Monday, January 18, 2010

What Goes Wrong Without the 6 Rights

I am blown away by a news story I just saw; several teachers at a school-based H1N1 flu clinic were given INSULIN instead of the flu vaccine they expected.
The school system is apparently investigating; no students received insulin thankfully, however the superintendent has sent out a pre-emptive letters to parents.

This is not rocket science; this is not a terrorist attack; this is unlikely faulty packaging. This is human error, and I imagine someone's head will be served on a platter because they failed to follow the rules of engagement of medication administration. These are taught practically Day 1 of nursing school, the "Rule of the 6 Rights": the right drug, the right dose, the right route, the right time, the right patient and the right reason. It is vitally important to get the right DRUG, for Pete's sake read the label.

It is reported that no teachers suffered any lasting damage which is fortunate. I imagine that there will be a few inservices in that school in the wake of this calamity.

I have been a school nurse; it is a tough job as you operate as a stranger in a strange land. The priority is the kids' health, but the job is really what everyone else thinks it should be. School nurses are asked to teach health classes; educate teachers; act as a resource for anyone in the school from the teachers, the custodians, the cafeteria ladies as well as parents. School nurses are mandated to be the immunization police, do health screenings such as hearing, vision, height and weight, scoliosis as well as the follow up and try to get responses back from parents who really could give a crap. Then there are field trips, meds and of course the everyday parade of booboos and broken bones from PE (for you non-school nurses, that's gym, not a pulmonary embolism). School nurses are asked to sit in on, and give commentary in team meetings that involve kids with disabilities, health issues, and anything that impacts learning. I could write a book about it; I did it for almost 10 years.

I feel bad for the school nurse who made this mistake, and that's what it is. Makes ya think. School systems tend to cut and run at the first sign of bad press; it's the modern equivalent of human sacrifice.

Annoying People

This young woman complained of back pain, having fallen on ice 2 days before. Her pain was 10/10 even despite the one dose of Tylenol she had taken the night before. I asked the usual questions about her significant medical history, allergies and medications. With a woman of childbearing age we ask the date of the last menstrual period, particularly if there is a possibility of needing any xrays. Her response to this question was, "oh, I don't know. A couple of months ago. I don't want any xrays, I'm really scared of them". For some reason, I begin to smell a rat; there is something just not right. However, I failed to ask the important follow up: "is there any possibility you might be pregnant?". Hey, we were busy and I did the best I could; it was some time before she got into a treatment room.

Gil, my doc of the day seemed to be in the room for a long time. He is very thorough. I had a minute to pull up a couple of past visits: only three for 2009. Not drug seeking behavior. I noticed she was seen for a possible miscarriage in July.

As I was reading this, Gil came out of the room. "Did you know she was pregnant?", he asked. "Nope. She didn't mention it, in fact she said her LMP (last menstrual period) was a couple of months ago".

"She didn't say anything to me either", Gil shook his head. "I inquired when I examined her gravid belly".

I am hearing dissonant clash of very loud warning bells now. "You know, in 30 some-odd years I have never had a gone-to-ground pregnant woman whose first words after a fall are NOT 'I'm pregnant'. Yet this one doesn't disclose it to either you or me, and hedges on the LMP by saying she's afraid of xrays and doesn't say why? I have her old record up, maybe you should have a look".

A look at a visit months ago revealed an ultrasound for a possible miscarriage; some higher math determined what the young woman didn't tell us: she was about 32 weeks pregnant.

Now I get it; it's about her, not the baby. At first I thought that this was scamming for narcotics, perhaps to sell, but she was asking for pain medicine. The fetal heart beat was fine; she had no signs of labor. Did she have an obstetrician? Nope. It had been at least 3 months (if she was being honest) since she had any prenatal care; probably none at all since her ER visit months ago. Our plan was to send her to the mother ship.

Gil didn't trust that she would show up at the downtown ER; I didn't trust her as far as I could throw her with an IV in her hand. She would go by ambulance. Must we always save people from themselves?

Her charming female companion burst out of the room, and in a voice that would melt paint off the walls demanded to know who was going to bring her home. "I had to borrow my brother in law's car because her's is crap; I can't wait around for her all day and she is freaking out about how to get home. How will she get back here?"

"Well, she could take a cab, or perhaps another family member could pick her up; that is her problem. And keep your voice down, you're disturbing others".

She was nearly apoplectic with rage, but I stared her down while she appeared to swallow her tongue. "She won't go then", charming compantion said sulkily.

