I recently had a reader send me this comment:

“As a full-time dad I have to deal with just about every minor illness my two children pickup, everything from a bump on the head to chicken pox. I found the Highway to Health ebook very useful and it’s one of the first things I reach for when something goes wrong!”

Mr John Bradbury
United Kingdom

It got me thinking - although the Highway to Health does cover headaches, perhaps going into a little more detail about ‘bumps on the head’ would be useful. So here we go…

There are two main types of head injury - concussion and compression.

*Concussion* is the commonest:

For the head of the trauma department at one of America’s top pediatric facilities, Chicago’s Children’s Memorial Hospital, having to notifying parents that their children have been the victims of trauma or identify pediatric Jane Does, is an every day occurrence. But just because they look like they’re handling it well, doesn’t mean that it ever becomes routine.

When a child comes into the ED without a parent, it’s usually the result of an accident or traumatic event. Even though their first priority is to tend to the child’s medical needs, their next priority is to identify the child. They need to get his parents or guardian down to the hospital, to give consent for his treatment, provide vital medical history and most importantly, to be at their child’s side when he needs them most.

You’d be surprised how often a child is brought into Children’s Memorial without anything pointing to his or her identity. Many times it’s the result of a car accident, where the parents are injured as well as the child, and are taken to another hospital, while the child is brought to Children’s for specialized pediatric treatment. Since children don’t have driver’s licenses or checkbooks, identifying a child can be challenging.

Just the other day, three children ranging from 8 months to 3 years were brought into the ED after a serious automobile accident.

Their parents, who were in bad shape, were taken to another hospital and the paramedics had no clue about their names, ages or medical history. The trauma team began their medical evaluation and as they always do when dealing with an unidentified child, opened a trauma pack for each, using a patient number to identify them. We estimated their ages, did a full physical description including any identifying marks and clothing, then ordered a full set of x-rays, which helps to identify any conditions or injuries that aren’t readily apparent.

The team’s biggest asset in this situation was the solid relationships that they’ve built with police, fire department, and other local hospitals ? as they work together to get the children identified as quickly as possible. After a major accident like this, the police and fire department were already in the ED coordinating efforts. With their special emergency landline system they’re instantly linked by phone with any local hospital they need to reach. As the team began calling to find out where the children’s parents were taken, hospitals began to call them, to say, “I know you’re looking for the mom and dad of the accident victims. They’re not here,” saving them precious time. In this case, we found the hospital relatively quickly and found out that even though the children’s parents had been seriously injured, the children’s caregiver who had also been in the accident, was fine. The hospital sent her over to Children’s and she ? and later on the parents ? were able to give them all the information theyneeded to identify and treat the children.

In the case of a completely unidentified child, especially babies, they depend on our procedures. Usually the fire department, police or DCFS dropped the child off, so they are already aware of the situation and have already begun going through the child’s clothing and personal effects to gather evidence and identify the child. The trauma team will send the police or paramedics right back to the scene to gather additional information, medicine bottles, names, and to canvass the area. There is almost always someone who saw something. Someone from pastoral care automatically comes down and a social worker will get involved if it looks like any abuse was involved. Together, they take care of figuring out where to go from here, while the team takes care of the child medically.

If these steps don’t elicit any clues to the child’s identity, the hospital will get media affairs involved. Children’s will never show the face or reveal the name of any child. Instead, they photograph the child’s clothing and personal effects and release it to the media along with the child’s estimated age, description and the vicinity in which she was found. They work closely with detectives and DCFS to give them all the details they need to chase down any leads they get from the public. Many times just calling DCFS or the police will locate parents or bring about an identification. In the case of severe trauma, abuse or inflicted injury, Children’s always balances treating the child, with carefully gathering as much evidence as possible, to help the eventual police investigation. They had a young girl a few years ago, whose brutal attacker was convicted mainly on the evidence gathered and catalogued in the trauma room.

When it comes to providing emergency contact information, kids aren’t always the best source. They have seven or eight year old kids come in everyday, who I’m sure are sophisticated in every other way. But get them in a trauma situation and ask them what their mom’s name is and they’ll say it’s “mom”. In this case, the first thing they’ll do is look at whatever they brought in with them. School-age kids almost always have a backpack. If they don’t find anything there, they’ll check our records to see if the child is in the system and begin to gently probe the child for information. They ask them where their house is, what their school looks like, information about their friend’s houses, maybe a familiar landmark on the corner like a 7/11 or the name of a park. If you can’t find their contact information right away, try to find the name of their school. Their books will probably have the name of their school stamped inside.

Schools are also a great source for emergency contact information. They’ll often even list alternate people to call in an emergency if the parents are at work or hard to reach. In an emergency, schools will usually send someone directly down to the hospital with the child’s emergency card and emergency consent forms. If the injury occurs at school, most schools will send someone from the school along with the child to the hospital, while someone else is calling the parent. For parents, I would suggest that every parent name someone else on the child’s emergency card, who knows the child well and would be able to step in to help out during an emergency if the parents can’t get there right away.

