mercurysmom 4,386 Views
Joined Jul 25, '11.
Posts: 147 (70% Liked)
This was one of my Mom's stories, but since we both worked at the same LTC at one point and had "experiences" with the same Dr, I believe her 100%...
One night, Mrs. Smith, a pt who was DNR, comfort care, with family at the bedside, finally passed away. Mrs. Smith's Dr routinely wrote orders for "No RN Pronouncement" on all of his patients and refused to refer them to Hospice, either, no matter what their primary Dx was or their current medical condition. (Mrs. Smith was admitted 5 days earlier, with CA mets to everywhere, sub-q morphine pump, scopolamine, etc.)
So, Mom called "Dr. ImInChargeDontForgetIt" to inform him that's Mrs. Smith's respirations had ceased, no audible apical pulse, no BP, etc. and reminded him that she needed to be pronounced, since he ordered "No RN pronouncement." It was just before midnight, and the family wanted to call the funeral home ASAP. Dr. I said "what the h*** is their rush? I'll be there at 8am.
Mom politely reminded him that the policy of that particular LTC was that patients who expire before midnight need to be pronounced within 4 hours of the next day, which meant he had a four-hour deadline to come in and pronounce her. Otherwise, she would have to call to have her transported to the ER to be pronounced, since he specified "no RN pronouncement."
Dr. I pauses, then says...
"Are there any stab wounds?" "Any bullet holes?"
Mom says "Of course not!" So Dr. "ImInChargeDontForgetIt" says, "Then leave her in bed, continue all care, and open the damn window. I'll be in at 8!" And slams down the phone.
Mom called the DON, who came in, did her own assessment, and called to have poor Mrs. Smith transferred to the ER, where the hospital's medical director was waiting for Dr. I to meet her as soon as she arrived (which he did!)
I worked a few days later...all of Dr. I's DNR/comfort care patients had orders for RN pronouncement andHospice consults! [emoji6]
One of my neighbors has never vaccinated her 15 y.o. son against anything. I love in an area with a high percentage of parents who choose to decline all vax due to "personal and/or religious reasons." Her explanation for continuing to refuse vax for her 6'w", 180lb son with size 14 shoes? "He was a preemie and I'm worried that his immune system wouldn't be able to handle all those chemicals forced into his body." 🐂💩
Yes, he was born prematurely, 33 weeks 6 days (IUI so dates are accurate), 4lbs 15oz, developmentally normal for gestational age and escaped all of the typical preemie tricks (RDS, NEC, anemia, sepsis, etc.). He was on CPAP for 12 hrs and room air via NC for a few days, occasionally a little whiff of O2 blended in during bottle feeds. Mom was quite unhappy. She was planning a home birth with a lay midwife and "no drugs in either of their systems," including eye prophylaxis after birth, it K, pitocin, pain meds, etc. She wanted to do something with his placenta where it stays attached for a few days (????!?!) and wasn't permitted to take home his placenta (I'm sorry, but...eww!).
Once blood cultures were negative for a few days he was moved to SCN as a feeder-grower. He was a model NICU baby, totally sailed right through every test and advanced quickly to gavage feeds, then bottle feeds, maintaining temp in an open crib, etc. Despite all of the good news and complications avoided, she constantly fought with the NICU staff re: IV ABX, fluids, anything "un-natural." (A serious chat with the NEonatologist and Social Workers helped her change her mind about refusing treatment for him. She wasn't happy and constantly voiced her displeasure to anyone who would listen, but she did what she needed to do in order to allow her son to come home with her!). Fortunately, he was big and healthy and was released a few weeks later. He was a total "rock star," even caught up developmentally by 18mos chronological age.
A few weeks ago, she texted me to say that he had a cough that was so severe that he would cough until his face was purple and he vomited. Knowing his vax status (actually lack thereof), I encouraged her to call the MD immediately. She replied " Oh, I know he doesn't have pertussis, since one of his friends had it recently, and he isn't making that "whoop" sound after he coughs (she compared his cough to a YouTube video in order to make this dx, so there ya go!). He's just throwing up." UGH. I have a kid who has complete IgA and IgG 2 and 4 deficiency, so it's kind of important to know if he's been exposed to these things, preferably by a real live doctor or FNP not Dr. Google!
