When a pediatric patient went into respiratory distress recently, the changes were subtle. His inpatient nurse consulted with a pediatrics intensive care unit nurse, who noticed the patient was using muscles on the side of his chest to help breathe, that his breathing rate wasn't normal for his age, and that he was in fact in distress. They immediately called an intensivist to escalate the level of care."He was literally transferred within 20 minutes of her reassessing this patient, and then further intubated which means we provided a breathing tube for this kid; that's how sick he really was," said Maj. Michelle Fredach, the clinical nurse officer-in-charge of Madigan Army Medical Center's PICU Unit and 4N Pediatric Inpatient Unit.Registered Nurse Allyce Valladares was rounding with the inpatient nurses and pediatric patients that day to offer additional expertise as part of new initiatives from the Madigan PICU this year, including rounding on the inpatient pediatrics floor and in the emergency room, making the use of nitrous oxide (or laughing gas) more accessible to help young patients through procedures, and offering on-call consultation through their new Rapid Response System.Although pediatric and emergency medicine nurses specialize in their own fields, PICU nurses offer unique skills as they are certified in pediatric advanced life support."As ICU nurses as well, we see the subtle signs. A kid can compensate for a very, very long time, but there are very subtle things with a pediatric patient that you can recognize that they are compensating, and it can just be as simple as them tripoding, where they're sitting up and they're expanding their chest cavity or sometimes people don't recognize that if a kid doesn't want to eat, it's actually an issue," said Valladares, who is leading the RRS initiative; she explained that children might stop eating to conserve energy needed to breathe. "As an ICU nurse … you do an across-the-room assessment of these patients and look for those smaller things that could actually calculate out to a big issue."PICU nurses specialize in the use of ventilators and intubation, and in administering medication drips; they also are purposely staffed to offer one-on-one care for the hospital's sickest pediatric patients.In addition to rounding and being on call with both inpatient pediatrics and the ER, the PICU team monitors new pediatric patients in the ER as well with the help of MHS GENESIS."We can pop up their screen and see what's in their waiting room. If there's something that kind of heightens our senses, we'll just go down there and take a look," said Fredach.She said the PICU RSS nurse recently saw that an infant in the ER was experiencing rapid respirations and needed PICU-level care; the PICU's extra eyes on brought the patient up to the unit faster than usual."It's more of a push versus a pull, and we're trying to be that pull," said Fredach.The PICU team also responds to emergencies throughout the hospital as a part of the Outpatient Medical Response Team. Although most OMRT incidents involve adult patients, the PICU team wants to ensure they're immediately on hand if a child is experiencing a medical emergency outside of the ER, according to Fredach.She encourages medical staff to contact them on Vocera if they ever want a PICU consult, even if they're uncertain if PICU expertise is needed as her team can also help provide education on the finer points of when a pediatric patient might need intensive care.