BE HEARD. WRITE A CASE REPORT FOR THE AEDR.

Are you a dispatcher or ED-Q? Do you manage a dispatch center or review emergency calls for a living? Then you have a valuable perspective, which you can share through writing a case report.

GET STARTED. LEARN HOW TO WRITE A CASE REPORT.

WHAT IS A CASE REPORT?

 

A case report is nothing more than a detailed description of a difficult or unusual emergency call, and research you can do in a fraction of the time of a larger study.

No need to think of a hypothesis or come up with a research design! If you can write a few paragraphs, then you can write a case report, which can end up being a crucial beginning step on your journey to becoming a researcher.

WHY WRITE A CASE REPORT?

 

Once it’s published, the case report you write won’t only be for your benefit. It will be for the benefit of all dispatchers and the many communities they serve. Like a megaphone, a published case report amplifies your voice so that your message reaches a broad circle of people.

You can use this megaphone to share the important insights you’ve learned on the job. And by sharing what you’ve learned, you can improve the way others do the hard work of dispatching.

HOW DO I START?

 

All that you will need to begin writing your report is access to an interesting emergency call.

From there, you can follow a series of simple steps, all provided on this webpage. Then before you know it, you will have a draft you can submit.

Check out the resources below to get started!

CASE REPORTS IN-DEPTH

WHAT IS A DISPATCH CASE REPORT?

A dispatch case report is a detailed description of the management of a caller’s complaint. These reports are often written to educate professionals on how to better manage difficult or unusual situations. A type of qualitative research, case reports carefully examine a single call using words and phrases rather than numerical measurement.

Case reports, in other words, are basically stories told for research purposes. Like stories, they describe a sequence of events relating to human beings. Usually they contain a moral, or learning point, similar to a type of story known as a fable. And because they are basically stories, case reports tend to be more accessible (and readable) than other forms of research, which can be hard to understand for those outside the “ivory tower.” In other words, to read or write a case report, you don’t need years and years of study. Essentially, you can begin when you have found a case worth writing about.

In addition to being a way to start doing research, case reports can offer valuable learning points to readers. Throughout their history, in fact, they have been used as a way for practitioners to develop and share medical knowledge. For instance, the Edwin Smith Papyrus, an ancient Egyptian manuscript dating back to around 1600 BC, contains what some consider to be the first medical case reports. These writings gave generalized advice on how to examine and treat various ailments such as a dislocated jawbone. Since then, authors have consistently written these articles with the intention of improving clinical practice, even as the case report has evolved in style and content over the centuries.

The dispatch case report is a descendant of the medical case report. But an important distinction is that while medical case reports can positively impact the practice of clinicians, dispatch case reports can also be an important first step toward the improvement of the protocols. You can not only help dispatchers manage difficult or unusual calls. You can also contribute to the always ongoing process of making the protocols perfect again.

WHY WRITE A CASE REPORT?

People are often intimidated by research writing. That’s understandable—there is a gap between how insiders (such as PhDs or MDs) and outsiders view research and the practices that go along with it. Although insiders might see academic style as necessary for building credibility and maintaining objectivity, for example, outsiders might think academic style is inaccessible and unnecessarily dry. As a result, all too often outsiders conclude that research is “not for them.” But it is our position that, if you are intellectually curious and willing to learn a little bit, research is for you. You don’t need a graduate degree or mastery of a specialized body of knowledge to start researching. All you need is the desire to begin.

If you are looking to begin your research, it is hard to imagine a better way to start than the case report. In contrast to a double-blind, placebo-controlled trial, or more generally research that requires sophisticated statistical methods, a case report demands nothing more than access to a unique and challenging case. And there are plenty of such cases out there. As Ivan Whitaker, author of the case report “Second-Party Caller Information for a Falls Case” has said, “the protocols keep evolving, and they keep evolving because we keep finding things we’ve never seen before.” Put another way, there are many challenging calls that have yet to be written aboutand every such call provides an opportunity to positively impact the protocols. By writing a case report, you can participate in the evolution of emergency dispatch.