I don't know what the vax rate is for my area, but I'm pretty sure it's nowhere near 95%. Herd immunity? I wouldn't count on it. I know that this kid isn't vaccinated, but how many other unvaxed kids are running around for every kid that I DO know isn't vaxed? 😷
When I was doing my pedi clinical rotations in the late 80's (LPN) and early 90's (RN), before kids received the HIB vax, there was always at least one infant/toddler with peri-orbital cellulitis on the floor for IV ABX. As a young, inexperienced nursing student, it seemed to be mostly an inconvenience, a relatively mild condition that needed admission and treatment "just in case there were complications." I heard the horror stories about kids developing meningitis, encephalitis, sepsis...blah blah blah, I had it written down on my Pedi Illness index cards, yet never seemed to witness anything but crabby little kids with facial swelling and IV's protected with an entire roll of Kling gauze. It felt a whole lot more like babysitting than nursing, in my naive opinion.
Well, wouldn't you know, that eventually I witnessed one of those "just in case there were complications" scenarios. The little boy was around 3 or 4. He was older than most kids that came in with the dx, and the swelling looked worse, even to my inexperienced student's eye. He hadn't been my patient, but I saw him walking in the hall and heard him singing, laughing, yelling, complaining, and talking up a storm. The next afternoon (we did evening clinicals in pedi), I noticed that his room was empty. He had started seizing, went into resp arrest, and was moved to PICU. The "inconvenient" peri-orbital cellulitis had spread to the area behind his eye, and within 24 hours he had meningitis. He remained in PICU for the rest of my pedi rotation.
He lived, but the meningitis was neurologically devastating. This was a child who walked into the room when he was admitted, and sang at least 50 verses of "Whoa, whoa, whoa a boat" with my classmate. The last time I saw him, he had a trach and a G tube, and the plan was to place him in a pedi LTC facility. He didn't respond to sight or sound, but he smiled and squirmed when his head was rubbed.
I live in an area where parents can choose not to vaccinate their children based on religious beliefs. As an EI Nurse Educator, I've met many families who have chosen not to vaccinate; they report religious conflict, but when asked about it informally many say that they "just don't believe in vaccinating their children." Religious conflict or personal choice? I'm not sure.
I would also ask the resident's family about his/her usual showering/bathing routine. I worked in a NH as a NA in the 80's. One particular resident had every single shower marked "refused" for several years. She would only allow a nightly "bird bath" and she had her hair washed and set once a week. She wore long-sleeved shirts and pants every single day, and would wear the same clothes about 3 days in a row. (She wore a nightgown to bed, and carefully folded her clothes and put them in a drawer each night.). She was alert and oriented and required very little assistance with ADL's; NA's only helped her with her feet, legs, and back and she did the rest. She spoke Polish and very little English.
Her son was able to explain everything. She was a Holocaust survivor, and bore unimaginable physical, mental, and emotional scars from her ordeal. Her care plan should have been changed to reflect her bathing and other preferences, rather than documenting shower refusals for years on end.
My LPN program was a hospital program that had included dorms up until about 5 years prior, so a student who was even less than 5 minutes early to clinical was met with gasps and horrified expressions.
My RN (ADN) program had its share of late arrivals, which really blew my mind. Unfortunately, since there are so many nursing schools in my area, there's a major fight for clinical sites, and my school apparently drew the short straw one year when it came to psych rotation. The site was in a hospital a good 70 miles from the school. The school was also famous at that time for being the only college to keep campuses open, even when the local universities with on-campus housing closed. So, one morning I woke up to a good foot of snow with a couple inches of ice on top of that, and left home at 4am to get to my 7am (6:45) clinical. Wouldn't you know it, the school canceled classes...but everyone showed up for clinicals, on time! We worked through the day and had an informal "study day" at the end of the semester. [emoji4]
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