Anoxic Brain Injury - Nurse Accused of Not Treating Asthma

[Katillac]

I feel horrible for everyone involved in this situation.

LAKEVILLE, Minn. (FOX 9) - A family says their daughter suffered a traumatic brain injury and is now in a vegetative state after her school nurse in Lakeville, Minnesota didn't treat her asthma.

In a lawsuit filed on Thursday, the family's attorneys say the nurse at McGuire Middle School failed to properly evaluate her and sent her to gym class where she lost consciousness and had to be taken to the hospital. Now, they say she will require caretaking services for the rest of her life.

Leading up to the date of her medical emergency, the family says their daughter Aaliyah had a long history of asthma with severe exacerbations that required medical intervention. The school district and nurse were aware of the severity of her condition, according to the lawsuit.

https://www.fox5ny.com/news/family-minnesota-girl-in-vegetative-state-after-school-nurse-failed-to-treat-her-asthma

[guest83140]

Wow, so sad to hear this for all involved. I have truly never heard of an asthma death after the person seeking help but anything is possible. I know most cases like this get nurse or medical consultation so our documentation is so vital to our assessments.

[Snatchedwig, BSN, CNA, LPN, RN]

That's so sad. Prayers for everyone

[brownbook]

On 9/6/2019 at 2:11 AM, beachynurse said:

I would reserve comment until I knew all facts to the story.

I wish people said or thought this more often.

[nursekoll, BSN, RN]

I'm glad my state has an emergency response protocol with standing orders to give epi-pen followed by albuterol neb to anyone with a life threatening breathing emergency. This is a valuable tool for school nurses in Nebraska in order to save lives. If a student has an action plan, but that plan fails, we go to the protocol, if there is no plan or history of asthma/anaphylaxis, we go to the protocol. I wish more states had this and would stock epi and albuterol in their schools. I have known a young person who died in ambulance en-route from status asthmaticus even after seeking help, so the sooner we can get meds on board the better. So sad.

[frozenmedic]

On 9/6/2019 at 10:14 AM, JenTheSchoolRN said:

School nursing is so much different than any other area of nursing because often you are a single practitioner; and every single person you work with doesn't understand your job (and sometimes its importance).

Though this may be true, and many people are implying that a "real" school nurse (as opposed to LPN, medical assistant etc) might have assessed and managed this situation differently; I'm alarmed by the amount of replies to this topic that are surprised to hear that Epi can be used in cases of refractory asthma, and that albuterol is also appropriate in cases of anaphylaxis. Both disease processes have a significant component of bronchospasm for which beta-2 agonists are appropriate. Albuterol is an (mostly) beta-2 specific agonist, while Epinephrine is both an alpha and beta agonist, and decreases mast cell release of inflammatory mediators.

What are we saying here when nurses as a group apparently don't know the underlying physiologic mechanism for the diseases they manage and treatments they are offering?

[JenTheSchoolRN, BSN, RN]

On 9/9/2019 at 6:59 PM, frozenmedic said:

Though this may be true, and many people are implying that a "real" school nurse (as opposed to LPN, medical assistant etc) might have assessed and managed this situation differently; I'm alarmed by the amount of replies to this topic that are surprised to hear that Epi can be used in cases of refractory asthma, and that albuterol is also appropriate in cases of anaphylaxis. Both disease processes have a significant component of bronchospasm for which beta-2 agonists are appropriate. Albuterol is an (mostly) beta-2 specific agonist, while Epinephrine is both an alpha and beta agonist, and decreases mast cell release of inflammatory mediators.

What are we saying here when nurses as a group apparently don't know the underlying physiologic mechanism for the diseases they manage and treatments they are offering?

A LPN or medical assistant cannot actually legally "assess" a student; meaning while they can administer treatments, looking at vitals (or lung sounds, etc) and then determining treatment is out of scope of practice. In a school there isn't often another health care professional there to "check in with" and then get advised on treatment. So, yes, I asked this, because it may or may not matter in the situation - this article provides very few details.

Also in the school setting, RNs, LPNs, MAs, we all have to act on our orders - until very recently I have never had one for epi for asthma. I can't just grab my stock epi and give it for asthma even if I know it will work - my orders are for Epi for anaphylaxis only (one could argue that asthma symptoms are similar, but that is another discussion of the fine line of orders). My orders are from my school doc, who I cannot reach easily to amend them in real time. So I call 911.

So, yes, I know it can work - I'm not surprised at that. But in my career have not had a doc write a scrip for it for a student with asthma only and no allergies. Not sure if insurance would cover that way, to be honest.

Are you a nurse?

[frozenmedic]

I am a nurse and a paramedic. I have been both constrained by orders, and at the receiving end of many of those 911 calls. I have spent much of my career working out of the hospital, often without another advanced level provider to "check in" with. Although I quoted you, my comment wasn't to you specifically, but to the many commenters who were apparently unaware of how the essential medications they administer work on a basic level, and are seemingly blindly following orders/protocols.

You speak of only nurses being able to perform an assessment, but why even bother if the knowledge base ends there? I have spent my entire nursing career frustrated by how hard the nursing field tries to separate itself from every other health profession. We have our own "diagnoses," our own innumerable "nursing theories," our own self imposed division of labor where only RNs are special enough to perform an "assessment." Then we chase our tails trying to stay in this fantasy world we have created, instead of seeking common ground just like every health profession. Example: I used to work at a large academic medical center where a nurse could use the 1-10 scale to "perform a pain assessment" while an aid, when performing routine vitals could ask the patient the same question and "record a pain score."

It's ridiculous and patently false. EMT students (a semester long course with essentially the same hours as NA I) are taught patient assessment as the foundation for all further levels of care. Lifeguards and wilderness professionals too.

