School Nurses on the Front Lines of Healthcare: Recognizing "BONES" and Knowing When to Pick Up the Phone: Eating Disorders Among Students in the School Setting.

Through a case presentation, this article describes the assessment and management of a student presenting with a history of disordered eating and weight loss. As medical concerns are brought to the attention of the school nurse, it is important for the school nurse to be aware of common signs and symptoms seen in students with undiagnosed or established eating disorders, as well as possible medical complications associated with untreated or poorly controlled eating disorders. Possible signs and symptoms associated with eating disorders that require outpatient referral or emergent management is delineated in this article, and school nurses are provided with a helpful mnemonic called "BONES" to aid in the recognition of eating disorders in the school setting.

School Nurses on the Front Lines of Healthcare: A Guide in the Recognition of and Response to Teen Dating Violence in Your Schools.

Teen dating violence (TDV) has become more prevalent in our schools, exacerbated by the omnipotent presence of social media and portals of what dating and gender roles "should be" in Hollywood films and television shows. It is important to recognize that TDV is a threat to mental health, and potentially physical health, and school nurses should develop a framework for recognizing problematic social, physical, and emotional interactions between students. This article describes typical presentations of TDV through a case, providing a mnemonic for recognition and resources for prevention.

School Nurses on the Front Lines of Health Care: "STICKS & STONES" May Hurt More Than Your Students' Bones: A Guide to the Recognition of Bullying in Your Schools.

Although students commonly present to the school nurses' office with physical chief complaints, there are many mental health concerns in the school-age population associated with emotional and physical consequences. Bullying is considered to be a public health crisis, plaguing students across the nation. It is important to develop a framework for recognizing problematic social and emotional interactions between students, like bullying, given the dire consequences on a student's physical and emotional well-being. This article describes typical presentations of bullying through a case scenario, providing a mnemonic for recognition and resources for prevention.

"SPORTS ARE FUN": A Guide for the Discussion of Sport-Related Films.

Sport participation is an important part of the development of children and adolescents in the United States. Due to the popularity of sport-related films, coaches, athletic trainers, and parents have used these films to both educate and motivate pediatric athletes. The objective of this study was to develop a discussion guide template based on common positive and negative themes depicted in sport-related films, and demonstrate the application of this discussion guide template to a select number of sport-related films released from 2014 to 2018. A discussion guide template ("SPORTS ARE FUN") was developed by the co-investigators, reflecting common themes of "Sportsmanship, Participation for All, Obstacles, Relationships, Teamwork, Setting Realistic Goals, Academics, Responsibility, Exercise/Nutrition/Rest/Drugs/Performance Enhancing Drugs, Fun, Unrelenting Spirit, and "No Pain, No Gain." The authors hope that pediatric health care providers, athletic coaches/staff, and parents can utilize this discussion guide template in the education and development of children and adolescents who participate in sports.

Themes Depicted in Running-Related Films: An Opportunity for Co-Viewing and Active Mediation.

Sport participation is an important part of the development of children and adolescents. The objective of this study was to identify and quantify themes depicted in a select number of running-related films. Thirty-one running-related films were independently viewed and analyzed by 4 reviewers. The number of positive and negative themes was 29.5 (95% confidence interval = 26.1-33.4) and 9.0 (95% confidence interval = 7.9-10.2) mean events per hour for all included films, respectively. The most common positive themes were "overcoming physical limitations," "overcoming mental obstacles," and "encouragement from family/friends/fans" (2.6, 2.4, and 2.3 mean events per hour, respectively). The most common negative themes were "giving up/losing confidence," "ignoring injuries," and "discouragement/ridicule from coach/athletic trainer" (1.2, 1.1, and 0.66 mean events per hour, respectively). In conclusion, the co-viewing of running-related films with pediatric athletes in order to focus on "teachable moments" may encourage the acquisition and development of positive themes and the avoidance and de-emphasis of negative themes.