Furthermore, case reports are educationally valuable. If you feel like you have learned a lot from a challenging call, for instance, then a case report can be the right vehicle to share your learning experience with others. This is exactly what Andrew Bacon and Paul Taylor accomplish in their case report “An Unorthodox Delivery: ‘I’ve Never Done One of These Before.’” Detailing a call taker’s first breech case in six years of experience, the case report concludes with numerous learning points—such as “draw on your own experiences when empathizing with the caller”—to help those who want to prepare for calls of similar complication. In addition to presenting a compelling situation, this case report makes for an effective teaching tool.

Lastly, the Academy is on the lookout for the next generation of leaders. You can demonstrate that you have the motivation, commitment, and understanding to lead in the field of emergency dispatch through getting involved in research–and specifically writing case reports. The council and board members of tomorrow, we believe, are going to be the researchers and case report writers of today.

In short, if undertaking a large research project seems like too much, it might be a wise idea to start with a case report. You don’t even need to have a research question. You only need a challenging or unique case. From there, a lot of good can happen.

MAIN POINTS AND CONCLUSION

To sum up, dispatch case reports:

  • are detailed descriptions of unusual or challenging calls
  • are meant to teach professionals how to better manage these difficult or unfamiliar situations
  • are relatively easy and quick to write
  • can be more accessible than other kinds of research, which might be highly theoretical or statistically sophisticated
  • can lead to changes in a protocol system through their potential to detect novelties
  • through their publication, can result in exciting opportunities

We all learn important lessons from doing our jobs. If you are an emergency dispatcher or ED-Q, it is safe to say that you have learned something valuable from the experience. One call might stand out to you, or several, because there is a meaning or significance there that has not yet been put into words. By writing a case report, you will take that experience and put it into words, and better yet, you will turn those words into enduring knowledge.

HOW TO WRITE AND PUBLISH A CASE REPORT

During school, you probably heard about the scientific method. If you haven’t, it’s only a name for a series of steps that describe a process for investigating the natural world. The method can vary from discipline to discipline, but usually it involves making an observation, formulating and testing a hypothesis, drawing conclusions, and communicating the results.

Think of these steps as a less demanding version of the scientific method. For this project, you won’t need to produce a testable hypothesis or design a study. However, like with most other research, you should start with observation, a word that can mean both the act of noticing or the more rigorous idea of recording data.

IDENTIFY AN INTERESTING CALL

What is meant by interesting here? From our experience, interesting calls tend to be the ones that strike readers as being either challenging or unusual.

Below is a list of examples that can be said to fall into one or both categories:

Call SituationChallengesUnusual Features
A first-party caller diagnoses himself as suffering from Morgellons disease, a controversial disorder.Selecting a protocol for unusual symptoms, handling a caller diagnosis.Patient describes fibers protruding from skin.
A second-party caller gives an incomplete description of a patient’s fall, which results in the call being given a too-high priority. Handling a caller who doesn’t know answers to protocol questions.
A second-party caller reports that his friend was bitten by his pet sting ray.Exotic pet causes injury.
A second-party caller reports her newborn daughter’s vomit is green.Patient’s vomit is bilious (green).
A first-party caller reports with a calm voice that he is having chest pain with no other symptoms. The dispatcher senses that something is off. Accounting for intangibles or dispatcher’s gut feeling.Patient has rare symptom presentation for aortic dissection.

It is helpful to think about why your call is interesting. Knowing this can shed light on your case’s value to your readers.

On the one hand, if you describe a challenging call, then your readers can benefit from the learning points or lessons learned from managing the situation. Did the dispatcher handle the call flawlessly? Or were there significant errors in management? In either case, readers can learn a lot from careful examination of good or bad decisions made.

Unusual calls, on the other hand, can be thought of as tests of a protocol system. Just as in software testing, where a user executes a program with the intent of discovering problems, a case report might examine a unique case to test whether a dispatch system is reliable. Therefore, a result saying the system passes increases faith in that system. Meanwhile a negative result, where for instance a protocol system does not adequately address a unique symptom presentation, can lead to a proposal for change request (PFC) and an enduring impact on the practice of emergency dispatch.

GATHER THE DATA

Data is only another word for information. A very useful piece of information to gather is an audio recording of the emergency call. Having this information allows you to review the call as many times as you need. Then while reviewing, you can make additional observations as you figure out what conclusions to draw. And as you do all this, it’s guaranteed that a faulty memory is not contributing any significant errors.

