: say that over an hour the Oxygen Saturation falls from 100 to 93. Clearly, there is something wrong, but the alarm doesn’t go off. To spot the trend, somebody’s got to be watching the child. That’s what nurses used to do, back in the day -- they would get to know their small patients and be alert to such changes. Now it’s up to YOU.
So keep your eyes open, and if you think your child’s condition is changing for the worse, press the Call Button. If no one comes, get out there in the corridor and snag the next nurse you see. Worse case scenario, blow that whistle.
Finally: yes, it’s nice to bring treats for the nurses. But even better, bring them real help, a positive attitude that assumes that they know what they are doing and have your child’s best interests at heart. A note of praise to the nurse, with a copy to the supervisor and the head of the hospital, goes a lot farther than chocolates. If you really want to bring a treat, fresh fruit is appreciated even more than processed sweets by most nursing staffs.
When you get home from the hospital, it’s always appreciated if you can drop a note to your pediatrician to report on your stay, and any comments on the care your child received.
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