Injury and Illness Depicted in Running-Related Films.

The perception that children and adolescents have of injury and illness may be influenced by their depiction in sport-related films. The objective of this study was to determine the depiction of injury and illness in a select number of running-related films. A sample of 31 running-related films were analyzed, with a total of 77 injuries/illnesses depicted. The most common injuries/illnesses depicted were categorized as exertional heat exhaustion/stroke (26%), lower leg muscle cramps/not heat related (12%), ankle sprain (9%), knee ligamentous/meniscus injury (6%), exercise-associated collapse/not heat related (6%), and blister of the toe/foot (6%). Overall, 48/67 (64%) of the injuries/illnesses were considered severe emergencies (injury/illness requiring prompt intervention and immediate discontinuation of sport participation). The disposition of 46% of severe emergencies was the immediate continuation of training/competition. Pediatric health care providers, coaching staff, and parents should stress the importance of injury/illness recognition/disclosure and realistic expectations for rehabilitation to pediatric runners.

School Nurses on the Front Lines of Medicine: Emergencies Associated With Sport and Physical Activities: Part 1.

Illness and injury associated with sport and physical activities may occur in the school setting. Although most sport-related illness and injury in students are considered minor emergencies, life- and limb-threatening illnesses or injuries may occur, such as sudden cardiac arrest, heat stroke, status asthmaticus, catastrophic brain or cervical spine injuries, hypoglycemia, blunt chest/abdominal injuries, or extremity fractures requiring surgery. It is important for the school nurse to recognize potential life- and limb-threatening emergencies associated with sport and physical activity, to initiate stabilization of the student with life- and limb-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow up at their primary healthcare provider's office, or directly to the closest emergency department via emergency medical services). This article describes the initial assessment and management of three common emergencies associated with sport and physical activities.

School Nurses on the Front Lines of Medicine: The Approach to a Student After a Syncopal Event: Don't "PASS OUT".

Students presenting with syncope and/or seizure occur occasionally in the school setting. Several studies have shown that seizures as well as respiratory distress are the most common medical emergencies that prompt school nurses and staff to contact emergency medical services (EMS) to transport students to the closest emergency department (Knight 1999, Olympia 2005). It is important to develop a differential diagnosis for syncope, to initiate stabilization of the student with life-threatening symptoms, and to triage these students to an appropriate level of care (back to the classroom, home with their guardian with follow-up at their primary health care provider's office, or directly to the closest emergency department via EMS). This article describes the initial assessment and management of two students presenting after syncopal events.

School Nurses on the Front Lines of Medicine: Uppers and Downers: The Approach to the Student With Altered Mental Status.

Although a student presenting with altered mental status due to substance use may occur infrequently in the school setting, it is of utmost importance to develop a differential diagnosis and to initiate stabilization of the student. This article describes the initial assessment and management of a student presenting with altered mental status, focusing on the differential diagnosis of altered mental status, on the varying presentations associated with common intoxications and ingestions, and on the screening tools available for the detection of depression and substance use.

Emergency and Disaster Preparedness of School Transportation Staff and School Buses in the United States: Compliance With Recommendations for School Transportation Safety.

OBJECTIVE: The aim of the study was to determine the compliance of school transportation staff and school buses with recommendations for the safe transportation of children to and from school and school-related activities. METHODS: An electronic questionnaire was distributed to school transportation staff represented by the International Brotherhood of Teamsters during the 2013-2014 academic year. RESULTS: Analysis was performed on 558 completed questionnaires (13% usable response rate). Responders had previous training in first aid (89%), basic life support (28%), and cardiopulmonary resuscitation (52%). Seventy-eight percent of school buses in our sample had restraint devices and 87% had seat belt cutters. Responders reported the immediate availability of the following on their bus: communication devices (81%), first aid kits (97%), fire extinguishers (89%), automated external defibrillators (1%), and epinephrine autoinjectors (2%). Thirty percent of responders have had no previous training in the management of emergencies such as trouble breathing, severe allergic reaction, seizures, cardiac arrest or unresponsiveness, and head, neck, or extremity trauma. Thirteen percent of responders are unfamiliar with or have had no previous training on protocols regarding emergency shelters and community evacuation plans in the event of a disaster. CONCLUSIONS: Variability exists in the compliance of school transportation staff and school buses with recommendations for the safe transportation of children. Areas for improvement were identified, such as educating school transportation staff in the recognition and initial management of pediatric emergencies, ensuring the presence of restraint devices, increasing the immediate availability of certain emergency medications and equipment, and familiarizing school transportation staff with designated emergency shelters and community evacuation plans.