However, deep diving into your memory is an acceptable option if you don’t have access to a recording—just not a preferred one. After all, it’s not like your case report needs to depict every moment during the call. Your report only needs to present the most relevant moments, which are determined by what main ideas (usually learning points) you want to communicate to readers. If you can’t get access to an audio recording, then you should at least take a few minutes and write up the call to the best of your memory. By doing this, you will have something to work with before writing your report.

Additionally, you can choose to gather information from external sources, like textbooks or even Wikipedia articles, to better inform yourself about important ideas or topics that seem most relevant. This is called doing background reading. Since you might not know everything there is to know about something dispatch or medical related, it is perfectly alright to build familiarity with what you’re writing about. Keep in mind, however, that the sources you use to better inform yourself about a topic are probably not going to be sources you will want to cite or reference.

A reference, by the way, is information from a source that you present as evidence inside a research paper. If you are looking to reference sources in your case report, you are better off combing through something called a peer-reviewed journal, a source that has experts evaluate submissions before the work is published. Material from these more serious sources can be used to provide background information for your readers or compared to your own conclusions.

In summary, your data can be:

  1. An audio recording of an emergency call
  2. A written account of the call done from memory (if you don’t have access to a recording)
  3. External sources that better inform you about a topic
  4. References that you present as evidence inside your case report

WRITE DOWN YOUR LEARNING POINTS

In high school, your English teacher probably taught you to begin your essays by writing down your thesis statement. Similarly, with a case report, it makes sense to begin with your most important ideas, which will be your learning points—these are lessons to be learned from a careful review of your call. Most likely, these lessons will be the most important conclusions you’ll draw when writing your case report. For this reason, writing down learning points should be the starting point of your analysis.

Your learning points will make composing the rest of your case report an easier process, too. Once you better understand these lessons to be learned, for instance, you can determine what details to focus when you report the key moments of a call. More specifically, if your learning points all concern, say, how a dispatcher should react to a caller giving certain obvious death descriptors (terms a caller uses that suggest an obvious death), then you should describe call intervals when those terms emerged. The other parts of the call, like when the dispatcher and caller are waiting for the ambulance to arrive, won’t be as necessary to present to the reader.

As well, your learning points can illuminate what background information to include in your Introduction. If your case report’s learning points relate the idea of an obvious death descriptor, then you should present some general information about the obvious death descriptor concept at the beginning—such as a definition of the term and examples.

 

DO A SELF-ASSESSMENT OR (OPTIONALLY) ASK FOR FEEDBACK

If your first draft isn’t perfect, don’t worry too much. First drafts are rarely beyond revision. That’s why writing is often described as a process, and not as something instantaneous, because it can take many drafts or iterations to get things right.

To help improve your drafts, you can use our case report self evaluation form. You can also ask someone else for feedback if you are comfortable sharing early drafts of your writing with others.

SUBMIT

When you are ready, you can submit your dispatch case report to us through the AEDR webpage. Don’t feel intimidated about submitting your case reports—we are willing to work with you to get your writing published.

CASE REPORT WRITING GUIDE

If you’ve never written a case report before, you might need help translating your ideas into a fleshed-out final product. This writing guide does just this: It explains the sections of a case report and lays out strategies for writing each part.

But before getting to that, you should know what the components of a case report are. They are known as the Introduction, Management and Outcome, and Discussion. If a case report can be likened to a story, then the Introduction is the beginning, the Management and Outcome is the middle, and the Discussion is the end.

Your finished case report should include these sections, and they should be clearly labeled. Without clearly labeled sections, your work will lack guideposts to help readers who want to quickly find information about your case. As you will see, each section title tells the reader what to expect. A case report with labeled sections, therefore, will seem a lot more organized and comprehensible than one without them.

INTRODUCTION

The Introduction section has two important purposes: to 1) give background information and 2) explain or justify the selection of the case.

In other words, a good Introduction section will orient the reader and establish that the case report is worth reading.

What does it mean to orient the reader? Well, in any piece of writing, there is a gap between what the reader knows and what the writer knows. What is familiar to you is not necessarily going to be familiar to a stranger. To help close this divide, authors generally include background information to make the topic or situation more familiar to their audiences.