"No problem, she can sign herself out AMA (Against Medical Advice). If you have any influence with her, I suggest you talk her into it. She's had a fall, basically no pre-natal care and her baby is at risk. There is an obstetrician waiting to see her. Up to you. She can talk to social services when she gets down there about comping her a cab, I don't do that here. Let me know what you decide", I said dismissively.

She went. The baby was fine. She got excellent free care even though she had little interest in the baby and no insurance. We already have socialized medicine. People who are paying for health insurance, following the rules, and working damn hard are getting the shaft. This one not only gets excellent free care but expects door to door service. Sheesh.

Some people just bring out the worst in me, more so as I get older. I am letting my annoyance show, which will likely get me into trouble. I have zero tolerance for complete idiocy and listening to bullshit, and it's not just at work. Last night at skating practice I was pretty rude myself to one completely annoying teammate; not that she didn't have it coming. She travels in her own orbit, says stupid things and never bloody shuts up. Urrgh. I have given up trying to be nice to her and can't wait for the end of the season so I will never have to see her again. Most of the time I just want to slap the ears off her head. Urrrrrhhhhgggghhhh. The point is until recently I never would have let the verbal zingers fly. Best get a handle on that.

Saturday, January 2, 2010

Today's Last Patient of the Night

Every so often there is a patient who will haunt me forever; our Last Patient of the Night is one I will think about often.

He was small for a 4 year old, a beautiful blue eyed blond little boy. He was whimpering strangely in the arms of a woman whom I assumed was his mother, also blond and blue eyed. They were accompanied by two little girls, probably 8 to 10 years old. They were silent.

"He's an orphan", said the mom. "We're his host family for the holidays, and we have a folder of his medical records. He burned his finger tips when he touched the glass screen of the fireplace".

I took a look at the little boy's fingers; the 2nd, 3rd, and 4th fingers of his left hand had a blister on the pads where they had come into contact with the blistering heat. He was alternately putting his hand on the ice covered in a wet paper towel, and removing them and sobbing, clenching his fists with pain. These types of burns usually do fine, but are excruciatingly painful for the first few hours.

The mother went on, "He's from Latvia, and he's deaf. He's from a program where orphans spend time with families for the holidays; we would like to adopt him".

"We love him", the youngest of the little girls said simply.

Normally immune to such situations, my heart melted on the spot.

His records were, uselessly, in Latvian. We tried some numbing medicine on the burns, gave him some Tylenol with codeine and tried to make him comfortable. I got a sterile cup, filled it with room temperature saline and had him dip his little fingers in it. Immediately he stopped crying. After several seconds, he lifted his fingers out of the cup experimentally; his face crumpled with pain, and he howled like a wounded animal. I gestured to him to put his fingers back in the water and was rewarded with a surprised grin. He put his head on the mother's shoulder and sighed contentedly.

I really didn't want to pry, but I asked, "Does he have to go back to Latvia after the holidays?"

"Yes, and that's going to be so hard. He's such a precious boy; he never cries, well, at least until he hurt his fingers. I wonder, do you think it's because he's deaf?"

"It's an orphan thing", explained the older of the two little girls sagely. I was astonished at her insight.

"Does he sign at all?", I asked. I vaguely recalled that American Sign Language (ASL) is not universal; most countries have their own sign language and their own rules. From some deep, forgotten part of my brain I recalled some signs I had learned years and years ago when my friend Geri and I took 2 semesters of an evening school sign language course.

The little boy had started to shiver; I balled both my hands into fists with the thumbs sticking out between the index and middle fingers. Shaking my hands in front of my I said, "Cold".

No reaction from the little boy, but the mom was interested. "What's the sign for 'hot'?"

I just couldn't remember. I remembered "play", "mom", "girl and boy", "friend". The two little girls quickly picked up on the few signs I could remember. One final sign popped into the front of my brain; I made a motion as if to pull at the visor of a ball cap, followed by touching my lips with the fingertips of my hand and then touching my other hand with both palms up.

"Good boy". Such a good, sweet boy; this family was in love.

" I know how to say 'I love you'", offered the youngest little girl, as she extend her thumb, index and pinky finger and held her palm side out; "That's the most important sign of all".

They were ready to go home. The two little girls wordlessly gathered up their coats, the mom's purse and car keys. The oldest gently put the little boy's hat on his head and softly kissed his flushed, tear stained cheek. They went out into the snowy night.

My New Year's wish is the hope, with all of my heart, that this lovely family will be able to make the little guy a permanent part of their family. They all deserve a happily ever after ending.