School Nurses on the Front Lines of Medicine: An Adolescent Female Student with Severe Abdominal Pain.

Abdominal pain is a common chief complaint encountered by school nurses. This article explains the etiology of abdominal pain in children and adolescents, describes the office assessment, and delineates life-threatening conditions associated with severe abdominal pain that may prompt the school nurse to transfer the student to a local emergency department.

Low Compliance of Urgent Care Centers in the United States With Recommendations for Office-Based Disaster Preparedness.

OBJECTIVES: The aim of the study was to determine the compliance of urgent care centers in the United States with published recommendations for office-based disaster preparedness. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: One hundred twenty-two questionnaires of the 872 distributed were available for analysis (14% usable response rate). Twenty-seven percent of centers have an established disaster plan for events that involve their establishment and surrounding community; 49% practice the plan at least once a year, 19% less frequent than once a year, and 32% never practice. Forty-seven percent of centers are familiar with designated emergency shelters and community evacuation plans. Seventeen percent of centers function as part of a surveillance system to provide early detection of any biologic/chemical/nuclear agents. Twenty-two percent of centers take part in local community and hospital disaster planning, exercises, and drills through emergency medical services and public health systems. Five percent of centers aid schools, child care centers, camps, and other child congregate facilities in disaster planning. Twenty-eight percent of centers have an assembled emergency/disaster kit, containing such items as water, first aid supplies, radios, flashlights, batteries, heavy-duty gloves, food, and sanitation supplies. CONCLUSIONS: Areas for improvement in urgent care center disaster preparedness were identified, such as developing an office disaster plan that is practiced at least yearly, becoming familiar with designated emergency shelters and community evacuation plans, providing surveillance to detect potential acts of terrorism, assisting community organizations (hospitals, schools, child care centers, etc) in disaster planning, and assembling office emergency/disaster kits.

Clinical Symptoms and Adverse Effects Associated With Energy Drink Consumption in Adolescents.

OBJECTIVE: The aims of the study were to determine the prevalence of energy drink consumption by adolescents, to identify associated clinical symptoms and adverse effects, and to gain an understanding to the motivation behind its consumption. METHODS: A prospective, questionnaire-based study was conducted at 2 emergency departments from June 2011 to June 2013. The questionnaire was distributed to a convenience sample of adolescents aged 12 to 18 years. Stratification was performed on the basis of frequency of consumption: frequent consumption (at least once a month) and infrequent consumption (less frequent than once a month). RESULTS: Data analysis was performed on 612 completed questionnaires. Two hundred two responders (33%) were considered frequent energy drink consumers. Frequent consumers were more likely to be involved in high-risk behaviors and more likely to consume other caffeinated drinks. In the previous 6 months, frequent energy drink consumers were more likely to report headache (76%), anger (47%), and increased urination (24%) and were more likely to require medical evaluation for headache (41%) and difficulty breathing (22%). Frequent energy drink consumers were more likely to believe that energy drinks "help me do better in school" (12%), "help me do better in sports" (35%), "are just for fun" (46%), "help me stay up at night" (67%), and "make me concentrate/focus better" (34%). CONCLUSIONS: Clarifying common misconceptions associated with energy drink consumption, especially in high-risk adolescents and frequent energy drink consumers, may decrease the frequency of symptoms experienced by adolescents, such as headache and difficulty breathing, requiring medical evaluation.