For a dispatch case report, you might consider orienting the reader through first describing the call center where the dispatcher handled the challenging or unusual call. This description can answer questions— assuming they are relevant—about the center such as:

  • Where is it located?
  • Which communities are served?
  • What protocol system is used (if any)?
  • What is the background or expertise of a typical call taker?

The answers to these questions establish a setting and give readers a sense of the dispatch center’s organization.

You should, however, make sure your background information serves a clear purpose. For instance, you don’t want to include every bit of information you know about a dispatch center—that’s a certainly going to irritate your readership. Therefore, it’s important to write down your learning points or main ideas before writing the Introduction. That way, you can know which details are going to be relevant, which is the information that supports, illustrates, or explains your most important ideas.

Additionally, you can’t assume somebody will want to read your work merely because it exists. For this reason, at some point in the Introduction you should also communicate why the case is worth reading about. Remember that, by our criteria, a case is worth reading about if it is challenging or unusual, the sort of memorable call where something new or unforeseen is detected or a valuable lesson is (or can be) learned.

The good news is that establishing the noteworthiness of such a case can be straightforward. For instance, if it is clear the situation is going to be unusual or difficult near the beginning, you can communicate why the case has been selected through simply describing the start of a call.

As an illustration, consider this paragraph taken from Introduction of the wonderfully-titled case report, “You Said It Was Quite Green This Morning…:”

“The call reviewed here was received by the center at around 2:30 am on a Sunday morning. The mother of a 4-day-old female newborn reported that the baby’s stomach ‘just makes the craziest noises.’ She also reported increasing episodes of regurgitation and vomiting over the past few days, including more than two episodes on that day alone. She stated that some of the vomit was green, saying that ‘this morning there were two really big ones with green breastmilk.’”

Notice how this paragraph answers some basic questions such as:

  • Who is calling?
  • When?
  • Why?
  • What information is first given?

You might also notice that this text very clearly communicates why the case was selected, even if the reason is not directly stated. After all, it should go without saying the presence of green breastmilk is, well, not exactly normal.

Finally, if you want a simple pattern to follow, you can organize your Introduction this way:

  • Describe the call center where the call was managed
  • Then describe events from the start of a call until it is obvious the situation is going to be unusual or challenging

EXAMPLE INTRODUCTION

Clinical call handlers at a contact center in Queensland Health, Australia, use a clinical decision support system (CDSS) called Priority Solutions Integrated Access Management (PSIAM™) (PSIAM version 3.6.1.1, 2012 release, Priority Solutions Inc., Salt Lake City, USA) to provide community members with telephonic triage, referrals, and health information. The contact center operates 24 hours a day, 7 days a week, and all calls are handled by Registered Nurses (RNs). Callers requiring emergency services, usually an ambulance attendance, are transferred to Emergency Medical Dispatchers (EMDs) at the local emergency dispatch center. This accounts for approximately 5-6% of calls. The majority of calls received at the dispatch center are for minor, self-limiting, or low-acuity ailments.

A RN received a call from a 34-year-old male around 6:45am on a Sunday morning. This call had been referred from the caller’s local hospital switchboard. The caller initially stated he was suffering from “Morgellons disease” and was requesting information for where he could get help. On further questioning, the caller described that a cotton or nylon type of fibre was protruding from his skin in various areas of his body, including two lower limb superficial wounds. The caller reached the conclusion that he had Morgellons disease based entirely on Google searching.

MANAGEMENT AND OUTCOME

The Management and Outcome section 1) presents the case in chronological order, 2) describes using specific language relevant parts of the case, and 3) avoids personal judgments or opinions.

Even though it might be tempting to play around with time a la Pulp Fiction in your description, you will need to curb your creative impulses here. Keep in mind that you are writing a research paper, and that means you should consider this section of the case report as your “data.” Accordingly, the case should be presented using specific language in the order that it happened (that is, chronologically), and with as little authorial manipulation as possible. As well, don’t think you need to write up everything about the call. Just focus on the part of the call you want to discuss, which should be the moments most relevant to your learning points or main ideas.

