all for good…

16 Jul

Once again, God is showing us his faithfulness, even through hard times.  We talked about the little boy who died after receiving large doses of seizure medications in our blog a few days ago (from the 13th).  We have spent the last several days discussing what we think led to his death and what needs to be changed in order to prevent this from occurring in the future.  To summarize briefly… Most children are admitted by M.A.’s (medical assistants) who work during all hours of the day, including during clinic hours.  The rest are admitted by us from clinic.  We have noticed that all children who come in with a history of convulsions gets an order for valium (a short-acting seizure medication) every 4 hours as needed.  Those that come in and are seizing at the time of admission get an order for both valium and phenobarbital (a longer acting seizure medication) STAT, in addition to the valium every 4 hours as needed.  On top of this, there is a standing protocol in the pediatrics ward that allows the nurses to give valium and phenobarbital to children who are seizing without a physician’s order.  There are several big issues with this system.  First of all, the doses of valium ordered by the M.A.’s and those allowed by the protocol are big doses, usually the maximum recommended (for the medical people, 0.3 mg/kg IV at a minimum is what we’ve seen).  The phenobarbital dose ordered is usually 10 mg/kg, which is not huge, but a significant dose given that it is given in conjunction with the valium.  Secondly, the nurses and M.A.’s like to give the medications no matter how long the seizure lasts, which often means that the kids get the medication either BEFORE the seizure has even lasted a minute or AFTER the seizure has already ended.  Finally, the way the orders are written allows the nurses to give far beyond the recommended amount of valium per 24 hour period because there are no limits set.

To make this a little more clear (hopefully) for the non-medical people… The management of a child with a seizure in theU.S.is very different from what is described above.  Valium is only given for seizures as they are happening, because its purpose is to stop the seizure from going on for a prolonged time.  It is rarely given in the first 5 minutes of a seizure, because the seizure itself does not pose significant harm to the child unless it is very prolonged.  Phenobarbital is a medication to prevent future seizures, and it can also be used in large doses to stop seizures when valium does not work.

So let’s say a child comes in with a seizure.  We would usually give 0.1 mg/kg of valium.  If the seizure stopped, great, no more meds.  If it didn’t, we would maybe give another dose of valium or move on to phenobarbital.  We would give what’s called a loading dose of phenobarbital (20 mg/kg) – a large dose meant to get good levels of the drug in the bloodstream quickly – and then consider starting a maintenance dose depending on the child’s condition.  After this, you can still give valium for breakthrough seizures, but still the smaller dose and only when the child is actively seizing.

So what happened to our boy?  He got 0.3 mg/kg valium plus 10 mg/kg phenobarbital upon admission, even though he was no longer actively seizing, but had had a seizure in the M.A.’s office.  He then got two more doses of valium over the next several hours for seizures that lasted less than a minute (both given after the seizure had subsided).  When he had his next seizure, he was given phenobarbital 10 mg/kg again per the “standing protocol” in the peds ward, despite orders NOT to give any more.  About 3-4 hours after this dose, he stopped breathing.

So now to the point of this whole post.  We were talking with Dr. Hewitt about our frustrations the other night and he agreed with our assessment of the situation.  He suggested that we give an in-service (teaching session) to the nurses who work on the peds ward on Tuesday afternoon regarding appropriate seizure management.  We are also going to modify the current protocol for the peds ward that dictates what the nurses give should there be no order on the chart for seizure medications.  We are so excited to have this opportunity.  We feel like it gives a chance to make a good, lasting change here that will keep kids as safe as possible.  In some ways, it helps to cope with the loss of one life – we hope to be able to prevent the loss of future lives in some small way.

“And we know that in all things God works for the good of those who love him, who have been called according to his purpose.” (Romans 8:28)

– Courtney & Rachel

5 Responses to “all for good…”

  1. carl & Elaine Baldridge July 16, 2011 at 1:07 pm #

    Your follow-up on this little one and what happened is such good medicine and something we always hope is happening in hospitals, clinics and doctors offices everywhere. The opportunity to have” all things work together for good” is so valuable. Again we see God’s hand in the work you are all doing there. We continue to pray for that work and for those things learned that will stay there after you have left as well as the those things that you are learning and will bring back to the children you work with here. We love all your posts and each of you! Mom and Dad B.

  2. Jonathan Whitmore July 16, 2011 at 4:48 pm #

    You girls are sharp. I felt like I was reading through the script of a “House” episode as I read your post… that’s probably a silly comparison for you real doctors, but what do I know :). Praise Jesus for the gifts He’s given you!

  3. Karen Tucker July 17, 2011 at 7:31 pm #

    Rachel & Courtney – I know this was a victory day – to be allowed to do some teaching that will have a long-term impact on the life of these children – it’s a Praise the Lord day 🙂

    Love to all of you!
    Mamasita

  4. Linda Jamison July 18, 2011 at 10:55 am #

    Wow! Praise God for the outcome of such a hard, hard situation. I am so thankful for you both and that you are there to teach what you know and I pray that the nurses will be very grateful for the info you are going to teach them. Like you quoted… what a wonderful way for God to use “all things working together for good…”
    Love to all four of you,
    Linda

  5. Caleb July 24, 2011 at 11:41 am #

    Beautiful.

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