So yes, I am a nurse, and while I am proud of the work I do, I can't help but be disappointed by the incredible diservice we have done to ourselves, our students, and patients. We start with an insane system of nursing education where reflective journaling, care plans, and RN professional socialization take precedence. Pathophysiology and pharmacology? These are mere afterthoughts. We end with RNs who know exactly who can do what orders and know what skills "separate" them from other healthcare providers, but have no idea of the science or the "why" behind anything, yet want more and more professional autonomy. This discussion is only one example, and that's what really disappoints me.

[Mickey]

This is for Jenthenurse.

Quote

I attended a SN conference in the spring that discusses asthma, allergies, and all the big issues - and both the pulmonologist and allergist said that EPI in the case of an asthma attack can be helpful (or, specifically, "will not hurt"), and that albuterol in the case of severe allergic reaction can also be helpful (or, "will not hurt").

What conference is this? The ones in my area do not have such knowledgeable speakers!

[Sayyadina, BSN]

On 9/6/2019 at 9:26 AM, ruby_jane said:

Not that I have it to give...but I wonder if an Epi pen would have been efficacious. That walks me into the fine line of assessing versus prescribing....

I have epinephrine (and naloxone) in an emergency kit in the clinic, the school has stock EpiPens in the office and the cafeteria, and kids have their own pens at school if it's part of their health plan. I can't imagine not having access to it.

[MunoRN, RN]

Here is the court filing: https://static.fox9.com/www.fox9.com/content/uploads/2019/09/Bowen-Complaint-file-stamped.pdf

Part of the basis of negligence is that the student's HR was 124 after a albuterol neb, and that the nurse should have recognized that wasn't normal. A HR of 124 after an albuterol neb is actually completely normal.

The part of the complaint that might have some teeth is that there was a care plan for the patient that had defined parameters to release from monitoring after treatment was initiated, which included basic pulmonary function testing as well as a minimum amount of time to monitor after the last albuterol tx, which the nurse apparently did not follow. As a side note, my pet peave is that we still use albuterol in these kids, levalbuterol should be considered the only option and may have prevented this outcome.

[JenTheSchoolRN, BSN, RN]

On 9/13/2019 at 2:58 AM, frozenmedic said:

I am a nurse and a paramedic. I have been both constrained by orders, and at the receiving end of many of those 911 calls. I have spent much of my career working out of the hospital, often without another advanced level provider to "check in" with. Although I quoted you, my comment wasn't to you specifically, but to the many commenters who were apparently unaware of how the essential medications they administer work on a basic level, and are seemingly blindly following orders/protocols.

You speak of only nurses being able to perform an assessment, but why even bother if the knowledge base ends there? I have spent my entire nursing career frustrated by how hard the nursing field tries to separate itself from every other health profession. We have our own "diagnoses," our own innumerable "nursing theories," our own self imposed division of labor where only RNs are special enough to perform an "assessment." Then we chase our tails trying to stay in this fantasy world we have created, instead of seeking common ground just like every health profession. Example: I used to work at a large academic medical center where a nurse could use the 1-10 scale to "perform a pain assessment" while an aid, when performing routine vitals could ask the patient the same question and "record a pain score."

It's ridiculous and patently false. EMT students (a semester long course with essentially the same hours as NA I) are taught patient assessment as the foundation for all further levels of care. Lifeguards and wilderness professionals too.

So yes, I am a nurse, and while I am proud of the work I do, I can't help but be disappointed by the incredible diservice we have done to ourselves, our students, and patients. We start with an insane system of nursing education where reflective journaling, care plans, and RN professional socialization take precedence. Pathophysiology and pharmacology? These are mere afterthoughts. We end with RNs who know exactly who can do what orders and know what skills "separate" them from other healthcare providers, but have no idea of the science or the "why" behind anything, yet want more and more professional autonomy. This discussion is only one example, and that's what really disappoints me.

Some excellent points. Apologies, as many folks come into our space not truly understanding that school nursing is really a very unique field of nursing. I'm not separating nursing, just protective of school nursing. And sometimes an RN with other training is lost in the school nursing world, along with a MA or LPN who come from another specialty.

To be fair, nursing school also has some large gaps in education as well. Nursing school didn't prepare for school nursing really - yes, the knowledge was there, but the time I spend as sub working directly with an awesome seasoned school nurse taught me how to truly take my knowledge and apply it. But that is another thread in itself.

Still, I wish I had access to the orificenal of things EMS has when I call them. But I don't. So I call them. And I've worked some awesome EMS folks, alongside the awesome firefighters down the street that arrive first and bring me O2 if I need it.

Thanks for your insight.

[JenTheSchoolRN, BSN, RN]

On 9/14/2019 at 9:26 PM, MunoRN said:

Here is the court filing: https://static.fox9.com/www.fox9.com/content/uploads/2019/09/Bowen-Complaint-file-stamped.pdf

Part of the basis of negligence is that the student's HR was 124 after a albuterol neb, and that the nurse should have recognized that wasn't normal. A HR of 124 after an albuterol neb is actually completely normal.

The part of the complaint that might have some teeth is that there was a care plan for the patient that had defined parameters to release from monitoring after treatment was initiated, which included basic pulmonary function testing as well as a minimum amount of time to monitor after the last albuterol tx, which the nurse apparently did not follow. As a side note, my pet peave is that we still use albuterol in these kids, levalbuterol should be considered the only option and may have prevented this outcome.

Interesting. 124 is totally normal.

I will admit - I would not send a student I'd just given a neb treatment to to gym class. That student would sit the class out and do work in my office if possible and I'd monitor them.