Pediatric Care Provided at Urgent Care Centers in the United States: Compliance With Recommendations for Emergency Preparedness.

OBJECTIVES: To describe the compliance of urgent care centers in the United States with pediatric care recommendations for emergency preparedness as set forth by the American Academy of Pediatrics. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: A total of 122 questionnaires of the 872 distributed were available for analysis (14% usable response rate). The most common diagnoses reported for pediatric patients included otitis media (72%), upper respiratory illness (69%), strep pharyngitis (61%), bronchiolitis (30%), and extremity sprain/strain (28%). Seventy-one percent of centers have contacted community emergency medical services (EMS) to transport a critically ill or injured child to their local emergency department in the past year. Sixty-two percent of centers reported having an established written protocol with community EMS and 54% with their local emergency department or hospital. Centers reported the availability of the following essential medications and equipment: oxygen source (75%), nebulized/inhaled ß-agonist (95%), intravenous epinephrine (88%), oxygen masks/nasal cannula (89%), bag-valve-mask resuscitator (81%), suctioning device (60%), and automated external defibrillator (80%). Centers reported the presence of the following written emergency plans: respiratory distress (40%), seizures (67%), dehydration/shock (69%), head injury (59%), neck injury (67%), significant fracture (69%), and blunt chest or abdominal injury (81%). Forty-seven percent of centers conduct formal reviews of emergent or difficult cases in a quality improvement format. CONCLUSIONS: Areas for improvement in urgent care center preparedness were identified, such as increasing the availability of essential medications and equipment, establishing transfer and transport agreements with local hospitals and community EMS, and ensuring a structured quality improvement program.

Return to Learning After a Concussion and Compliance With Recommendations for Cognitive Rest.

OBJECTIVE: To determine the compliance of schools and school nurses in the United States with national recommendations for cognitive rest in students who sustain a concussion. DESIGN: Cross-sectional questionnaire based. PARTICIPANTS: Members of the National Association of School Nurses working at the high school level. INTERVENTION: A questionnaire, developed by the authors and based on recommendations for cognitive rest, was electronically distributed 3 times during the 2012 to 2013 academic year. MAIN OUTCOME MEASURES: Self-reported responses were collected regarding demographics and compliance of schools and school nurses with recommendations for the management of the postconcussion student, including the presence of specific guidelines for individualized care and the responsibility of the nurse for the prevention, detection, and management of concussions. RESULTS: Analysis was performed on 1033 completed questionnaires (36% usable response rate). Fifty-three percent of schools have guidelines to assist students when returning to school after a concussion. These guidelines include extension of assignment deadlines (87%), rest periods during the school day (84%), postponement or staggering of tests (75%), reduced workload (73%), and accommodation for light or noise sensitivity (64%). Sixty-six percent of nurses in our sample have had special training in the recognition and management of concussions. Nurses reported involvement in the following roles: identifying suspected concussions (80%), providing emotional support for recovering students dealing with concussion-related depression (59%), and guiding the student's postconcussion graduated academic and activity re-entry process (58%). CONCLUSIONS: We detected a wide variability in compliance of schools and school nurses with national recommendations for cognitive rest. CLINICAL RELEVANCE: Ensuring that schools have policies established for a student's return to learning, having specific guidelines to provide an individualized approach to return to learning based on postconcussion signs/symptoms, training school nurses in the recognition and management of concussions, and involving school nurses in the re-entry process are identified areas for improvement. Schools in the United States should be aware of these recommendations to guide a student's postconcussion graduated academic re-entry process.

Medical and Disaster Preparedness of US Marathons.