A simple way to do all this is to present the relevant portions in the form of a transcript, a written version of an audio call that captures what was said verbatim. A transcript has an evidentiary quality—this is a fancy way of saying it resembles courtroom evidence—that can lend your writing an extra bit of authority. And using this format takes care of one other potential issue, the tendency of some people to inject their writing with unnecessary bias. Although having strong opinions about how a call should be managed is great, the Management and Outcome section is not the right place to give your own point of view. A better place is the next section of the case report, the Discussion.

EXAMPLE MANAGEMENT AND OUTCOME

A review of the audio recording of the case revealed that the Emergency Medical Dispatcher (EMD) began by verifying the address and telephone number and continued with the following interrogation sequence:

Case Entry

Calltaker (CT): Okay, tell me exactly what happened?

Second Party Caller (SPC): I am with a patient that fell to the ground. She may be injured.

CT: How old is she?

SPC: 57

CT: Is she awake?

SPC: Yes

CT: Is she breathing?

SPC: Yes

Key Questions

CT: How far did she fall?

SPC: I don’t know?

CT: What caused the fall?

SPC: Don’t really know, just came in and found her.

CT: Is there any serious bleeding?

SPC: No

CT: Is she completely alert?

SPC: Yes

CT: What part of the body was injured?

SPC: She is not complaining of any injuries.

CT: Is she still on the floor (ground)?

SPC: Yes

DISCUSSION

The Discussion section 1) does not present any new information about the case and 2) answers the question: what has been learned from a careful review of the events?

Additionally, this section can 3) compare or contrast your case with similar literature that has been published and 4) propose solutions to a problem that has been discovered.

This section of the case report might be the most important. Until now, the report (hopefully) has presented an interesting situation in an unbiased and informative fashion, but here in the Discussion is where readers discover the meaning or significance of the case.

Readers generally will find a case meaningful if it teaches them a lesson, or at least assists them to make sense of difficult situations. Therefore, during this part of the report, you can think of yourself as a teacher, someone whose purpose is to instruct professionals on how to properly handle a very challenging call. For instance, if the case reveals a mistake committed during a call’s management, such as in “Second-Party Caller Information for a Falls Case,” it becomes the role of the writer to teach how to avoid making similar errors. Or, if the case reveals an emergency dispatcher’s exemplary conduct, like with “An Unorthodox Delivery: ‘I’ve Never Done One of These Before,’” then the Discussion section should explain to readers how the emergency dispatcher achieved that high level of professionalism. And here is a piece of advice: Any learning points you give will be more effective if you support them with details, which you can take from your case’s description.

Comparison

A fable is a story where, among other characteristics, the author presents a moral or lesson at the end. You might have already heard about the most famous collection of these type of stories: Aesop’s Fables. Usually, a case report writer does the same thing as Aesop. After the writer tells the events of the case, they make meaning out of the incident through sharing what can be learned.

If you want to, additionally, expand your conversation to include other authors, you can read about your topic in the literature. By “the literature,” we mean the existing body of credible research on your topic. The case report “A Case with a Sting in the Tail,” for instance, which concerns the treatment of a stingray sting, cites a study called “Is Hot Water Immersion an Effective Treatment for Marine Envenomation?” from The Journal of Emergency Medicine. Why? Well, for one thing, The Journal of Emergency Medicine is a credible medical journal, so it is certainly acceptable as a reference. As well, this article happens to confirm a main idea of the case report, which is that “the advice with regards to HWI [Hot Water Instructions] given by the RN [is] current best practice.” Since a case report is by its nature anecdotal, it is sometimes a good idea to see how your findings measure up to a general body of evidence. In this example, the details of the case happened to confirm what has been written. But it certainly can be as interesting, if not more interesting, if your case complicates or challenges assertions made by an existing research paper (though, given the case report’s anecdotal nature, you should avoid coming to sweeping conclusions).