So once you identify a child, how do you know if the person who comes to the hospital is really his parent or relative? It’s not always easy. Remember that the parents didn’t expect to have to come to the hospital today, and probably won’t be carrying three forms of ID and their child’s birth certificate. For people that come in and say they’re related to a child who’s been in the media, they get as much ID as they can, be it a driver’s license, pictures or other proof. With kids, the biggest test is to watch their response when that person goes in the room. Usually you’ll here a resounding “Mom!” or “Daddy!” and you know you’ve got the right person. If there’s no response from the kid, or if they’re not sure of the adult, it’s probably not the right person. Or worse, the child might recoil from the adult, which could indicate an abusive situation.

Treating kids also means caring for their parents. When Children’s has to make a notification call they’ll begin by telling the person on the phone who they are and ask them how they are related to the child. If it’s the mom or dad, they’ll tell them that their child has been brought to Children’s Memorial Hospital. Of course the parent will immediately ask how the child is. This is always the hardest part of the call. If the child is clearly fine, they’ll say “Don’t worry, they’re fine, we just need you to come down here.” But if there is a more serious injury, or if the child hasn’t survived, they say that the child has been in an accident, that they need to come down, and if necessary, that they need to get their medical history. If they refuse to get off the phone until they find out what’s wrong, the trauma coordinator will say that they’re very concerned about their child’s health and that they need to come down right away. They’ll always try to calm the person down as much as they can ? tell them to go and get a pencil and paper to take down the address of the hospital, to take down the hospital’s name and they’re direct number. They tell them to ask for them right away when they get here so they don’t have to waste any time at the desk and then try to make sure they have someone to drive them over. And they finish by reminding them that they need to drive carefully and slowly and to make sure that they get there in one piece!

At Children’s the top priority is the restoration of the health of every child who comes through our door, no matter who they are and where they come from.

For tools you and your staff can use to facilitate pediatric notification, identification and communication, download a free copy of the Seven Steps to Successful Notification System, in PDF format, at the Next of Kin Education Project web site. Along with the Information Kit, you’ll find patient chart pages and notification worksheets using the Seven Steps, that you can purchase and customize to use as part of your own charting system. You’ll find them on the NOKEP web site along with reminder products like mouse pads, posters and coffee mugs, to keep the Seven Steps at your staff’s fingertips.

The patient, known only as John Doe, was difficult to see under the hodgepodge of tubing, the quiet clicking of the ventilator the room’s only sound.

From all appearances he was homeless, but in the opinion of his nurse, who has had vast experience in dealing with patients just like him, everyone has a mother or a father, a son or a daughter, and homeless or not, it’s a nurse’s responsibility to do what he can to help find them. Usually it’s just a matter of taking that extra few minutes to connect the dots. “Homeless people are very savvy and self-sufficient when it comes to survival skills,” he explains. “They write important phone numbers on the insides of a hat, put them in their shoes, or sew numbers inside the seams of their coats. I go through every stitch of clothing.”

If that doesn’t turn up any emergency contact numbers or personal information, he examines the patient’s body for needle tracks, scars or tattoos and if necessary, sends fingerprints to the police for a background check.

Sometimes the police’s theory is that the homeless person had a desire to be a loner, and they see no need to reconnect them with their family after they are injured or dead. But the nurse is quick to disagree.

“Things change, [and] these people are still human beings. I believe that every homeless person is still a father or mother, [or a] son or daughter to somebody out there. These people may have done things they are not proud of, they may have mental illness, but their family has a right to know what happened to them.”

From a hospital’s perspective, a patient without an identity is a patient without funding. But once a nurse or a social worker positively IDs a patient as a US citizen, the hospital can help the patient apply for Medicaid and then get reimbursement for the bill.

“Identifying people is a reasonable endeavor. It is part of a holistic approach. When you locate family, you find a surrogate to speak on behalf of the patient, to be an advocate. The family should decide on the patient’s follow-up and if the patient has died, the family should decide where they are buried.”

For tools you and your staff can use to identify John Does download a free copy of the Seven Steps to Successful Notification System, in PDF format, at the Next of Kin Education Project web site. Along with the Information Kit, you’ll find patient chart pages and notification worksheets using the Seven Steps, that you can purchase and customize to use as part of your own charting system. You’ll find them on the NOKEP web site along with reminder products like mouse pads, posters and coffee mugs, to keep the Seven Steps at your staff’s fingertips.

When an unconscious patient arrives in the ED, every hospital agrees that timely next of kin notification is vital. Not only is it important to have a family member present to comfort the patient, but to make informed decisions for his care and provide the medical history that can make the difference between life and death. From a liability standpoint, as we know all too well, having a family member making medical decisions, often means that if complications do arise, the family will be much less likely to sue, than if they hadn’t been in attendance.

Although most hospitals make notification calls quickly, between personnel shortages and overworked staffers, that call can often be delayed or forgotten.