BACKGROUND: Despite the events that occurred at the 2013 Boston Marathon (Boston, Massachusetts USA), there are currently no evidence-based guidelines or published data regarding medical and disaster preparedness of marathon races in the United States. Purpose To determine the current state of medical disaster preparedness of marathons in the US and to identify potential areas for improvement. METHODS: A cross-sectional, questionnaire-based study was conducted from January through May of 2014. The questionnaire was distributed to race directors of US road and trail marathons, as identified by a comprehensive internet database. RESULTS: One hundred twenty-three questionnaires were available for analysis (19% usable response rate). Marathon races from all major regions of the US were represented. Runner medical information was not listed on race bibs in 53% of races. Only 45% of races held group training and planning sessions prior to race day. Automated external defibrillators (AEDs) were immediately available on 50% of courses, and medications such as albuterol (30%), oxygen (33%), and IV fluids (34%) were available less frequently. Regarding medical emergencies, 55% of races did not have protocols for the assessment of dehydration, asthma, chest pain, syncope, or exercise-induced cramping. With regard to disaster preparedness, 50% of races did not have protocols for the management of disasters, and 21% did not provide security personnel at start/finish lines, aid stations, road crossings, and drop bag locations. CONCLUSIONS: Areas for improvement in the preparedness of US marathons were identified, such as including printed medical information on race bibs, increasing pre-race training and planning sessions for volunteers, ensuring the immediate availability of certain emergency equipment and medications, and developing written protocols for specific emergencies and disasters.

A review of the management of patellofemoral pain syndrome.

OBJECTIVE: Patellofemoral pain syndrome (PFPS) is one of the most frequently diagnosed knee conditions in the primary care, orthopedic, and sports medicine settings. Although strength training and stretching programs have traditionally been the mainstay of patient treatment, there are no consensus recovery protocols for runners experiencing PFPS. The purpose of our review is to examine recent literature regarding the efficacy of various treatment modalities in the management of patients with PFPS. METHODS: Our review included 33 articles from a PubMed literature search using the search term PFPS treatment. The search was limited to randomized controlled trials, crossover case-controlled studies, and cohort studies with ≥ 10 participants, with trial data that were published within the last 5 years. RESULTS: Strength training and stretching exercises continue to be strongly supported by research as effective treatment options for runners with PFPS. Recent studies have confirmed that quadriceps and hip strengthening combined with stretching in a structured physiotherapy program comprise the most effective treatment for reducing knee pain symptoms and improving functionality in patients with PFPS. As previous studies have shown, therapies such as proprioceptive training, orthotics, and taping may offer benefits as adjunctive therapies but do not show a significant benefit when they are used alone in patients with PFPS. Additionally, recent research has confirmed that surgical and pharmacologic therapies are not effective for the management of patients with PFPS. CONCLUSION: A large number of athletes are impacted by PFPS every year, particularly young runners. Sports medicine researchers have investigated many possible therapies for patients with PFPS; however, no clear guidelines have emerged regarding the management of the syndrome. Our review analyzes recent literature on PFPS and identifies specific treatment recommendations. The most effective and strongly supported treatment modality for patients with PFPS is a combined physiotherapy program, including strength training of the quadriceps and hip abductors and stretching of the quadriceps muscle group. Adjunctive therapies, including taping, biofeedback devices, and prefabricated orthotic inserts, may provide limited additive benefits in select populations. Surgery should be avoided in all patients with PFPS.

Emergency preparedness in high school-based athletics: a review of the literature and recommendations for sport health professionals.