Since there is a lot of bad information out there, you will need to be careful about what sources you choose to reference. After all, referencing a bad source can seriously harm a reader’s perception of your judgment or seriousness (Wikipedia for instance might have lots of easy-to-find information, but it is not necessarily accurate). So, what does the medical or scientific community consider to be a good source? The answer is the best sources use a peer-review process. And in case you are not already familiar with the concept—a journal is peer-reviewed when work is evaluated by experts in the field before it is published. To give you an idea of what a peer-reviewed journal looks like, here is a short list to investigate (or reference in your own writing!):

Finally, the Discussion section can propose a solution to a problem that has been discovered. The problem might have to do with a gap in dispatcher training, or it might relate to the protocols themselves. For instance, the case report “You Said It Was Quite Green This Morning…” identifies an issue with a protocol system, in this case a version of the Emergency Communication Nurse System (ECNS). ECNS, it turns out, did not include a way to detect the presence of bilious (green) vomit, which could be a symptom of a disease that requires urgent treatment, and sounds eerily like the demonic hurl from The Exorcist. At the end of the report, the author mentions the solution, a proposal for change request to include a question that detects the green spew’s presence.

EXAMPLE DISCUSSION

Based purely on the answers given, the determinant coding was actually correct, but this coding overlooks a key fact: the caller was a second party, meaning he/she was right there with the patient. In that context, some of the caller’s answers appear odd or incomplete.

Given that the caller is second party (“with the patient”), and the patient is completely alert, it is surprising that the caller was unable to answer the Key Questions. The underlying issue may be that the EMD did not prompt the caller to obtain the information from the patient using an enhancement or clarification those specific Key Questions.

When using the MPDS protocols, the answer choice of “unknown” is offered for a variety of reasons:

I. The caller is not with the patient (3rd party or 4th party).

II. The patient is not able to relay the appropriate information to a 2nd party caller due to an altered mental status (see below example).

III. The emergency dispatcher (ED) has appropriately restated the question and the caller still does not understand the question.

IV. After obtaining an answer of “unknown”, the ED clarifies or enhances the Key Question, but the caller still has no further information.

V. There are safety issues preventing the caller from obtaining the required information.

If the EMD has taken the appropriate steps to clarify the information, an answer of “unknown” to one or more Key Questions may represent a more serious underlying condition. EMDs must have a high index of suspicion that the underlying cause may be medical in nature; in other words, if a second-party caller cannot provide the information even after clarification or prompting, the patient is likely unable to answer the questions; thus, the true cause of the fall could be cardiac, circulatory, or neurological, as opposed to a simple accident trip or slip. Under those circumstances, the EMD would certainly want to assign the BRAVO level priority to get a more rapid response.

An example would be a case in which a woman walks into a room and finds her mother on the ground. The daughter finds that the mother fell but does not know how she fell. During Key Question interrogation, the caller clearly indicates that her mother cannot remember the cause of the fall.

In this example, the coding of a 17-B-3G is appropriate EMD, since there would be a specific reason for the answer of “unknown” despite the second-party caller.

In the case outlined here, however, there was no such specific reason.

What we can learn from this case is that EMDs must clarify and enhance the protocol Key Questions when the information provided by the caller is vague or ambiguous, especially when the caller is second party and near enough to the patient to gather more information. Not doing so may lead to a final code that is not representative of the patient’s true condition, and generally leads to assigning a higher response level than may be necessary. With complete information, including the knowledge of a ground-level fall with no dangerous cause—as the fire department responders found upon arrival—an ALPHA-level coding could have been assigned.

During emergency situations, the caller may genuinely not know the answers to all of the Key Question, even when they are ready and willing to obtain information from the patient, or the caller may simply need a little more prodding, in the right way, from the EMD. Through good caller management technique, including enhancing the questions where necessary, the EMD can obtain the most complete information available.

EMDs may need training on the use and purpose (as listed above) of the “unknown” selection choice in the dispatch protocol. Such training need not always be formalized classroom instruction. It can be delivered in various less-formal formats such as training bulletins, one-on-one audio playback sessions, and other instructional platforms. Regular case review must also be administered to ensure that final determinant codes are compliant with protocol rules and performance standards.

CASE REPORT EXAMPLE

TITLE

You Said It Was Quite Green This Morning…

AUTHOR INFORMATION

Dr. Kim McFarlane and Dr. Mark Conrad Fivaz

INTRODUCTION

The Health Contact Centre (HCC) in Brisbane Australia is one of the Health Support Queensland’s services that provides clinical support, either directly to the community (4.7 million Queenslanders) or in support of Hospital and Health Services (HHS) and the Department of Health. Registered nurses (RNs) use the Emergency Communication Nurse System™ (ECNS™) as Clinical Decision Software System (CDSS) to triage callers who access this service via telephone. The RN uses a set of symptom-based protocols in the ECNS to telephonically triage the caller/patient and recommends the most appropriate healthcare resource and timeframe in which to access the resource.