That’s exactly what happened to Elaine Sullivan, a very active seventy-one-year-old woman, who slipped and fell, while getting into the bathtub. When paramedics arrived, they realized that injuries to her mouth and head had made her unable to communicate, or as the hospital later discovered, to give informed consent for her own care.

Although stable for the first few days, she began to slip into critical condition. On the seventh day, Elaine died. But that tragedy was soon overshadowed by another. Despite having her daughter’s phone number and contact information clearly indicated on the front of her chart, the hospital failed to notify her family that she’d been hospitalized until six and a half days after her admission, only hours before she died, unnecessarily and alone.

Elaine Sullivan was my grandmother.

In her case, placing that phone call right away, would have saved her life. Not only would my mother Janet and I have had the time to fly back to Chicago to be at her bedside, but we would have made sure she received the care she needed. We also would have been able to give the physicians treating her, the medical history they needed to prevent the complications and drug interactions, responsible for her death.

After researching our own case and others like it, we realized that failing to notify a patient’s next of kin wasn’t an isolated problem ? it’s something that’s been experienced by countless families nationwide. According to the CDC, nearly one million patients come into the ED every year unconscious or physically unable to give informed consent. And with the growing number of emergency room admissions and baby boomers turning into senior citizens, the problem is only going to escalate. We began meeting with medical and trauma professionals, to create an easy-to-implement solution to this growing problem, by bringing together the best practices of successful trauma teams from hospitals nationwide. The result is the Seven Steps to Successful Notification System.

The complete system is presented in The Seven Steps Information Kit, which is available for download, free of charge, on the NOKEP web site. It’s filled with tools your staff can use on the patient care floor to identify and locate your unconscious patient’s family or surrogate decision makers, identify John Does and improve patient care and satisfaction by locating patient’s medical histories quickly and easily, while complying with HIPAA standards.

Even better, following the Seven Steps system provides the facility with a documentation of the steps taken to find the patient’s next of kin, make the notification, and the staff members responsible for making it. This releases you from subsequent liability, while providing proof that your facility has met its statutory responsibility.

Here is a quick look at the Seven Steps.

Step 1: Patient status confirmed

The moment that your staff realizes that an ED patient is unconscious or physically unable to give informed consent, and that there is no family member or surrogate decision maker in attendance, a nurse or physician is tasked with following the notification process through to completion. The staff member indicates the patient’s status on his chart along with the time, date and the staffer’s initials.

Step 2: Examine the patient’s personal effects for emergency contact numbers

If the patient doesn’t have emergency contact information in his or her wallet, the staff member looks for it in the patient’s personal effects. The System has a comprehensive checklist of places to locate this information, from the usual to the downright creative.

Step 3: Retrieve patient’s home number

If the patient doesn’t have emergency contact information, the staff member then looks for the patient’s home number, going to step five if they find it and four if they do not.

Step 4: Seek other sources for contact information

Next, the staff member looks for the patient’s emergency contact information or home phone number on records from previous admissions at the facility, or by calling his personal physician’s office, or other locations on the checklist. If the staff member finds the information, he proceeds to step five ? if not, step seven.

Step 5: Oversee or make the notification call

When a contact has been identified, the staffer places a call to make the notification. They note on the chart when the call was placed, whom they contacted, the phone number and the result.

Step 6: Need to follow up? Recall main contact or second number

If a message had to be left for the contact, or the contact doesn’t come into the hospital within two hours, the staff member places one more call, to the first or a secondary contact. If no one is reached, the staff member proceeds to step seven.

Step 7: Shift to social service or police

When no contact name or number can be located, or if the staff member doing the notification, is unable to speak directly to the contact, they give the information to the social service department or to the local police department, as per your facilities’ policy, for follow up.

Along with the Information Kit, the non-profit Next of Kin Education Project has created patient chart pages and notification worksheets using the Seven Steps, that you can purchase and customize to use as part of your own charting system. You’ll find them on the NOKEP web site along with reminder products like mouse pads, posters and coffee mugs, to keep the Seven Steps at your staff’s fingertips.

Just as doctors, nurses, and staffers from every department make up a team to improve the health of the patients in their care, family and friends can play an important part in contributing to the patient’s well being. As a medical professional, you are a diagnostician, a caregiver and a healer. But most of all, you are the patient’s advocate. And so is his family. This Kit contains tools that will help you and his family work together to increase his care, trust and take patient satisfaction to a whole new level.

Madeline Mann once weighed less can a can of soda making her the tiniest surviving newborn known to medicine. Next week, she enters high school as something even more exrtaordinary- a honor student who likes to play violin and Rollerblade.

“Her survival wasn’t the miracle; her development was.” says Dr. Jonathan Muraskas of Loyola University Hospital in Maywood, Ill. She was Born 27 weeks into her mothers pregnancy, she weighed just 9.9 ounces, less than any surviving baby in medical history. Just 10 inches long, smaller than a football. She rested easily in the nurses hand.

Madeline, now 15, weighing 61 pounds and measuring 4 feet 7 has no major medical problems.