Approximately 7.6 million high school students in the United States participate in sports. Although most sport-related injuries in adolescents are considered minor emergencies, life-threatening illnesses or injuries may occur, such as sudden cardiac arrest, heat stroke, status asthmaticus and exercise-induced asthma, catastrophic brain injuries, cervical spine injuries, heat- and cold-related illness, blunt chest/abdominal injuries, and extremity fractures resulting in compartment syndrome. Emergency preparedness in athletics involves the identification of and planning for medical services to promote the safety of the athlete, to limit injury, and to provide medical care at the site of practice or competition. Several national organizations have published guidelines for emergency preparedness in school-based athletics. Our article reviews guidelines for emergency preparedness put forth by the Sideline Preparedness collaboration (comprised of 6 major professional associations, including the American Academy of Family Physicians, American Academy of Orthopedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and American Osteopathic Academy of Sports Medicine), the National Athletic Trainers' Association, the American Academy of Pediatrics' Committee on School Health, and the American Heart Association. Additionally, we review published data examining compliance of US high schools with these recommendations for emergency preparedness in school-based athletics, determine deficiencies, and provide recommendations for improvement based on these deficiencies.

Emergency department visits from a local amusement park.

BACKGROUND: There are limited published data examining Emergency Department (ED) presentations associated with amusement parks, and even fewer data on presentations not associated with roller coaster rides. STUDY OBJECTIVES: To determine the spectrum of medical and traumatic presentations to two EDs from nearby amusement parks. METHODS: A retrospective chart review of prospectively identified, enrolled, and surveyed patients was conducted at two EDs in Pennsylvania during the summer of 2006. Any patient presenting with a medical or traumatic complaint that occurred within 12 h of ED presentation and was associated with a visit to the local amusement park was prospectively identified and details of the visit were retrospectively reviewed. RESULTS: There were a total of 325 discharge diagnoses for the 296 ED visits identified; 74% of discharge diagnoses were trauma related. The most common traumatic diagnoses were laceration (27%) and head injury or concussion (14%). The most common non-traumatic diagnosis was heat-related illness (24%). Twenty-nine percent of discharge diagnoses were directly associated with amusement park rides. Eighty-nine percent of patients were discharged home. There were no mortalities reported. CONCLUSION: The majority of ED visits from nearby amusement parks were benign and did not require hospitalization.

Compliance of child care centers in Pennsylvania with national health and safety performance standards for emergency and disaster preparedness.

OBJECTIVES: To determine the preparedness of child care centers in Pennsylvania to respond to emergencies and disasters based on compliance with National Health and Safety Performance Standards for Out-of-Home Child Care Programs. METHODS: A questionnaire focusing on the presence of a written evacuation plan, the presence of a written plan for urgent medical care, the immediate availability of equipment and supplies, and the training of staff in first aid/cardiopulmonary resuscitation (CPR) as delineated in Caring for Our Children: National Health and Safety Performance Standards for Out-of-Home Child Care Programs, 2nd Edition, was mailed to 1000 randomly selected child care center administrators located in Pennsylvania. RESULTS: Of the 1000 questionnaires sent, 496 questionnaires were available for analysis (54% usable response rate). Approximately 99% (95% confidence interval [CI], 99%-100%) of child care centers surveyed were compliant with recommendations to have a comprehensive written emergency plan (WEP) for urgent medical care and evacuation, and 85% (95% CI, 82%-88%) practice their WEP periodically throughout the year. More than 20% of centers did not have specific written procedures for floods, earthquakes, hurricanes, blizzards, or bomb threats, and approximately half of the centers did not have specific written procedures for urgent medical emergencies such as severe bleeding, unresponsiveness, poisoning, shock/heart or circulation failure, seizures, head injuries, anaphylaxis or allergic reactions, or severe dehydration. A minority of centers reported having medications available to treat an acute asthma attack or anaphylaxis. Also, 77% (95% CI, 73%-80%) of child care centers require first aid training for each one of its staff members, and 33% (95% CI, 29%-37%) require CPR training. CONCLUSIONS: Although many of the child care centers we surveyed are in compliance with the recommendations for emergency and disaster preparedness, specific areas for improvement include increasing the frequency of practice of the WEP, establishing specific written procedures for external disasters and urgent medical emergencies, maintaining the immediate availability of potentially life-saving medications, and ensuring that all child care center staff are trained in first aid and CPR.