The call reviewed here was received by the center at around 2:30 am on a Sunday morning. The mother of a 4-day-old female newborn reported that the baby’s stomach “just makes the craziest noises.” She also reported increasing episodes of regurgitation and vomiting over the past few days, including more than two episodes on that day alone. She stated that some of the vomit was green, saying that “this morning there were two really big ones with green breastmilk.”

MANAGEMENT AND OUTCOME

The RN utilized the Unwell irritable newborn (0-3 months) Protocol and asked the relevant questions, ruling out the presence of respiratory distress, cortical neurological symptoms, meningeal irritation, underlying injury, dehydration, concerned caregiver, underlying septic arthritis, vascular constriction, groin swelling, fever, and crying with bowel movement.
A positive response was eventually triggered in response to a question about the presence of more than two episodes of vomiting, prompting a disposition.

The disposition or Recommended Care Level (RCL) reached suggested the baby should be seen by a doctor within 12 hours. In spite of the fact that the child looked well, the mother was given a range of options to seek care sooner if she was concerned. These options included accessing the out-of-hours general practitioners, going to the hospital, or accessing primary care facilities where she could take her baby to be seen early that morning.

DISCUSSION

The infant’s mother presented to the Emergency Department (ED) that same morning, and the baby was diagnosed with intestinal malrotation. A pediatric surgeon and fellow of the Royal Australasian College of Surgeons (who was involved in the infant’s treatment) contacted the call center to create awareness and to discuss the importance of the presence of bilious vomiting (green vomit) and the likelihood of an underlying intestinal malrotation or obstruction being present in patients with this presentation. He also emphasized the need to be seen at an ED as soon as possible so that the diagnosis can be made and preparation for surgery initiated.

More importantly, he stressed the fact that patients who present with bilious (green) vomiting, and who are not currently unwell or in any distress, should not be dealt with any differently than those patients who presents with bilious vomiting and are unwell, and thus are considered to be having an emergency. This is because it is impossible to distinguish between babies who have a life-threatening cause for bilious vomiting and babies who have a more “benign” cause. Bilious (green) vomit in childhood is a condition that must be taken seriously, as it can indicate the presence of potentially serious gut pathology.1 A diagnosis of malrotation (estimated as 1 in 500 live births) of the gut cannot be excluded when bilious vomit is present.

These young patients can present as being well at presentation, with the only symptom being the green vomit (bilious vomiting). This can lead to false reassurance, as their condition can quickly (in a matter of hours) deteriorate as the bowel becomes ischemic.2 Malrotation is an eminently treatable disease, but if cardinal symptoms are missed or ignored, or if treatment is not instituted urgently, it can lead to extensive bowel loss and short bowel syndrome, or even an avoidable death.3

Newborns who present with even one bilious vomiting episode (with or without abdominal distention) should be considered to be having intestinal obstruction (a surgical emergency) and referred urgently for diagnosis and peri-operative management. Intestinal obstruction with bilious vomiting can be caused by duodenal atresia, jejunoileal atresia, malrotation and volvulus, meconium ileus, and necrotizing enterocolitis.4

A proposal for change request has been submitted to the proprietors of ECNS to add a question to the relevant protocols to address the presence of bilious (green) vomit to ensure RNs are identifying this potentially fatal presentation of intestinal malrotation or obstruction and referring these patients urgently to an ED.

REFERENCES

1. Williams H. Green for danger! Intestinal malrotation and volvulus. Arch Dis Child Educ Pract Ed. 2007; 92:ep87–ep91.
2. Shalaby M. S., Kuti K., Walker G. Intestinal malrotation and volvulus in infants and children. BMJ. 2013;347
3. Kumar N., Curry J.I., Bile-stained vomiting in the infant: green is not good! Problem solving in clinical practice. Arch Dis Child Educ Pract Ed. 2008; 93:84–86
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CASE REPORT SELF EVALUATION

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